EMPOWERING PHYSICIANS WITH EVIDENCE-BASED CONTENT
cart 0 Items $0.00 | STORE | SUBSCRIBE/RENEW LOGIN | REGISTER | CONTACT US
Home Browse Topics Points & Pearls Take CME Tests Editorial Boards About Us Store Subscribe/
Renew

Home > Browse Topics

<< Identifying And Treating Thyroid Storm And Myxedema Coma In The Emergency Department

Disposition

Most patients with myxedema coma or thyroid storm require intensive care admission. Myxedema coma is by definition an alteration in mental status and thus requires admission. Patients require intensive cardiovascular monitoring for worsening of the thyroid crisis as well as for adverse effects of the treatment. Continuous intravenous infusions generally require ICU admission. In addition, mortality rates for myxedema coma and thyroid storm still exceed 20% despite modern therapies. Prognostic factors for those in thyroid storm have not been reported. A number of poor prognostic factors in myxedema coma have been reported in the literature.64,66,134 (See Table 8.).



Although the prognosis of patients with myxedema coma is difficult to determine, case series demonstrate consistently poor predictors of outcome, as reported in the literature, including bradycardia, persistent hypothermia, altered level of consciousness, a high APACHE II score at presentation, hypotension, need for mechanical ventilation, precipitation of myxedema coma by use of sedatives, accompanying sepsis, and baseline and mean SOFA scores greater than or equal to 6. Advanced age was not consistently reported as predictive of increased mortality in myxedema coma when survivors and nonsurvivors were compared.135,136

Patients who are stable, have mild symptoms that improve in the ED, and do not require continuous infusions of cardiovascularly active medications are candidates for admission to a telemetry unit. This is more commonly seen in thyroid storm because of the rapid effects of beta-blocking agents. Myxedema coma patients rarely have an accelerated recovery.

No formal admission or discharge criteria for those with mild to moderate thyroid disease have been reported to the author's knowledge. Patients with clinical signs and symptoms of hypothyroidism may be discharged from the ED for evaluation and treatment by the primary care physician. Patients with minor symptoms of hyperthyroidism, such as subjective palpitations, heat intolerance, anxiety, and weight loss, may be discharged if no signs of cardiac instability are present. Patients with tachycardias that respond to beta-blockers in the ED without other cardiovascular manifestations of thyrotoxicosis are also candidates for discharge from the ED. Patients with atrial fibrillation that is controlled in the ED who have a known diagnosis of hyperthyroidism may be candidates for discharge if appropriate follow-up can be arranged.

Other Articles Similar To This One:

EMplify, the new Emergency Medicine Practice podcast, is now available

 

About EB Medicine:

Products:

Accredited By:

ACCME ACCME
AMA AMA
ACEP ACEP
AAFP AAFP
AOA AOA
AAP AAP

Endorsed By:

AEMAA AEMAA
HONcode HONcode
STM STM

 

Last Modified: 03/27/2017
© EB Medicine