From the Guidelines
Patients with suspected myxedema coma should be immediately transferred to a hospital for emergency treatment, as it is a life-threatening emergency requiring admission and a high level of care 1. The parameters that warrant hospitalization include severe hypothyroidism with altered mental status (confusion, lethargy, or coma), hypothermia (temperature below 95°F or 35°C), bradycardia, hypotension, hyponatremia, hypoglycemia, hypercapnia, or respiratory failure. Additional concerning signs include:
- Significant edema, especially facial and periorbital
- Delayed reflexes
- Seizures Any patient with these symptoms, especially in the context of known hypothyroidism, recent thyroid medication discontinuation, or precipitating factors like infection, cold exposure, trauma, or certain medications (sedatives, opioids, anesthetics), should be urgently hospitalized. Treatment should not be delayed for laboratory confirmation, as myxedema coma has a high mortality rate (30-60%) 1. Initial management includes:
- Intravenous levothyroxine (usually 300-500 mcg loading dose, followed by 50-100 mcg daily)
- Intravenous hydrocortisone (100 mg every 8 hours until adrenal insufficiency is ruled out)
- Supportive care including mechanical ventilation if needed, careful fluid management, passive warming, and treatment of precipitating factors. Early recognition and aggressive treatment are essential for improving survival in this life-threatening medical emergency 1.
From the FDA Drug Label
Myxedema coma is usually precipitated in the hypothyroid patient of long standing by intercurrent illness or drugs such as sedatives and anesthetics and should be considered a medical emergency.
The parameters to send a patient to the hospital for myxedema coma include:
- Intercurrent illness in a hypothyroid patient
- Use of sedatives or anesthetics in a hypothyroid patient
- Severe and prolonged hypothyroidism with decreased level of adrenocortical activity
- Signs or symptoms of thyroid hormone deficiency, such as chest pain, increased pulse rate, palpitations, excessive sweating, heat intolerance, nervousness, or any other unusual event 2 It is essential to consider myxedema coma as a medical emergency and provide prompt treatment, including simultaneous administration of glucocorticoids 2.
From the Research
Parameters for Sending a Patient to Hospital for Myxedema Coma
The following parameters indicate the need to send a patient to the hospital for myxedema coma:
- Altered mental status 3, 4, 5, 6, 7
- Hypothermia 3, 4, 5, 6, 7
- Hypotension 3, 4, 5
- Bradycardia 3, 4, 5
- Hyponatremia 4, 5
- Respiratory failure 4
- Multisystem organ dysfunction 4, 6
- Precipitating factors such as infection, cardiac issues, or other stressors 5, 6
Clinical Presentation
Patients with myxedema coma may exhibit:
- Dry skin 6
- Coarse hair 6
- Non-pitting edema 6
- Fatigue, weight gain, constipation, and cold intolerance (common symptoms of hypothyroidism) 5
Importance of Early Recognition and Treatment
Myxedema coma is a life-threatening condition with high mortality rates, emphasizing the need for prompt recognition and aggressive management 4, 6. Early treatment, including intravenous levothyroxine and hydrocortisone, can improve outcomes 4, 5.