Thanks to Austin for presenting the case of an elderly woman with h/o psychiatric disorder who presented with acute/subacute onset of AMS, severe hypothermia, sinus bradycardia, and hypotension with work up revealing hypothyroidism suspicious for myxedema coma!

Clinical Pearls

• Exam findings for hypothermia change depending on severity of hypothermia (see below).
• It is crucial to measure core body temperature for accuracy especially when you are rewarming the patient (esophageal is the best, rectal/bladder are ok prior to rewarming but can remain low in spite of increasing core body temp so do not rely on these metrics alone)
• Think of etiologies of hypothermia broadly within the categories of increased loss or decreased heat generation.
• The most common causes of hypothermia are sepsis, exposure, and hypoglycemia.
• The hallmarks of myxedema coma are AMS, hypothermia, and a precipitating event (i.e. infection, exposure, meds, etc.)
• Myxedema coma is a medical emergency with a high mortality rate.  So consult endocrine early when you are suspecting it.
• Always treat myxedema coma with levothyroxine AND steroids until you have ruled out a concurrent adrenal insufficiency.

HYPOTHERMIA

Types:

• Mild (32-35°C)
  • Clinical manifestations
    • Shivering, rigors
    • ↑ HR, ↑ RR, ↑ BP, hyperventilation
    • Cold diuresis
      • Body’s attempt to preserve heat.  When peripheral vasoconstriction occurs to keep blood closer to vital organs, BP rises.  Kidneys see this rise in BP and act to correct it by dumping fluid! (Oh kidneys…)
  • Treatment
    • Passive, external
      • Blankets
      • Humidified inspired air
• Moderate (28-32°C)
  • Clinical manifestations
    • ↓ shivering
    • Confusion, slurred speech
    • ↓ HR, hypoventilation
    • Can also start to notice other cardiac manifestations such as prolonged QTc, QRS, osborn (J) waves, ST elevations/depressions.
    • ↓ renal blood flow
  • Treatment
    • Passive, external (see above) PLUS
    • Active external
      • Forced heated air
      • Warm blankets
      • Warm water immersion
    • Active internal
      • Warm humidified air (42°C)
      • Warm IV fluids (42°C)
      • Body cavity lavage (in trauma patients only)
• Severe (<28°C)
  • Clinical manifestations
    • NO shivering
    • Edema (due to poor renal blood flow) of extremities and lung
    • ↓ HR, ↓ BP (due to drop in cardiac output), hypoventilation, ventricular arrhythmias
    • Cardiac manifestations more common as with moderate hypothermia
    • AMS
    • Paradoxical undressing
      • mechanism is poorly understood but thought to be due to paralysis of the nerves regular vascular muscle tone leading to vasodilation and sensation of a heat flush which results in the patient wanting to take their clothes off.
  •  Treatment
    • Any of the above (passive external, active external, active internal) and/or
    • Extracorporeal
      • HD
      • ECMO

Etiologies of hypothermia:

Items in red above are the most common causes of hypothermia.

Lab findings:

• Less reliable since labs have to be warmed prior to processing
  • ABG is often inaccurate
  • Coagulopathy may be masked
  • Hyperkalemia due to rewarming

Complications of rewarming:

• Hypotension due to peripheral vasodilation
• Ileus and urinary retention
• Worsening coagulopathy
• Arrhythmias
• Hyperkalemia
• Core temperature after-drop (a condition in which cold peripheral blood gets shunted to the core and results in further decline in temperature.  You can avoid this by active internal rewarming like warmed IV fluids)

MYXEDEMA COMA 

Learn all about it from our prior blog post here.