Myxedema coma

Revision as of 19:41, 15 July 2011 by Ckim (talk | contribs) (→‎See Also)

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