Clinical features of myxedema coma
- Classic combination of AMS and hypothermia but may also manifest with:
- hypotension, bradycardia
- hyponatremia, hypoglycemia
- Non-pitting edema of the hands/feet/face and enlarged tongue (abnormal deposits of mucin)
- Often precipitated by infection, cessation of thyroid replacement, ACS
Posted 07/14/16 02:24:29 PM by Matthew Cummings
- Extensive scoring system exists surrounding above criteria but derived from small sample size (21 patients), thus...
- MUST consider in any altered patient w/ hypothermia, hyponatremia, and/or hypercapnia and send TSH, FT4, and cortisol (assessing for concomitant adrenal insufficiency)
Posted 07/14/16 02:32:22 PM by Matthew Cummings
Supportive care for myxedema coma
- Supportive care is CRUCIAL
- Hypercapnia --> NPPV (depending on mental status), mechanical ventilation
- Hypotension --> volume resuscitation
- Hypothermia --> rewarming in monitored setting (at risk for hyperkalemia, arrhythmias)
- Hyponatremia --> frequent BMPs, appropriate correction
- Precipitant --> pan-culture/abx, EKG/troponin/TTE, etc
- Glucocorticoid administration: treat empirically w/ "stress" dose hydrocortisone (100mg q8h) until can rule out adrenal insufficiency
- Therefore important to send cortisol early prior to treatment if possible
Posted 07/14/16 02:37:05 PM by Matthew Cummings
Thyroid replacement strategies --> controversial issue (limited prospective clinical data)
- Debate as to benefit of administering BOTH T3/T4 or just T4
- Always prefer IV therapy (poor GI absorption in myxedema)
- T4 (levothyroxine): loading doses usually begin ~200mcg and then daily dose of ~1.5mcg/kg/day
- T3 (liothyronine): loading doses begin ~5mcg, and then daily doses starting at 2.5mcg q8h
- Prefer lower doses in elderly, underweight patients and those w/ arrhythmia, ACS, CHF)
Posted 07/14/16 02:46:19 PM by Matthew Cummings
For further reading...
Posted 07/14/16 06:16:47 PM by Matthew Cummings
Created by Christopher Kelly
The information on the website does not constitute official guidelines except where explicitly stated.
It is not meant to replace the advice of a health professional.