Myxedema coma: Difference between revisions
No edit summary |
Ostermayer (talk | contribs) No edit summary |
||
| Line 1: | Line 1: | ||
==Background== | ==Background== | ||
*Hypothyroidism + mental status changes/coma + hypothermia + precipitating stressor<ref>Wall CR. Myxedema coma: diagnosis and treatment. Am Fam Physician. Dec 1 2000;62(11):2485-90.</ref> | |||
*Majority of the patients will be > 60yo<ref>Davis PJ, Davis FB. Hypothyroidism in the elderly. Compr Ther. 1984;10:17–23.</ref> | |||
*Occurs in 0.1% of patients with hypothyroidism | |||
*Mortality may be as high as 60%<ref>Arlot S et al. Myxoedema coma: response of thyroid hormones with oral and intravenous high-dose L-thyroxine treatment. Intensive Care Med. 1991;17:16–8.</ref> | |||
*Coma does not need to be present but there will be a decline in the patient's mental status. Sever hypothyroidism may present with severe decompensated hypothyroidism as the first presentation of undiagnosed hypothyroidism<ref>Nicoloff JT et al. A form of decompensated hypothyroidism. Endocrinol Metab Clin North Am. 1993;22:279–90.</ref> | |||
*The classic myxedematous face, which is characterized by generalized puffiness, macroglossia, ptosis, periorbital edema may not be present, but other signs such as a palpaple goiter and thyroid medication use will help in suspecting the diagnosis. | |||
===Precipitants=== | ===Precipitants=== | ||
# | #[[Sepsis]] | ||
#Bradycardia and hypothermia | |||
#Cold exposure | #Cold exposure | ||
#Trauma | #Trauma | ||
| Line 15: | Line 18: | ||
#Metabolic conditions ([[hypoxia]], [[hypercapnia]], [[hyponatremia]], [[hypoglycemia]]) | #Metabolic conditions ([[hypoxia]], [[hypercapnia]], [[hyponatremia]], [[hypoglycemia]]) | ||
#Burns | #Burns | ||
#Meds: B-blockers, sedatives, narcotics, phenothiazine, amiodarone | #Meds: B-blockers, sedatives, narcotics, phenothiazine, amiodarone<ref>Mazonson PD et al. Myxedema coma during long-term amiodarone therapy. Am J Med. 1984;77:751–4.</ref> | ||
#Medication non-compliance (thyroid meds) | #Medication non-compliance (thyroid meds) | ||
==Diagnosis== | ==Diagnosis== | ||
===Hypothermia=== | |||
*Temperature <35.5°C (95.9°F). | |||
===Cardiovascular=== | |||
*[[Bradycardia]] | |||
*[[Hypotension]] | |||
===Pulmonary=== | |||
*Hypoventilation | |||
**Early respiratory support with intubation is necessary to prevent respiratory collapse | |||
*[[Hypercapnia]] | |||
**There is often diaphragmatic dysfunction that causes worsening hypoventilation. The dysfunction is reversed after thryroid hormone administration<ref>Martinez FJ et al. Hypothyroidism. A reversible cause of diaphragmatic dysfunction. Chest. 1989;96:1059–63.</ref> | |||
*[[Pleural Effusion]] | |||
*Upper airway obstruction from glottic edema, vocal cord edema, and macroglossia can complicate intubation. | |||
===Neurologic=== | |||
*[[AMS]]/[[Coma]] | |||
==Work-Up== | ==Work-Up== | ||
| Line 43: | Line 47: | ||
#CXR | #CXR | ||
#EKG | #EKG | ||
==Lab Abnormalities== | |||
*Abnormal Thyroid Hormone Levels | |||
**In primary hypothyroidism then TSH will be elevated and T4 and T3 will be low | |||
**If the patient has secondary hypothroidism (Pituitary dysfunction) the TSH can be low or normal and T4 and T3 will be low | |||
*[[Anemia]] | |||
*[[Rhabdomyolysis|Elevated CPK]] | |||
*[[Renal Failure|Elevated creatinine]] | |||
*Elevated transaminases | |||
*[[Hypercapnia]] | |||
*Hyperlipidemia | |||
*[[Hypoglycemia]] | |||
*[[Hyponatremia]] | |||
*[[Hypoxia]] | |||
*Leukopenia | |||
*Respiratory acidosis | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
| Line 56: | Line 76: | ||
==Treatment== | ==Treatment== | ||
===Respiratory Support=== | |||
*Early mechanical ventilation will prevent resipatory collapse and severe respiratory acidosis. | |||
===Fluid Resuscitation=== | |||
*Patients are often intravsascularly depleted and have an underlying infection mandating agressive fluid resususcitation | |||
*In patients who are hyponatremia, be cautious with rapid correction of hyponatremia and choose an appropriate fluid | |||
*Hypoglycemic patients will require intravenous dextrose added into the fluids | |||
===Hypotension=== | |||
*[[Vasopressors]] will be ineffective without concomitant thyroid hormone replacement | |||
===Hormone Replacment=== | |||
*'''Hydrocortisone''' 100mg q8hr IV since there is also adrenal insufficiency present | |||
*'''Levothyroxine (T4)''' (generally agreed upon first line therapy) | |||
**Dose: 100 to 500 mcg (4mcg/kg IV) followed by 75 to 100 mcg administered IV daily until the patient takes oral replacement.<ref>Smallridge RC. Metabolic and anatomic thyroid emergencies: a review. Crit Care Med. 1992;20:276–91</ref> | |||
**Does require extrathyroidal conversion which can be reduced in myxedema but will have a slow steady onset of action and potentially safer in patients with coronary artery disease (CAD). | |||
*'''T3''' | |||
*Dose: 20mcg IV followed by 10mcg q8hr (Start with 10mcg if elderly or has CAD) | |||
*Does not require extrathyroidal conversion and has more rapid onset but may be harmful in patients with severe coronary artery disease. | |||
===Hypothermia=== | |||
*Treat with passive rewarming | |||
*Hypothermia will also reverse with thryoid hormone administration | |||
==Disposition== | ==Disposition== | ||
| Line 99: | Line 108: | ||
==Source== | ==Source== | ||
<references/> | |||
[[Category:Endo]] | [[Category:Endo]] | ||
Revision as of 21:15, 1 February 2015
Background
- Hypothyroidism + mental status changes/coma + hypothermia + precipitating stressor[1]
- Majority of the patients will be > 60yo[2]
- Occurs in 0.1% of patients with hypothyroidism
- Mortality may be as high as 60%[3]
- Coma does not need to be present but there will be a decline in the patient's mental status. Sever hypothyroidism may present with severe decompensated hypothyroidism as the first presentation of undiagnosed hypothyroidism[4]
- The classic myxedematous face, which is characterized by generalized puffiness, macroglossia, ptosis, periorbital edema may not be present, but other signs such as a palpaple goiter and thyroid medication use will help in suspecting the diagnosis.
