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MYXEDEMA COMA

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 Becoming increasingly withdrawn, lethargic, sleepy and confused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

 ICU admission is required for


ventilatory support, continuous
close monitoring of pulmonary and
cardiac status
 IV medications
General & supportive
1. ABC
2. IV access-large bore 18 guage
3. Fluid replacement
 isotonic crystalloid solutions like NS/RL
 Avoid hypotonic solutions
 Avoid vasopressors-risk of dysrythmia

4. Treatment of hypothermia-corrected once


T4 is administered
 Treatment of hypoglycemia -50% Dextrose
initially. Then 5%Dextrose infusion in
NS/RL
 Glucocorticoids-Hydrocortisone Na
phosphate/succinate 100mg every 8hrs for
48hrs.Then taper over 1 week
 Treat the precipitating cause
Specific Therapy

 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

 Hyponatremia  Cautious fluid replacement

 Hypotension  Volume expansion-crystalloids


 Dextrose
 Hypoglycemia
Prognosis
 When recognized & treated early, mortality is
15-20%, and is mostly due to underlying and
precipitating diseases.
 If not recognized early, mortality is 60-70%,
especially in elderly.
Thank you

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