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.
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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