Precipitants
- Sepsis
- Bradycardia and hypothermia
- Cold exposure
- Trauma
- MI
- CHF
- CVA
- GI bleed
- Metabolic conditions (hypoxia, hypercapnia, hyponatremia, hypoglycemia)
- Burns
- Meds: B-blockers, sedatives, narcotics, phenothiazine, amiodarone[5]
- Medication non-compliance (thyroid meds)
Diagnosis
Hypothermia
- Temperature <35.5°C (95.9°F).
Cardiovascular
Pulmonary
- Hypoventilation
- Early respiratory support with intubation is necessary to prevent respiratory collapse
- Hypercapnia
- There is often diaphragmatic dysfunction that causes worsening hypoventilation. The dysfunction is reversed after thryroid hormone administration[6]
- Pleural Effusion
- Upper airway obstruction from glottic edema, vocal cord edema, and macroglossia can complicate intubation.
Neurologic
Work-Up
- Chemistry
- CBC
- TSH, FT4, FT3
- Cultures
- LFT
- Cortisol level
- VBG
- CXR
- EKG
Lab Abnormalities
- Abnormal Thyroid Hormone Levels
- In primary hypothyroidism then TSH will be elevated and T4 and T3 will be low
- If the patient has secondary hypothroidism (Pituitary dysfunction) the TSH can be low or normal and T4 and T3 will be low
- Anemia
- Elevated CPK
- Elevated creatinine
- Elevated transaminases
- Hypercapnia
- Hyperlipidemia
- Hypoglycemia
- Hyponatremia
- Hypoxia
- Leukopenia
- Respiratory acidosis
Differential Diagnosis
Treatment
Respiratory Support
- Early mechanical ventilation will prevent resipatory collapse and severe respiratory acidosis.
Fluid Resuscitation
- Patients are often intravsascularly depleted and have an underlying infection mandating agressive fluid resususcitation
- In patients who are hyponatremia, be cautious with rapid correction of hyponatremia and choose an appropriate fluid
- Hypoglycemic patients will require intravenous dextrose added into the fluids
Hypotension
- Vasopressors will be ineffective without concomitant thyroid hormone replacement
Hormone Replacment
- Hydrocortisone 100mg q8hr IV since there is also adrenal insufficiency present
- Levothyroxine (T4) (generally agreed upon first line therapy)
- Dose: 100 to 500 mcg (4mcg/kg IV) followed by 75 to 100 mcg administered IV daily until the patient takes oral replacement.[7]
- Does require extrathyroidal conversion which can be reduced in myxedema but will have a slow steady onset of action and potentially safer in patients with coronary artery disease (CAD).
- T3
- Dose: 20mcg IV followed by 10mcg q8hr (Start with 10mcg if elderly or has CAD)
- Does not require extrathyroidal conversion and has more rapid onset but may be harmful in patients with severe coronary artery disease.
Hypothermia
- Treat with passive rewarming
- Hypothermia will also reverse with thryoid hormone administration
Disposition
- Admit to ICU
- Endocrine consult
See Also
Source
- ↑ Wall CR. Myxedema coma: diagnosis and treatment. Am Fam Physician. Dec 1 2000;62(11):2485-90.
- ↑ Davis PJ, Davis FB. Hypothyroidism in the elderly. Compr Ther. 1984;10:17–23.
- ↑ Arlot S et al. Myxoedema coma: response of thyroid hormones with oral and intravenous high-dose L-thyroxine treatment. Intensive Care Med. 1991;17:16–8.
- ↑ Nicoloff JT et al. A form of decompensated hypothyroidism. Endocrinol Metab Clin North Am. 1993;22:279–90.
- ↑ Mazonson PD et al. Myxedema coma during long-term amiodarone therapy. Am J Med. 1984;77:751–4.
- ↑ Martinez FJ et al. Hypothyroidism. A reversible cause of diaphragmatic dysfunction. Chest. 1989;96:1059–63.
- ↑ Smallridge RC. Metabolic and anatomic thyroid emergencies: a review. Crit Care Med. 1992;20:276–91