MYXEDEMA COMA

MYEDEMA COMA

End stage of untreated or insufficiently treated hypothyroidism Typical clinical picture:

Elderly obese female Becoming increasingly withdrawn, lethargic, sleepy and confused Slips into a coma Previous thyroid surgery Radioiodine Default thyroid hormone therapy

History:

Precipitating Events

Cerebrovascular accidents Myocardial infarction Infection

UTI Pneumonia

Gastrointestinal hemorrhage Acute trauma Administration of sedative, narcotics, tranquilizers, potent diuretics CCF

Pathogenesis of Myxedema coma

Symptoms

Cold intolerance, dry skin Constipation, weight gain, poor appetite Neurological-weakness, slow speech, disorientation ,apathy, psychosis Symptoms progress to lethargy, disorientation, grandmal seizures, coma

Physical Findings

Comatose or semi comatose Dry coarse skin, cold peripheries Puffy face, hands, feet Bradycardia Delayed reflex relaxation time Hypothermia, hypotension, hypoventillation Pericardial, pleural effusions, ascites GI ileus, urinary retention

Lab Findings

Free T4-low and TSH-high If TSH-low/N and FT4-low, consider central or pitutary hypothyroidism. Blood gases-hypoxemia, hypercapnia, acidosis Hypoglycemia, hyponatremia Blood culture, urine culture, CXR ECG LFT,RFT Distinguish from euthyroid sick syndrome

Low T3, Normal or low TSH, normal free T4

Management of Myxedema coma

ICU

admission is required for ventilatory support, continuous close monitoring of pulmonary and cardiac status IV medications

General & supportive

ABC 2. IV access-large bore 18 guage 3. Fluid replacement isotonic crystalloid solutions like NS/RL Avoid hypotonic solutions Avoid vasopressors-risk of dysrythmia 4. Treatment of hypothermia-corrected once T4 is administered
1.

Treatment of hypoglycemia -50% Dextrose initially. Then 5%Dextrose infusion in NS/RL Glucocorticoids-Hydrocortisone Na phosphate/succinate 100mg every 8hrs for 48hrs.Then taper over 1 week Treat the precipitating cause

Specific Therapy

Parenteral thyroxine
Loading

dose of 200 500 g T4, IV over 1 hr Then 50-100 g daily until oral intake is tolerated

Controversy exists as to whether to give T3, in addition to T4

Treatment

Hypothyroidism Hypocortisolemia Hypoventillation Hypothermia Hyponatremia Hypotension Hypoglycemia

IV 200-500 g loading dose T4.Then 50-100 g IV hydrocortisone 100mg 8hrly Intubation, mechanical ventilation Blankets, no active methods Cautious fluid replacement Volume expansioncrystalloids Dextrose

Prognosis

When recognized & treated early, mortality is 15-20%, and is mostly due to underlying and precipitating diseases. If not recognized early, mortality is 60-70%, especially in elderly.

Thank you