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MYEDEMA COMA
End stage of untreated or insufficiently treated hypothyroidism
Typical clinical picture:
Elderly obese female
Becoming increasingly withdrawn, lethargic, sleepy and confused
Slips into a coma
History:
Previous thyroid surgery
Radioiodine
Default thyroid hormone therapy
Precipitating Events
Cerebrovascular accidents
Myocardial infarction
Infection
UTI
Pneumonia
Gastrointestinal hemorrhage
Acute trauma
Administration of sedative, narcotics,
tranquilizers, potent diuretics
CCF
Pathogenesis of Myxedema coma
Symptoms
Cold intolerance, dry skin
Constipation, weight gain, poor appetite
Neurological-weakness, slow speech,
disorientation ,apathy, psychosis
Symptoms progress to lethargy, disorientation,
grandmal seizures, coma
Physical Findings
Comatose or semi comatose
Dry coarse skin, cold peripheries
Puffy face, hands, feet
Bradycardia
Delayed reflex relaxation time
Hypothermia, hypotension,
hypoventillation
Pericardial, pleural effusions, ascites
GI ileus, urinary retention
Lab Findings
Free T4-low and TSH-high
If TSH-low/N and FT4-low, consider central or
pitutary hypothyroidism.
Blood gases-hypoxemia, hypercapnia, acidosis
Hypoglycemia, hyponatremia
Blood culture, urine culture, CXR
ECG
LFT,RFT
Distinguish from euthyroid sick syndrome
Low T3, Normal or low TSH, normal free T4
Management of Myxedema coma
Parenteral thyroxine
Loading dose of 200 – 500 μg T4, IV over
1 hr
Then 50-100 μg daily until oral intake is
tolerated
Controversy exists as to whether to give T3, in
addition to T4
Treatment
Hypothyroidism IV 200-500 μg loading dose
T4.Then 50-100 μg
Hypocortisolemia IV hydrocortisone 100mg
8hrly
Hypoventillation Intubation, mechanical
ventilation
Hypothermia Blankets, no active methods