Hypothyroidism and Myxedema Coma Treatment & Management
- Author: Erik D Schraga, MD; Chief Editor: Romesh Khardori, MD, PhD, FACP more...
Stabilize acute life-threatening conditions in patients with hypothyroidism, and initiate supportive therapy.
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.
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.
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.
Dubbs SB, Spangler R. Hypothyroidism: causes, killers, and life-saving treatments. Emerg Med Clin North Am. 2014 May. 32 (2):303-17. [Medline].
[Guideline] Screening for congenital hypothyroidism: US Preventive Services Task Force reaffirmation recommendation. Ann Fam Med. 2008 Mar-Apr. 6(2):166. [Medline].
Teng W, Shan Z, Teng X, Guan H, et. al. Effect of iodine intake on thyroid diseases in China. N Eng J Med. Jun 2006. 354(26):2783-2793. [Medline].
Popoveniuc G, Chandra T, Sud A, Sharma M, Blackman MR, Burman KD, et al. A diagnostic scoring system for myxedema coma. Endocr Pract. 2014 Aug. 20 (8):808-17. [Medline].
Lee CH, Wira CR. Severe angioedema in myxedema coma: a difficult airway in a rare endocrine emergency. Am J Emerg Med. 2009 Oct. 27(8):1021.e1-2. [Medline].
Sanda S, Newfield RS. A child with pericardial effusion and cardiac tamponade due to previously unrecognized hypothyroidism. J Natl Med Assoc. Dec 2007. 99(12):1411-3. [Medline].
Ragland G. Hypothyroidism and myxedema coma. Tintinalli JE, Krome RL, et al, eds. Emergency Medicine: A Comprehensive Study Guide. 4th ed. New York, NY: McGraw-Hill; 1996. 964-67.
Unuane D, Tournaye H, Velkeniers B, Poppe K. Endocrine disorders & female infertility. Best Pract Res Clin Endocrinol Metab. 2011 Dec. 25(6):861-73. [Medline].
Flynn RW, MacDonald TM, Morris AD. The thyroid epidemiology, audit, and research study: thyroid dysfunction in the general population. J Clin Endocrinol Metab. 2004 Aug. 89(8):3879-84. [Medline].
Franklyn JA. The management of hyperthyroidism. N Engl J Med. 1994 Jun 16. 330(24):1731-8. [Medline].
Hehrmann R. [Coma in myxedema--a rare complication of hypothyroidism. Possible iatrogenic factors should be taken into account]. Fortschr Med. 1996 Dec 10. 114(34):474-8. [Medline].
Kinuya S, Michigishi T, Tonami N, et al. Reversible cerebral hypoperfusion observed with Tc-99m HMPAO SPECT in reversible dementia caused by hypothyroidism. Clin Nucl Med. 1999 Sep. 24(9):666-8. [Medline].
Menendez CE, Rivlin RS. Thyrotoxic crisis and myxedema coma. Med Clin North Am. 1973 Nov. (6):1463-70. [Medline].
Rimar D, Kruzel-Davila E, Dori G, Baron E, Bitterman H. Hyperammonemic coma--barking up the wrong tree. J Gen Intern Med. Apr 2007. 22(4):549-52. [Medline].
Roberts CG, Ladenson PW. Hypothyroidism. Lancet. 2004 Mar 6. 363(9411):793-803. [Medline].
Smith SA. Commonly asked questions about thyroid function. Mayo Clin Proc. 1995 Jun. 70(6):573-7. [Medline].