2 min read - Myxedema Coma


A 75 years old lady was brought to the medical casualty ward semiconscious. Her consciousness had deteriorated over the preceding 3 days. There was no history of fever.

On examination, she was overweight and had generalized edema. The pulse rate was 46/min and blood pressure was 80/50mmHg. There were bilateral basal crepitations.


RBS was 130mg/dl.





A bolus of IV normal saline was given, but there was no improvement of blood pressure. She was given several boluses of atropine but the response was transient and blood pressure didn't improve.



What are the possibilities?

 In a bradycardic patient coming with a reduced level of consciousness, apart from the usual differentials such as myocardial infarction, you should always suspect less common causes. Some of them are,

1. Myxedema coma
2. Beta-blocker poisoning
3. Calcium channel blocker poisoning
4. Organophosphate poisoning


What features would suggest the diagnosis of myxedema coma?

 Their appearance itself will be diagnostic. They will be hypothermic and edematous. You will be able to elicit all the other features of hypothyroidism as well. (https://day2daymedicine.blogspot.com/2019/09/1-min-read-lady-with-multiple.html)

Picture from internet

Make sure to take a history and do the relevant examination to exclude the possibility of poisoning.


Is it a serious condition?

 Why not! The mortality rate can go up to 50%.



What are the treatment principles?

 1. Stabilize the airway. Respiration may be severely compromised. Remember, the intubation may be extremely difficult. Always get experts to help. Correct hypotension with isotonic fluids and inotropes if necessary. Remember they may have pericardial effusions!

2. Try to warm the patient with blankets.

3. Arrange urgent basic investigations including blood sugar, arterial blood gas, and cultures. Also, arrange CPK and S. Creatinine to look for rhabdomyolysis and AKI.

4. Take blood samples for Thyroid profile and Cortisol before starting specific treatment.

5. Start IV hydrocortisone 100mg 6-8hourly before starting thyroxine. Read why!

6. The recommended thyroxine dose is 200-400ug IV, but as IV thyroxine is not widely available here in SL, give 400-500ug of thyroxine through a NG tube.

7. Give empiric broad-spectrum antibiotics.

8. Look for hyponatremia, prevent worsening by avoiding hypotonic fluids. It will get corrected with thyroxine administrations. Take experts' help before attempting to actively correct hyponatremia.

9. Closely monitor the ECG and hemodynamic parameters as there is a high risk of patients developing arrhythmias and myocardial infarctions with thyroxine treatment.

10. From the next day continue the maintenance dose of thyroxine.



Acknowledgment: Dr. Sonali Gunatilake, Consultant Endocrinologist.


Comments

  1. NirodhaOctober 12, 2019 at 9:58 PM

    1. hypothyroid features, respiratory rate, temperature for hypothyroid emergency features

    ReplyDelete
  2. UnknownOctober 18, 2019 at 9:44 PM

    Great explanation. Two things to add - check CK (Rabdomyolysis) and Creatinine (ARF).

    ReplyDelete

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