1. Thyroid disorder: Emergencies
Dr Hiren Patt
D.M. (Endocrinology)

2. Myxoedema Coma

3. What is Myxoedema Coma? Severe hypothyroidism
Slowing of functions of multiple organs
Medical emergency
High mortality rate (up to 40 %)
Rare nowadays (because of early diagnosis)

4. Coma: Must for Diagnosis ?
Confusion
Lethargy
Obtundation
Drowsiness
Stupor
Coma
Rarely, myxoedema madness (Psychosis)

5. Pathogenesis Old age, female Severe long-standing hypothyroidism
Precipitating factors:
Infection MI
Cold exposure
Sedative drugs

6. Clinical features Decreased mental status Hypothermia Hypoventilation
Bradycardia
Hypotension
Hyponatremia
Hypoglycemia

7. Investigations Total T4/ Free T4 TSH Cortisol ACTH
Before starting any treatment

8. Hypothyroidism + Cortisol deficiency
Primary hypothyroidism: Addison disease
TSH: high
ACTH: high
Secondary hypothyroidism: Panhypopituitarism
TSH: low/normal
ACTH: low/normal

9. Management
If the results for TSH, T4 & Cortisol are delayed, treatment can be started before results
Hydrocortisone dose:
100 mg i.v. stat
100 mg i.v. 8 hourly for 2 days
Tapering dose to minimum required dose
Supportive measures:
ABC
Rx of coexistent illness (e.g. infection)

10. Problems with T4 Rx T4 to T3 conversion: slow
T4 absorption: slow (GI motility: affected)

11. Management T4 + T3 preferred than T4 alone T4 (intravenously)
mcg i.v. stat
mcg i.v./day
Till patient starts taking orally
T3 (intravenously)
5-20 mcg i.v. stat
mcg 8 hourly
Till patient is stable

12. Case 1 60 yrs/F, Altered sensorium: 2 days
Hypoglycemia, but no improvement even after correction
K/c/o: Hypothyroidism: years
Stopped Rx: 1 year
P: 60/min, BP: 80/40 mm Hg

13. Rx: Thyroxine 50 mcg/day &
Biochemistry
Normal range
TSH
0.08
0.4 – 4 T4
0.4
4.5 – 12.5 Na
130
135 – 145
Rx: Thyroxine 50 mcg/day &
referred to us

14. Provisional Diagnosis
Myxoedema crisis with panhypopituitarism
(TSH + ACTH deficiency)
Pituitary Profile:
ACTH, Cortisol, FSH, Prolactin
Inj. Hydrocortisone 100 mg i.v. stat and then 8 hourly started

15. Pituitary Profile Normal range ACTH 6 18-46 S.Cortisol 0.8 5-25 FSH
NDT
> 10
Prolactin
0.2
5-20
MRI: Empty sella

16. Final Diagnosis TSH deficiency ACTH deficiency FSH/LH deficiency
Prolactin deficiency
Myxoedema crisis + Pahypopituitarism

17. Management: Issues T4 & T3 (i.v.): Not available
T4 (oral): Only option
T4: Dose ?

18. Management Tab.Thyroxine (400 mcg) stat through RT
No RT feeds for next 4 hours to improve absorption

19. Management Day Tab.Thyroxine Free T4 (normal range: 0.8-1.8) 1 400 mcg
0.4 2
300 mcg
0.7 3
250 mcg
0.9 4
150 mcg
1.0 5
1.2 6
100 mcg

20. Discharged:
Tab. Thyroxine 100 mcg 1-0-0
Tab. Prednisolone 2.5 mg with stress cover

21. Thyrotoxic crisis

22. Introduction Medical emergency High mortality rate (up to 30 %)
Rare nowadays (due to early diagnosis)

23. Etiology Long standing untreated hyperthyroidism
Precipitating factors:
Trauma
Infection
Surgery (thyroid/non thyroid)
Acute iodine load

24. T3, T4, TSH Required to diagnose hyperthyroidism
Doesn’t differentiate b/w compensated hyperthyroidism & Thyrotoxic crisis

25. Clinical features Tachycardia Nausea/vomiting/abdominal pain
Hepatic failure with jaundice
Hypotension/CHF/Arrythmia
Hyperpyrexia (Temp. upto 104 to 106)
Agitation/psychosis/delirium/stupor/coma

26. Management Beta blockers Methimazole/PTU Iodine solution
Glucocortisoids
Bile acid sequestrants
Supportive measures:
ABC
Rx of coexistent illness (e.g. infection)

27. Beta blockers Propranolol: 60-80 mg every 4-6 hourly
Adjusted by Heart rate/BP
To improve symptoms/signs related to sympathetic overactivity

28. Thionamides Carbimazole: 30 mg every 4-6 hourly Methimazole:
PTU
200 mg every 4 hourly
PTU > Methimazole:
Preferred, because it inhibits conversion of T4 to T3 as well

29. Glucocorticoid Hydrocortisone 100 mg i.v. 8 hourly
Interferes with T4 to T3 conversion
Possibly, halts autoimmune process in Grave’s disease.

30. Iodine solution SSKI: 5 drops every 6 hourly Lugol’s iodine:
Start 1 hour after the thionamide dose

31. How to make SSKI ?
144 gms potasium iodide
100 ml water

32. Iodinated contrast agents
Iopanoic acid
0.5-1 gm/day
Interferes with T4 to T3 conversion
Inhibits release of thyroid hormones from thyroid gland

33. Bile Acid Sequestrants
Cholestryramine
4 gm every 6 hourly
Interferes with enterohepatic circulation & recycling of thyroid hormones

34. Conclusion Thyroid emergencies: rare, but fatal Myxoedema coma:
Can use high dose oral T4
Rule out cortisol deficiency
Thyrotoxic crisis:
comprehensive management with beta blockers, thionamides, iodide, steroids etc.

35. Thanks