Myxedema coma: Difference between revisions

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==Background==
==Background==
* Myxedema: thick, nonpitting edematous changes to skin and soft tissues
* Myxedema: thick, nonpitting edematous changes to skin and soft tissues
* occurs in 0.1% of patients with hypothyroid
* occurs in 0.1% of patients with hypothyroid
* 80% mortality  
* 80% mortality  


==Precipitants==
==Precipitants==
 
#Exposure to Cold
 
#Infection (esp pulmonary)
* Exposure to Cold
#CHF
* Infection (esp pulmonary)
#Trauma
* CHF
#Drugs: phenothiazines, pheobarbitol, narcotics, anesthetics, bdzs, lithium
* Trauma
#Iodides
* Drugs: phenothiazines, pheobarbitol, narcotics, anesthetics, bdzs, lithium
#CVA
* Iodides
#Hemorrhage (GI)
* CVA
* Hemorrhage (GI)


==Diagnosis==
==Diagnosis==
 
#AMS
 
#unsteady gait  
* AMS
#Skin findings (cool, dry, coarse, pale)
* unsteady gait  
#soft tissues with nonpitting, waxy, dry edema (periorbital edema)
* Skin findings (cool, dry, coarse, pale)
#loss of axillary and pubic hair  
* soft tissues with nonpitting, waxy, dry edema (periorbital edema)
#Hypothermia (core temp <37C)
* loss of axillary and pubic hair  
#Cardiovascular alterations (bradycardia)
* Hypothermia (core temp <37C)
#Hypoventilation --> respiratory collapse
* Cardiovascular alterations (bradycardia)
#abdominal distension  
* Hypoventilation --> respiratory collapse
#Delayed DTRs
* abdominal distension  
#Precipitant
* Delayed DTRs
#Hypoglycemia
* Precipitant
#Hyponatremia
* Hypoglycemia
* Hyponatremia


==Work-Up==
==Work-Up==
 
#Chem panel (shows hyponatremia)
 
#serum osms  
* Chem panel (shows hyponatremia)
#accucheck (may be normal or low)
* serum osms  
#CBC
* accucheck (may be normal or low)
#cultures  
* CBC
#total CK
* cultures  
#LFTS
* total CK
#LDH
* LFTS
#TSH, FT4, FT3
* LDH
#cortisol level  
* TSH, FT4, FT3
#ABG
* cortisol level  
#ECHO
* ABG
#CXR  
* ECHO
#EKG  
* CXR  
* EKG  
   
   
==DDx==
==DDx==
 
#CHF
 
#Pulmonary Edema
* CHF
#hypoventilation syndromes  
* Pulmonary Edema
#hypothermia  
* hypoventilation syndromes  
#Depression/SI
* hypothermia  
#hepatic encephalopathy
* Depression/SI
#shock  
* hepatic encephalopathy
#CVA  
* shock  
* CVA  


==Treatment==
==Treatment==
 
#Intubation and mechanical ventilation if pt has significant respiratory acidosis, hypercapnia, or hypoxia
 
#IV thyroid replacement
* Intubation and mechanical ventilation if pt has significant respiratory acidosis, hypercapnia, or hypoxia
##500-800 mcg  of Levothyroxine then 50-100mcg IV qday  
* IV thyroid replacement
##consider 10-20mcg q12hrs IV of T3 in younger patients with low cardiovascular risk
* 500-800 mcg  of Levothyroxine then 50-100mcg IV qday  
#Steroid Replacement  
* consider 10-20mcg q12hrs IV of T3 in younger patients with low cardiovascular risk
##5-10mg/hr IV hydrocortisone  
* Steroid Replacement  
#treat associated infections
* 5-10mg/hr IV hydrocortisone  
#correct severe hyponatremia and hypoglycemia  
* treat associated infections
passive external rewarming   
* correct severe hyponatremia and hypoglycemia  
* passive external rewarming  
   


==Disposition==
==Disposition==
 
#Admit to ICU
 
#get endocrine consult  
* Admit to ICU
* get endocrine consult  


==See Also==
==See Also==
Hypothyroidism
Hypothyroidism


Thyroid (General)
Thyroid (General)


==Source==
==Source==
Emedicine
Emedicine


Adapted from PANI, Clarke
Adapted from PANI, Clarke


[[Category:Endo]]
[[Category:Endo]]

Revision as of 13:36, 12 March 2011

Background

  • Myxedema: thick, nonpitting edematous changes to skin and soft tissues
  • occurs in 0.1% of patients with hypothyroid
  • 80% mortality

Precipitants

  1. Exposure to Cold
  2. Infection (esp pulmonary)
  3. CHF
  4. Trauma
  5. Drugs: phenothiazines, pheobarbitol, narcotics, anesthetics, bdzs, lithium
  6. Iodides
  7. CVA
  8. Hemorrhage (GI)

Diagnosis

  1. AMS
  2. unsteady gait
  3. Skin findings (cool, dry, coarse, pale)
  4. soft tissues with nonpitting, waxy, dry edema (periorbital edema)
  5. loss of axillary and pubic hair
  6. Hypothermia (core temp <37C)
  7. Cardiovascular alterations (bradycardia)
  8. Hypoventilation --> respiratory collapse
  9. abdominal distension
  10. Delayed DTRs
  11. Precipitant
  12. Hypoglycemia
  13. Hyponatremia

Work-Up

  1. Chem panel (shows hyponatremia)
  2. serum osms
  3. accucheck (may be normal or low)
  4. CBC
  5. cultures
  6. total CK
  7. LFTS
  8. LDH
  9. TSH, FT4, FT3
  10. cortisol level
  11. ABG
  12. ECHO
  13. CXR
  14. EKG

DDx

  1. CHF
  2. Pulmonary Edema
  3. hypoventilation syndromes
  4. hypothermia
  5. Depression/SI
  6. hepatic encephalopathy
  7. shock
  8. CVA

Treatment

  1. Intubation and mechanical ventilation if pt has significant respiratory acidosis, hypercapnia, or hypoxia
  2. IV thyroid replacement
    1. 500-800 mcg of Levothyroxine then 50-100mcg IV qday
    2. consider 10-20mcg q12hrs IV of T3 in younger patients with low cardiovascular risk
  3. Steroid Replacement
    1. 5-10mg/hr IV hydrocortisone
  4. treat associated infections
  5. correct severe hyponatremia and hypoglycemia

passive external rewarming

Disposition

  1. Admit to ICU
  2. get endocrine consult

See Also

Hypothyroidism

Thyroid (General)

Source

Emedicine

Adapted from PANI, Clarke

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