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Hypothyroidism and Myxedema Coma Treatment & Management

  • Author: Erik D Schraga, MD; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
 
Updated: Dec 11, 2015
 

Prehospital Care

Stabilize acute life-threatening conditions in patients with hypothyroidism, and initiate supportive therapy.

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Emergency Department Care

Patients with myxedema coma may present in extremis; implement initial resuscitative measures, including intravenous (IV) access, cardiac monitoring, and oxygen therapy, as indicated. Mechanical ventilation is indicated for patients with diminished respiratory drive or obtundation.

Evaluate for life-threatening causes of altered mental status (eg, bedside glucose, pulse oximetry).

If myxedema coma is suspected on clinical impression, start IV thyroid hormone treatment.

Confirmatory tests often are not available to an ED physician.

With a diagnosis of myxedema coma, initiate hormonal therapy.

Myxedema coma may lead to profound hemodynamic instability and airway compromise. Emergency physicians should anticipate a potentially difficult airway in patients with myxedema coma.[7]

Investigate immediately for inciting events such as infection.

Treat respiratory failure with appropriate ventilatory support. The condition often requires mechanical ventilation. Treat underlying pulmonary infection.

Hypotension may respond to crystalloid infusion. Occasionally, vasopressive agents are required. In refractory cases, hypotension may resolve with thyroid hormone replacement.

Treat hypothermia. Most patients with myxedema coma respond to passive rewarming measures such as blankets and removal of cold or wet clothing; aggressive rewarming may lead to peripheral vasodilatation and hypotension. However, hemodynamically unstable patients with profound hypothermia require active rewarming measures. Treat hyponatremia initially with water restriction; however, if sodium levels are less than 120 mEq/L or any seizures occur, hypertonic saline is indicated.

Avoid medications such as sedatives, narcotics, and anesthetics. Metabolism of these agents may be slowed significantly, causing prolonged effects.

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Consultations

For patients with myxedema coma, consult a critical care intensivist regarding admission to an ICU and optimization treatment.

An endocrinologist should be consulted to help confirm the diagnosis and assist in patient management after admission.

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Contributor Information and Disclosures
Author

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Howard A Bessen, MD Professor of Medicine, Department of Emergency Medicine, University of California, Los Angeles, David Geffen School of Medicine; Program Director, Harbor-UCLA Medical Center

Howard A Bessen, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Chief Editor

Romesh Khardori, MD, PhD, FACP Professor of Endocrinology, Director of Training Program, Division of Endocrinology, Diabetes and Metabolism, Strelitz Diabetes and Endocrine Disorders Institute, Department of Internal Medicine, Eastern Virginia Medical School

Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, Endocrine Society

Disclosure: Nothing to disclose.

Acknowledgements

Jerome FX Naradzay, MD, FACEP Medical Director, Consulting Staff, Department of Emergency Medicine, Maria Parham Hospital; Medical Examiner, Vance County, North Carolina

Jerome FX Naradzay, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References
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Pericardial effusion. Note the "water-bottle" appearance of the cardiac silhouette.
 
 
 
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