This handout is for cardiac tamponade — myxedema-related pericardial effusion. Your care team identified this based on: severe hypothyroid features (cold intolerance, weight gain, lethargy, constipation, hoarse voice, periorbital edema, dry skin, bradycardia) + dyspnea + jvd → consider myxedema effusion (klein nejm 2007 pmid 17314344).
Other reasons your team may use this plan: echo: large pericardial effusion (often >2 cm, occasionally 1-2 l) without tamponade physiology in patient with myxedema features — chronic accumulation allows pericardial stretch (spodick compliance curve); known hypothyroidism off levothyroxine for months/years or post-thyroidectomy/rai lost to follow-up + pericardial effusion (ata 2014 pmid 25266247); myxedema coma (altered mental status, hypothermia, bradycardia, hypoventilation) + pericardial effusion → critical care emergency with thyroid + adrenal coverage (wartofsky).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| levothyroxine | 200-500 µg IV LOAD (200 elderly/CV; 500 young+healthy) → 50-100 µg IV daily | IV | load + daily | Wartofsky myxedema coma protocol — IV bioavailability ~70% PO; transition to PO once tolerated; T4 → T3 conversion preferred over direct T3 in severe disease + cardiovascular caution per ATA 2014 |
| liothyronine | 5-20 µg IV q8h (5 elderly/CV; 20 young+healthy) | IV | q8h × 24-48h then per response | Wartofsky controversial adjunct — faster onset than T4 but higher cardiovascular toxicity risk; reserved for severe coma per endocrinology decision |
| hydrocortisone | 100 mg IV q8h × 24-48h then taper if cosyntropin negative | IV | q8h | Wartofsky — empiric coverage MUST precede full levothyroxine because increased cortisol metabolism with thyroid replacement can precipitate adrenal crisis if AI present; 5-10% concurrent AI in myxedema (Schmidt syndrome, autoimmune polyglandular) |
| normal saline | 500 mL bolus then maintenance | IV | cautious bolus + maintenance | NS preferred over D5W in myxedema due to hyponatremia risk; avoid rapid correction (Wartofsky) |
| norepinephrine | 0.05-0.1 µg/kg/min titrate to MAP ≥65 | IV | continuous | Bridge in shock physiology; consider concurrent adrenal insufficiency, true tamponade, sepsis as shock contributors (Wartofsky) |
| glucose 50% | 25-50 mL D50 IV | IV | bolus per hypoglycemia | Hypoglycemia common in severe hypothyroidism + concurrent AI (Wartofsky) |
| magnesium sulfate | 2-4 g IV slow | IV | PRN | Bradycardia + prolonged QT in myxedema increases torsades risk; Mg replacement standard arrhythmia prophylaxis (Klein NEJM 2007) |
Plan: Myxedema-related pericardial effusion — levothyroxine load + hydrocortisone empiric coverage + supportive care + pericardiocentesis ONLY if true tamponade (rare given chronic accumulation) (ATA 2014 PMID 25266247; Wartofsky; Klein NEJM 2007 PMID 17314344)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Guideline: 2014 ATA Hypothyroidism Guideline (Jonklaas Thyroid 2014 PMID 25266247) anchors levothyroxine replacement strategy + cautious approach in cardiovascular disease; Klein I, Danzi S — Thyroid Disease and the Heart (NEJM 2007 PMID 17314344) anchors hypothyroid cardiomyopathy + effusion epidemiology + ECG features; Wartofsky L — Myxedema Coma (Endocrinol Metab Clin 2006 + updates) anchors myxedema coma protocol with adrenal coverage strategy; 2015 ESC Guidelines for pericardial diseases (Adler EHJ 2015 PMID 26320112) anchors pericardial drainage + ECG/echo baseline; 2016 Endocrine Society/AACE adrenal insufficiency guideline anchors concurrent AI management with empiric hydrocortisone before cosyntropin stimulation.