Thanks to Dr. Bradby for today’s Morning Report!

 

Myxedema Coma or Crisis

 

Definition:  Severe (decompensated) hypothyroidism leading to decreased mental status, hypothermia, and other symptoms related to slowing of function in multiple organs.

 

Epidemiology:

–       Mortality rate if not promptly diagnosed and treated:  approx. 50% or more

  • Even with prompt treatment, mortality rates of up to 25% have been observed

–       4-8x more common in women

–       Incidence increased with age, myxedema coma occurs primarily in the elderly

 

Pathophysiology:

–       Thyroid hormones are critical in cell metabolism and organ function

–       Decrease T3/T4 –> decrease in production of myocyte contractile proteins and enzymes including NA+/K+ ATPase

–       Decreased plasma volume

–       Increased systemic vascular resistance

–       Respiratory muscle dysfunction, depressed resp drive, fluid accumulation

–       Hyponatremia due to decreased Na reabsorption from reduced levels of Na+/K+ ATPase

–       Decreased intestinal motility

–       Summary:  Everything slows DOWN.

 

Clinical Presentation:

–       Neuro: lethargy, stupor, coma, altered mental status

–       Cardio:  bradycardia, decreased myocardial contractility, low cardiac output, hypotension, pericardial effusion à  all reversed with thyroid hormone therapy.

–       GI:  decreased bowel sounds, distention secondary to ileus

–       Lung:  Hypoventilation, rales (pleural effusions)

–       Skin:  Edema, macroglossia, coarse/thinning hair

–       GU:  Bladder distention

–       Hyponatremia (seizures), Hypoglycemia

–       Hypothermia

 

Diagnosis:

–       Based on hx, px, and exclusion of other causes of coma

  • Ex: poorly responsive patient with a thyroidectomy scar or a history of I-131 therapy or hypothyroidism
  • Ask about: recent infections, trauma, burns, CVA symptoms, GI Bleeding, CHF, drugs (tranquilizers, sedatives, anesthetics, amiodarone, rifampin) – Basically anything that could cause the body any stress.

–       Send TFTs, cortisol

–       Tx should NOT wait for test results to come back –> ENDOCRINE EMERGENCY

 

Treatment:

–       Mechanical ventilation if needed (acidosis, hypercapnia, inability to protect airway, hypoxia)

–       Immediate thyroid hormone replacement

  • Give IV – GI absorption is compromised
  • IV loading dose:  200-400mcg of levothyroxine with T3 dose of 5-20mcg
  • Daily dose:  50-100mcg of levothyroxine IV until patient is PO tolerant, with T3 dosing 2.5 to 10 mcg q8h.  T3 can be discontinued when patient has clinical improvement and becomes stable.
  • Know that full-dose T4 therapy can worsen myocardial ischemia by increased myocardial oxygen consumption, so use caution.

–       Stress hormone replacement (after cortisol level sent)

–       Passive rewarming (active rewarming increases risk of vasodilation and worsening hypotension)

–       Antibiotics if there is signs of infection, as well as pan culture

–       Correct electrolyte derangements

 

Reference:

Ross, DS. Myxedema Coma. In: UpToDate, Rose, BD (Ed), UpToDate, Waltham, MA, 2013.

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Jay Khadpe MD

  • Editor in Chief of "The Original Kings of County"
  • Assistant Professor of Emergency Medicine
  • Assistant Residency Director
  • SUNY Downstate / Kings County Hospital

Latest posts by Jay Khadpe MD (see all)

Categories: Morning Report

Jay Khadpe MD

  • Editor in Chief of “The Original Kings of County”
  • Assistant Professor of Emergency Medicine
  • Assistant Residency Director
  • SUNY Downstate / Kings County Hospital

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