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endo.myxedema-coma.core.v1

Myxedema coma

endocrinologyacuteadultacuteinpatient
Start encounter →Print handoutPRODUCTION

No problem-package folder under src/lib/tier3/problem-package/packages/ for myxedema coma — design brief + atoms have not been authored yet. Manifest references calc_popoveniuc_myxedema_score / calc_news2 / calc_corrected_na / calc_free_water_deficit which are not yet in clinical-tools-registry.ts; mapped to closest available calc.qsofa + calc.na_correction. Regimen_axes empty — hydrocortisone + T4 ± T3 + supportive drugs run via insulin-dosing/fluid services but no structured myxedema-specific regimen builder.

Entry points (4)

  • symptom
    AMS + hypothermia + bradycardia (ETA 2018 consensus; Wall JCEM 2000)
    altered_mental_status
  • vital_abnormality
    Core temperature <35 C (Mathew Thyroid 2011)
    hypothermia
  • lab_abnormality
    TSH markedly elevated + FT4 low (ATA 2014 Jonklaas)
    severe_hypothyroidism
  • problem_list
    Known hypothyroidism with missed levothyroxine + acute illness (ETA 2018 consensus)
    hypothyroidism_decompensated

Required inputs (11)

  • agerequired
    demographic • used at CONTEXT
    Elderly women in winter — classic substrate; drug pharmacokinetics differ (Wall JCEM 2000; Mathew Thyroid 2011)
  • core_temperaturerequired
    vital • used at RED_FLAGS
    Hypothermia is hallmark; passive rewarming only — active risks vasodilation (ETA 2018 consensus)
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension common; vasopressors poorly responsive without thyroid hormone (ETA 2018 consensus)
  • hrrequired
    vital • used at CONTEXT
    Bradycardia hallmark (ETA 2018 consensus)
  • tshrequired
    lab • used at INITIAL_WORKUP
    Markedly elevated in primary; inappropriately low/normal in secondary (ATA 2014 Jonklaas)
  • ft4required
    lab • used at INITIAL_WORKUP
    Low FT4 confirms hypothyroidism severity (ATA 2014 Jonklaas)
  • cortisolrequired
    lab • used at INITIAL_WORKUP
    Concomitant adrenal insufficiency common — give hydrocortisone BEFORE T4 (ETA 2018 consensus; ATA 2014)
  • sodiumrequired
    lab • used at INITIAL_WORKUP
    Hyponatremia common (SIADH-like); slow correction (ETA 2018 consensus)
  • glucoserequired
    lab • used at INITIAL_WORKUP
    Hypoglycemia common (ETA 2018 consensus)
  • levothyroxine_adherencerequired
    history • used at CONTEXT
    Non-adherence is leading cause; surgical/RAI history suggests post-ablative substrate (Mathew Thyroid 2011)
  • current_meds
    medication • used at CONTEXT
    Amiodarone, lithium, IFN, TKIs cause hypothyroidism; opiates/sedatives precipitate (ETA 2018 consensus)

12-phase flow (12)

  1. 1FRAME
    Recognize triad (AMS + hypothermia + precipitant) in hypothyroid patient; mortality 30-50% — empirical therapy without delay (ETA 2018 consensus; Wall JCEM 2000)
    inputs: core_temperature
    advance: myxedema coma suspected; treatment threshold crossed
  2. 2ENTRY
    Capture trigger (AMS, hypothermia, severe hypothyroid lab pattern, decompensated known hypothyroid) (ETA 2018 consensus)
    inputs: age
    advance: entry trigger captured
  3. 3CONTEXT
    Hypothyroid history + adherence + post-thyroidectomy/RAI status, precipitant screen (cold exposure, infection, MI, stroke, sedating meds) (Mathew Thyroid 2011; ETA 2018 consensus)
    inputs: levothyroxine_adherence, current_meds, hr
    advance: precipitant + thyroid history captured
  4. 4RED_FLAGS
    Hypothermia, hypotension, respiratory failure (CO2 narcosis), seizure, severe hyponatremia <120, hypoglycemia, sepsis (ETA 2018 consensus)
    inputs: core_temperature, sbp, sodium, glucose
    actions: calc.qsofa
    advance: red flags screened; airway secured if needed
  5. 5INITIAL_WORKUP
    TSH/FT4/FT3 + random cortisol (PRE-steroid) + ACTH; CMP; CBC; ABG; lactate; ECG (low voltage, prolonged QT); CXR; cultures; troponin; CK (rhabdo); pregnancy test (ETA 2018 consensus; ATA 2014)
    inputs: tsh, ft4, cortisol, sodium, glucose
    actions: panel.thyroid, panel.hormone, panel.renal, workup.myxedema_coma
    advance: baseline endocrine + sepsis labs sent
  6. 6BRANCHING_WORKUP
    Etiology workup once stabilized: anti-TPO (autoimmune), MRI pituitary if secondary, thyroid US if goiter, source workup if infection (ATA 2014 Jonklaas)
    advance: etiology workup queued
  7. 7DIFFERENTIAL
    Phenotype: known hypothyroid decompensated, newly-diagnosed severe hypothyroidism, post-thyroidectomy/RAI, drug-induced (amio/lithium/IFN/TKI) (ETA 2018 consensus)
    advance: phenotype assigned
  8. 8RISK_STRATIFICATION
    Popoveniuc diagnostic score (≥60 diagnostic) (Wartofsky Endocrinology 2006); NEWS2; need for ICU + mechanical ventilation
    actions: calc.qsofa
    advance: severity scored; ICU disposition assigned
  9. 9TREATMENT
    Hydrocortisone 100 mg IV q8h FIRST (rule out concomitant AI) → levothyroxine 200-400 mcg IV load → 50-100 mcg/d IV; add liothyronine 5-20 mcg IV load → 2.5-10 mcg q8h in severe/comatose; passive rewarming with blankets; cautious fluids; D50 if hypoglycemic; treat precipitant; ventilator support if respiratory failure (ETA 2018 consensus; ATA 2014 Jonklaas)
    inputs: core_temperature, sbp, sodium, glucose
    advance: hydrocortisone + levothyroxine ± T3 + supportive care + precipitant therapy in flight
  10. 10DISPOSITION
    ICU mandatory; endocrinology day 1; ID + cardiology if precipitant; ventilator wean once stable (ETA 2018 consensus)
    advance: ICU disposition + consults secured
  11. 11MONITORING
    Continuous telemetry, art line BP if unstable, core temp q1h, serial electrolytes + glucose q4-6h, TSH/FT4/FT3 q24-48h, neuro checks q2h, daily ECG (QT) (ETA 2018 consensus)
    inputs: sodium, glucose
    actions: panel.renal, panel.thyroid
    advance: parameters trending toward normal; transition to PO levothyroxine
  12. 12FOLLOWUP
    Endo within 1 wk; titrate PO levothyroxine; education on adherence + sick-day continuation; address precipitant prevention; review medications causing hypothyroidism (ATA 2014 Jonklaas; NICE 2019)
    advance: PO regimen + follow-up scheduled; adherence plan documented