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

Post a Comment

Popular posts from this blog

2 min read - Cirrhosis

Image
A 55 years old male patient admitted to medical casualty with a febrile illness for 3 days with myalgia. Examination was unremarkable. He was previously well except for chronic bilateral knee joint osteoarthritis. He consumed liquor quarter to half a bottle on a daily basis. Investigations revealed. WBC - 5.6 Hb - 11.2 Plt - 135 AST - 45 ALT - 42 S.Cr - 54 He was managed as viral fever and became fever free the next day. However the platelet count was persistently low around 130. Further investigations arranged. Blood picture - Thrombocytopenia probably due to liver disease S. Bilirubin, ALP - Normal S. Albumin - 38, S globulin - 37 USS abdomen - Coarse echogenicity of liver. Mild portal hypertension. Mild splenomegaly. Compatible with chronic liver cell disease. This patient has Cirrhosis with portal hypertension. Now the obvious cause for his cirrhosis is alcohol, isn't it? NO! Just because of the history of significant alcohol consumption you ca...
Read more

Describing an ECG

Image
Sir, this is a 12 lead ECG of Mr. blah blah. It is correctly calibrated. Heart rate is around 60/min, but there is a slight irregularity. P waves are normal and all p waves are followed by QRS complexes. Therefore, it is in sinus rhythm, and the irregularity is most likely to be due to sinus arrhythmia. The cardiac axis is normal. PR interval is normal. There are small Q waves in inferior and lateral leads. QRS complexes are normal and there is good R wave progression in anterior leads. There are prominent ST elevations in leads II, III and aVF. There are also mild ST elevations in V5 and V6. There is ST segment depression in aVL. T waves are upright and the QT interval appears to be normal. In conclusion, this patient has an ACUTE INFERIOR ST ELEVATION MI with possible lateral extension and reciprocal ECG changes in lead aVL. There is sinus arrhythmia, but no evidence of AV nodal dysfunction. I would like to do V4R and V7-V9 to look for right ventricular and posteri...
Read more