Prehospital Care
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. [5]
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.
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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Pericardial effusion. Note the "water-bottle" appearance of the cardiac silhouette.
