Identifying And Treating Thyroid Storm And Myxedema Coma In The Emergency Department

Mills, Lisa MD
Lim, Stephen MBBS
Radeos, Michael S. MD, MPH
Slovis, Corey M. MD, FACP, FACEP

Authors
Lisa Mills, MD
Director, Emergency Medicine Ultrasound, Associate Professor, Emergency Medicine, Louisiana State University at New Orleans, New Orleans, LA
Stephen Lim, MBBS
Staff Physician, Department of Emergency Medicine, Leonard J. Chabert Medical Center, Houma, LA
Peer Reviewers
Michael S. Radeos, MD, MPH
Assistant Professor of Emergency Medicine, Weill Medical College of Cornell University, New York, NY
Corey M. Slovis, MD, FACP, FACEP
Professor and Chair, Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN

Emergency Medicine Practice 11(8):p 1-21, August 2009.

Case #1: A 65-year-old woman is brought to the emergency department (ED) with altered level of consciousness and hypotension. Her neighbor found her on the kitchen floor. He checked on her because he hadn't seen her for 3 days. The patient is unable to provide any verbal history. Her vital signs are respiratory rate of 10 respirations per min, blood pressure of 90/60 mm Hg, temperature 35°C (95°F), and heart rate 50 beats per min. On physical examination, you see an obtunded woman in no apparent distress. You note a well-healed surgical scar on her anterior neck and that her left leg is shortened and externally rotated. The differential diagnosis of the presentation is long and complex, and you keep wondering if that scar on the neck has a bearing on her management.

Case #2: A 50-year-old man presents with complaints of a fever and “feeling anxious.” The patient has had a productive cough, subjective fever, and myalgias for 7 days. Yesterday, he began to “feel anxious” and like his “heart was racing.” His past medical history is significant for a goiter that is still being evaluated. His vital signs are respiratory rate of 18 respirations per min, blood pressure of 160/80 mm Hg, temperature 38°C (100.4°F), and heart rate 140 beats per min. On physical examination, you note that the patient appears nontoxic. He has a tender goiter, a fine tremor of his hands, and an irregular heart rhythm. On his lung examination, there are left midfield rales. You suspect community-acquired pneumonia, but the tender goiter introduces management concerns.