Thyroid Storm and Myxoedema ComaICU / resuscitation

Agitated, temperature 40 °C, AF at 160/min, vomiting, jaundice — two weeks after stopping carbimazole

• Temperature above 40 °C with atrial fibrillation
• New heart failure in thyrotoxicosis
• Hypothermia with bradycardia and CO₂ retention
• Hyponatraemia below 120 mmol/L with a depressed conscious level

• Sepsis
• Sympathomimetic or anticholinergic toxidrome
• Neuroleptic malignant syndrome and serotonin syndrome
• Heat stroke
• Adrenal crisis
• Hypothermia from exposure
• Sedative overdose

• Admit: Any suspected storm or myxoedema coma
• ICU: Arrhythmia with instability, heart failure, coma, hypoventilation, or temperature above 40 °C

• Storm order: β-blocker → thionamide → iodine ≥1 h later → hydrocortisone, then cool and find the trigger.
• Myxoedema coma: steroid before thyroxine, ventilate, rewarm passively.
• Both are clinical diagnoses — treat on suspicion, send TFTs and cortisol first.

• Give iodine before the thionamide
• Use aspirin for fever in thyroid storm
• Give levothyroxine before hydrocortisone in myxoedema coma
• Rewarm myxoedema coma actively — it causes vasodilated shock; rewarm passively
• Wait for thyroid function tests before treating

• Giving iodine before the thionamide, which fuels hormone synthesis
• Using aspirin to cool a storm
• Giving levothyroxine before hydrocortisone in myxoedema
• Rewarming actively and causing vasodilated shock
• Waiting for the thyroid function result before treating

Endocrinology involvement from the first hour; definitive treatment — radioiodine or surgery for thyrotoxicosis, lifelong replacement for hypothyroidism — is planned before discharge.