ENDOCRINE
HYPOTHYROID
PromptCauses of hypothyroidism
ResponsePrimary:
Autoimmune/hashimotos
Iatrogenic (Radiation, surgery, drugs)
Transient (subacute thyroiditis, Post partum)
Low iodine
Secondary - Pituitary failure/tumour
Tertiary - Hypothalamic failure
Autoimmune/hashimotos
Iatrogenic (Radiation, surgery, drugs)
Transient (subacute thyroiditis, Post partum)
Low iodine
Secondary - Pituitary failure/tumour
Tertiary - Hypothalamic failure
PromptMYXOEDEMA COMA
ResponseOld person, confusion, lethargy, hypothermia. Diagnosis often given in stem.
Impaired consciousness, hypoventilation, hypothermia
Impaired consciousness, hypoventilation, hypothermia
PromptClinical features of myxoedema coma
ResponseCVS - Hypotension, Bradycardia, Pericardial effusion (signs of this, muffled heart sounds etc)
Resp - Hypoventilation, Pleural effusion
General - Puffiness of hands/face, tongue enlargement, Non pitting peripheral oedema
Alopecia
Neuro - slow reflexes, peripheral neuropathy, psychosis, Carpal tunnel/other nerve entrapment signs
GUT - Retention
GIT - Ileus/pseudoobstruction
Shivering without hypothermia
Hyponatraemia
Resp - Hypoventilation, Pleural effusion
General - Puffiness of hands/face, tongue enlargement, Non pitting peripheral oedema
Alopecia
Neuro - slow reflexes, peripheral neuropathy, psychosis, Carpal tunnel/other nerve entrapment signs
GUT - Retention
GIT - Ileus/pseudoobstruction
Shivering without hypothermia
Hyponatraemia
PromptDifferential of myxodema coma
ResponseNeurological - ICH/Seizure
Endocrine - Adrenal insufficiency
Infective - Sepsis, mengoencephalitis
Environmental - hypothermia
Toxolocial - opioids, barbituates, valproate overdose
Endocrine - Adrenal insufficiency
Infective - Sepsis, mengoencephalitis
Environmental - hypothermia
Toxolocial - opioids, barbituates, valproate overdose
PromptTriggers for myxoedema coma
ResponseMedication non compliance, medication changes
Hypothermia
Infection - Pneumonia >UTI>Cellulitis
CVA
MI
Trauma
Meds - Amiodarone, lithium, anaesthetic agents, diuretics
Note: basically the same list as triggers for hyperthyroid!
Hypothermia
Infection - Pneumonia >UTI>Cellulitis
CVA
MI
Trauma
Meds - Amiodarone, lithium, anaesthetic agents, diuretics
Note: basically the same list as triggers for hyperthyroid!
PromptInvestigations/biochemical abnormalities in myxoedema coma
ResponseHyponatraemia
Hypoglycaemia
Hypercapnoea, hypoxia
Renal impairment (Raised urea/creatinine)
Low cortisol
Bloods consistent with trigger (eg. troponin with MI but needs to be well justified)
Hypoglycaemia
Hypercapnoea, hypoxia
Renal impairment (Raised urea/creatinine)
Low cortisol
Bloods consistent with trigger (eg. troponin with MI but needs to be well justified)
PromptManagement of myxoedema coma
ResponseReplace Thyroid hormones (T4+T3)
- Levothyroxine (T4) 300 mics slow IVI then 1.2mics/kg/daily
- Liothyonine (T3) - 20 mics slow IVI BD
- Convert to PO once no intestinal pseudoobstruction
- Note T3 peaks early, T4 peaks at 2 weeks
- Hydrocortisone 100 mics QID (An hour prior to T4)
- Fluid imbalance
- IV fluid replacement
- +/- inotropes (norad) - but may cause paradoxic worsening of BP
- Electrolyte replacement
- Passive rewarming
PromptWhy do you give steroids in myxoedema coma
ResponseUnlike hyperthyroidism which is typically a primary thyroid issue, hypo is usually central - so likely to have concurrent adrenal insufficiency as well