BOF: 3.38
A 75-year-old female has been admitted as an emergency
having been found collapsed on the floor at home. She is known to have
hypothyroidism but the bottle of tablets found by the ambulance crew appears
unopened.
On examination she is drowsy, has a core temperature of
30oC. Her pulse rate is
40 beats per minute and blood pressure 90/60. There are fine inspiratory
crepitations at the left base of her lungs.
ECG shows sinus bradycardia with low voltage complexes.
In this patient your most important course of action
would be:
a)
Rapid infusion of intravenous saline
b)
Bolus of 50 % dextrose 50 mls intravenously
c)
Rapid external rewarming
d)
Intravenous broad spectrum antibiotics after taking blood cultures
e)
Intravenous thyroxine
Answer: e)
The patient has myxoedema coma. This is caused by
decompensation of undiagnosed or poorly controlled hypothyroidism. The fact
that the bottle of tablets was unopened suggests the patient was
non-compliant with treatment.
The main features of myxoedema coma are hypothermia,
altered mental state and the presence of a precipitating cause. In this case
the patient has left basal pneumonia as a precipitating cause.
Where treatment is concerned this is an emergency
situation and one should not await blood tests to confirm the diagnosis.
Intravenous thyroxine should be used.
Care should be taken about fluid resuscitation, as
these patients may be fluid overloaded.
Rapid external rewarming may cause cardiovascular
collapse and gradual rewarming with space blankets should be instituted.
Broad-spectrum antibiotics should be used after taking
cultures and intravenous steroids would be necessary as well.
However, the question is regarding your most important
course of action and hence the answer is giving intravenous thyroxine
Revision Tip
Revise hypothyroidism KEYS to
SUCCESS in Medicine page 27-28
