A 71 year old males arrives by EMS for altered mental status that began this morning. He resides at an assisted living, where he recently moved three months ago from South Carolina.
His prior medical history is significant for osteoarthritis, hypertension, HFREF (45% EF) secondary to CAD s/p stent two years ago. His medication list includes nicardipine, metoprolol, statins, and aspirin.
Vitals: 88/60, HR: 72, T: 35.1, RR: 12
Initial fingerstick: 55
Physical Exam:
General: Overweight male resting on stretcher; responds yes intermittently to questions; does not follow commands
Head: Atraumatic, edematous face,
Skin: No rashes, no trauma, 2+ pitting edema ankles and hands
Eyes: Spontaneously opens, responds to sternal rub, reflexes 2+
CVS: S1, S2, 1+ bilateral pitting edema ankles, hands
Pulm: decreased breath sounds at bilateral bases
GI: obese abdomen; soft, non-tender, non-distended
Neuro: PERRL, symmetric responsive 3mm pupils
RUSH exam:
No B lines, b/l lung sliding
Trace pericardial fluid, no tamponade physiology
IVC collapsible,
Fluid anterior & posterior to desc. Aorta,
No free fluid Morrison’s, Splenorenal, Bladder
Rest of workup:
Na - 128
Other electrolytes, CBC, & UA - within normal limits
Salicylate/APAP/Utox negative
ABG - 7.38/46/94
TSH/T4: 34/ 0.31,
Random cortisol/CPK - within normal limits
BNP, trop, EKG - within normal limits
ECHO 45% with no regional wall motion abnormality
CXR: bilateral pleural effusions
CT head negative
Blood Culture x2 neg, Urine Culture neg (obtained after admission)
Interventions:
D50 amp
500 ccs lactated ringers
IV hydrocortisone
levothyroxine
norepinephrine gtt
Further history: Outside medication list reveals that the patient was prescribed levothyroxine, but was never re-prescribed dose when moved,
Admitted to MICU, patient regained mental status gradually, weaned off NE, and ultimately discharged.
Take Away #1:
Keep differential for AMS broad: ‘PIE TENT’
Psychiatric, Infectious, Endocrine, Toxicology, Electrolytes, Neuro, Trauma
Take Away #2:
Myxedema Coma/Decompensated hypothyroidism - usually the hypothyroidism is known, but patients just don’t have access or don’t receive their medications.
50% of cases become evident after admission.
Mortality 30-50%; If untreated, mortality approaches 100%.
Diagnosis is suggested by:
AMS – usually not in coma
Presence of hypothermia OR bradycardia
PE findings: loss of lateral 1/3 eyebrow, non-pitting edema
Check TSH, Free T4, random serum cortisol.
If known hypothyroidism and maxed out pressors: consider T4 as may increase MAP/decrease vasopressor requirement
Treatment:
Levothyroxine 200-400 mcg IV Push,
Hydrocortisone 100mg IV (empiric treat adrenal crisis,
send random cortisol before giving hydrocortisone)
T3 (controversial) 5-20 mcg IV; can precipitate arrhythmias
Take Away #3:
Identify Trigger, r/o adrenal crisis , monitor complications
Most common cause: Thyroid supplementation nonadherence – check external medication history
Precipitants include:
Medications – beta blockers, antipsychotics, diuretics
Infection – CXR, BC, UA, LP
MI or HF exacerbation
Monitor complications:
Hypoglycemia, Hyponatremia, Respiratory support (macroglossia), cardiovascular support (tamponade, low BP),
Adrenal insufficiency (stress dose steroids)
James Tavornwattana, MD is a current first year resident at Stony Brook Emergency Medicine.
References:
Edited by Bassam Zahid, MD