Myxedema Coma – 12/12/17

What is it?

  • Severe hypothyroidism leading to AMS and hypothermia
  • Can have other symptoms related to the slowing down of organs

Who gets it?

  • Usually older females with long standing hypothyroidism triggered by a precipitating event

How does it present?

  • Change in mental status (rarely presents as true overt coma)
  • Hypothermia
  • Hypotension
  • Bradycardia
  • Hyponatremia
  • Hypoglycemia
  • Hypoventilation

What labs should you check?

  • TSH, FT4
  • Cortisol (to rule out concurrent adrenal insufficiency)

What is the treatment?

  • IV T3 and/or T4 – data is mixed
    • Use IV because patient likely has gut edema so PO form may have decreased absorption
    • T3 has better bioavailability and is the active form
    • In acute illness, body’s normal conversion of T4 to T3 is impaired
    • Monitor patients on telemetry because biggest concern is arrhythmias
    • Use lower dosing in elderly patients or those with cardiac disease
    • Recheck TSH in one week – goal is drop by > 50%
  • Stress dose steroids (hydrocortisone 100 mg every 8 hours)
    • Until you rule out concomitant adrenal insufficiency
  • Supportive measures
    • Avoid dilute fluids which can worsen hyponatremia
    • Use passive rewarming
    • Pressors if needed

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