Myxedema Coma — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Decompensated severe hypothyroidism?
   Decompensated severe hypothyroidism (altered consciousness + hypothermia + trigger)? (Decompensated severe hypothyroidism. Triad: altered consciousness + hypothermia + trigger (infection, cold, MI, sedatives, missed levothyroxine, surgery); with bradycardia, hypotension, hyponatremia, hypoglycemia, hypoventilation. >95% primary (raised TSH, low FT4). Treat empirically, do not wait for all labs.)
   • Meets it (myxedema coma) → Confirmed → hormones + support
   • Does not fit → Does not fit
2. [End] Does not fit
   Evaluate other causes of altered consciousness/hypothermia (sepsis, intoxication, hypoglycemia, cerebrovascular disease, adrenal crisis, etc.) along the appropriate pathway.
3. [End] Confirmed → hormones + support
   ICU, empiric: 1) hydrocortisone 100 mg IV q8h, before thyroid hormone (to prevent precipitating adrenal crisis; draw cortisol first). 2) Thyroid hormone: IV levothyroxine T4 loading 200–400 µg → maintenance 50–100 µg/day; in the critically ill / no response at 24 h, add T3 (cautiously in cardiac disease, risk of arrhythmia/ischemia). 3) Support: passive rewarming (blankets, not rapid rewarming which causes hypotension), cautious fluids (NS ± dextrose, prevent CHF), correct hyponatremia (hypertonic saline if severe) and hypoglycemia, vasopressors for refractory hypotension, mechanical ventilation if needed. 4) Find and treat the trigger (empiric antibiotics if infection suspected). Endocrinology consult.

Source guidelines & references

• Management of myxedema coma (ATA hypothyroidism guideline; Endotext; EMCrit)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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