myxedema coma

History

  • personal or family hx of autoimmune disease
  • Grave's disease hx
  • recent pregnancy
  • medications: amiodarone, lithium
  • Hx of brain surgery, pituitary surgery, head trauma
  • trigger: any stress, infection/MI

Sx

  • AMS: slow or psychosis
  • hypothermia
  • slowed organ function
  • non pitting edema everywhere
  • pericardial effusion
  • heart block
  • bowel edema/constipation: distended abd
  • slowed reflex
  • hyponatremia
  • hypoglycemia

Labs

  • TSH, free T4, total T3
  • cortisol, ACTH

Treatment

  • IV levothyroxine (T4): 200 mcg followed by 75% of patient's weight based dosing
    • do not use T3, contrary to uptodate recs
    • avoid for tachycardia. If stable, go back to PO dosing
  • stress dose steroids: steroids and cortisol
    • continue until ruled out adrenal insufficiency
  • supportive care
    • fluids, pressors
    • vent
    • pacing
    • empiric abx