Author: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)

Editor: Brit Long, MD (@long_brit, EM Chief Resident at SAUSHEC, USAF)

Classic presentation: Elderly female with under-treated / undiagnosed hypothyroidism presents to ED during winter month; volume depleted + vasoconstricted, altered mental status

Why do we care? High mortality (30-60%)

How do patients present (clinical diagnosis)

AMS Hypothermia Hypotension

Respiratory Failure Hypoglycemia Hyponatremia

Potential physical exam findings

Hypothermia Sluggish/flat affect Hair loss

Puffy eyes Thin eyebrows Big tongue

Distant heart sounds Bradycardia Hoarse voice

Hypotension Slow RR Obesity

Decreased bowel sounds Nonpitting edema Dry/rough skin

Decreased reflexes

Don’t just make the diagnosis, but identify the etiology

Infection MI Hypoglycemia

Cold environment Hypoxia / hypercapnia Hyponatremia

Trauma Drug(s) CHF

GI bleed Stroke Recent surgery

Burns Medication non-compliance PE

DKA Hypercalcemia

Other diagnoses to consider

Sepsis Hypoglycemia Hyponatremia

Meningitis Hypercarbia Environmental hypothermia

Drug OD CHF Stroke

Adrenal crisis

Management

-ABC

-Passive rewarming

-Dextrose for hypoglycemia

-Hydrocortisone 100mg IV for potential adrenal insufficiency; give prior to thyroid hormone

-Levothyroxine (T4) 100-500 micrograms IV initially (most receive on higher end)

-+/- L-triiodothyronine (T3) 10-20mcg IV; avoid in elderly / CAD as may cause MI or arrhythmia

-Treat concurrent conditions (i.e. infection/ischemia)

-MICU admit

Other valuable tidbits

-Don’t hesitate to initiate sepsis care

-If thyroid labs don’t come back in timely fashion, proceed with thyroid replacement

-CK is often elevated

-Potentially challenging intubation: oropharyngeal edema, macroglossia

-Use US to evaluate for pericardial effusion

-Vasopressors may be ineffective, especially without thyroid hormone replacement

References / Further Reading

– Rosen’s Emergency Medicine, 8th edition

– Harwood-Nuss’ Clinical Practice of Emergency Medicine, 6th edition

– http://www.ncbi.nlm.nih.gov/pubmed/24360319

– http://www.ncbi.nlm.nih.gov/pubmed/24766938

– http://www.ncbi.nlm.nih.gov/pubmed/24766934

– http://www.ncbi.nlm.nih.gov/pubmed/24481020

– http://www.ncbi.nlm.nih.gov/pubmed/20537835

– http://www.ncbi.nlm.nih.gov/pubmed/19857436

– http://www.ncbi.nlm.nih.gov/pubmed/19371530