There are no prospective studies on the optimum therapy for patients in myxedema coma; therefore, treatment recommendations are not uniform. However, initial therapy is directed toward stabilization. Patients may require endotracheal intubation and mechanical ventilation for airway protection and correction of hypoventilation, hypercapnia, and hypoxia. Indications for airway intervention are the same as for other conditions (see Chap 15, "Tracheal Intubation and

Mechanical Ventilation"). Correction of hypothermia is directed toward decreasing further heat loss. Cautious use of gentle passive external rewarming should be initiated but care should be taken to avoid hypotension from reversal of a patient's hypothermic vasoconstriction.

Specific therapy includes intravenous levothyroxine, which is recommended by most authors.11 An initial intravenous bolus of levothyroxine (iT§ble..20.Z.:.§) is administered, followed by a reduced daily dose until the patient can take oral medication. This has the advantage of repleting the T 4 pool and allowing the hormone to enter tissues slowly. Other authors suggest that there may be decreased T4 to T3 conversion and subsequently recommend T3 as the initial replacement hormone.

TABLE 207-6 Treatment of Myxedema Coma

Routine administration of glucocorticoid is recommended to avoid the potential of precipitating adrenal crisis in patients with unrecognized adrenal insufficiency or hypothyroidism secondary to hypopituitarism. If possible, a baseline cortisol level should be drawn prior to initiating therapy. Correction of hyponatremia is by means of fluid restriction. Severe hyponatremia has been successfully treated with hypertonic saline administration (see Chap. 23, "Fluids and Electrolyte Problems").

A search for a precipitating etiology must be initiated and aggressively treated. Infection is a common precipitant of myxedema coma. If possible, appropriate cultures should be obtained prior to initiating empiric antibiotic therapy.

All patients with a suspected diagnosis of myxedema coma should be admitted to an appropriately monitored inpatient bed for further evaluation and treatment. CHAPTER REFERENCES

1. Mulder JE: Thyroid disease in women. Med Clin North Am 82:103, 1998.

2. Lindsay RS, Toft AD: Hypothyroidism. Lancet 349:413, 1997.

3. Harja KJ, Licata AA: Effects of amiodarone on thyroid function. Ann Intern Med 126:63, 1997.

4. Waldman SA, Park D: Myxedema coma associated with lithium therapy. Am J Med 87:355, 1989.

5. Sawin CT: Thyroid dysfunction in older persons. Adv Intern Med 37:223, 1991.

6. Helfand M, Redfern CC: Screening for thyroid disease: An update. Position papers: Clinical guideline, Part 2. Ann Int Med 129:144, 1998.

7. Senior RM, Birge SJ, Wessler S, et al: The recognition and management of myxedema coma. JAMA 217:61, 1971.

8. Jordan RM: Myxedema coma: Pathophysiology, therapy and factors affecting prognosis. Med Clin North Am 79:185, 1995.

9. Nicoloff JT, LoPresti JS: Myxedema coma: A form of decompensated hypothyroidism. Endocrinol Metab Clin North Am 22:279, 1993.

10. Tsitouras PD: Myxedema coma. Clin Geriatr Med 11:251, 1995.

11. Singer PA, Cooper DS, Levy EG, et al: Treatment guidelines for patients with hyperthyroidism and hypothyroidism. JAMA 273:808, 1995.

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