Severe Hypothyroidism: Clinical Presentation of Myxedema Coma (Nursing)

00:01 Let's look at the clinical presentation of a client with severe hypothyroidism who's presenting with a myxedema coma.

00:08 So you know that this myxedema coma is life threatening, but it's because a patient has life threatening low thyroid hormones.

00:16 That's why it's a medical emergency and the client needs immediate intensive care treatment, and you have to replace those thyroid hormones.

00:23 If we don't, the patients can have a really bad outcome.

00:27 So they need to be in ICU.

00:29 They need to have thyroid replacement.

00:30 And they need supportive care.

00:32 Because remember what your thyroid does with metabolism.

00:35 It's your energy production and usage.

00:38 It's your cell functions. And how would the speed they work at.

00:40 And there's also all these specific effects on your body systems.

00:44 Well that's where the clinical presentation is going to come from.

00:47 And I want to go from head to toe.

00:49 So let's think neurological.

00:51 If they have low thyroid hormones they're definitely going to have altered mental status, the least of which would be some confusion.

00:58 But the worst is going to be they're actually in a coma.

01:01 At the very best, they'll be lethargic or kind of sleepy.

01:05 They'll have a hard time waking up.

01:06 Some clients even have seizures.

01:09 So neurological, Illogical.

01:10 It's just going to be off.

01:12 Might just be confusion or tired, or it could be all the way to coma.

01:16 Now let's look at temperature regulation.

01:18 These patients, if they're low on thyroid hormones, they're going to be hypothermic, sometimes even below 95 Fahrenheit or 35 Celsius. They just don't have the engine working that can help regulate their temperature.

01:34 Their skin will be cold and dry, and they won't be able to bring their temperature back up. So we've got the neuro problems, right. They're going to be confused or in a coma.

01:44 They're going to have temperature regulation issues where they're going to be too cold.

01:48 They're not going to be able to warm themselves up.

01:50 What else would you expect with the heart? Well, you see other things.

01:54 Their function is slowing down.

01:56 It's the same with cardiovascular.

01:57 They're going to have bradycardia or a slow heart rate slower than normal for them. They're going to have low blood pressure.

02:05 Right. Hypotension their cardiac output is going to drop off right.

02:09 Their there. Heart rate is lower.

02:11 So of course their cardiac output is also going to be lower.

02:15 They might even have some QT interval prolongation if you look at their ECG.

02:20 So keep that in mind with all this going on depending on how long it took to evolve, they might also have cardiomegaly.

02:27 Now let's look at the lungs.

02:29 You wouldn't expect them to be hyperventilating, right? They're going to be hypoventilating. Another reason why they need to be in ICU, monitoring their neuro status, monitoring their cardiovascular status, monitoring their respiratory status, and providing support where needed.

02:43 So they're going to be hypoventilating, everything is slow.

02:47 When they're hypoventilating, they're going to have a build up of CO2.

02:51 So they're likely to be in respiratory acidosis.

02:55 So this could also lead to potential respiratory failure.

02:58 So you're right on them watching that to see if they need to be ventilated or if they need to be on a certain level of oxygen.

03:05 Also because they're hypoventilating we talked about that excess CO2 and I just wanted to point that out once again.

03:11 So when you're thinking about respiratory, everything is slow.

03:15 That makes sense that you would have CO2 build up.

03:18 The more CO2 you have in the blood, you're going to throw that TH into respiratory acidosis and the patient is at high risk for respiratory failure without treatment. Now there's some unusual physical findings you also want to keep in mind. And looking for with a myxedema coma, you're going to have non-pitting edema.

03:35 And it'll be especially in the face and in the extremities.

03:38 They're also going to have an enlarged tongue or macroglossia.

03:43 Their hair can be coarse.

03:44 You might see patterns of hair loss.

03:46 They have delayed reflexes and they might even have periorbital edema.

03:51 Now these are some really striking factors.

03:53 Remember these could change based on how long this series has been developing, or if it was quick, or if it happened over a very long period of time. But these are some unusual things that you want to keep an eye out for.

04:07 So let's look at the lab values you can expect to find.

04:10 Now think about what you know about severe hypothyroidism.

04:14 Well, if you've thought about a thyroid level, we would expect those to be low right there in because their thyroid gland cannot make enough thyroid hormone.

04:22 And something's gone wrong with either their medication wasn't enough to treat it, or they stopped taking their medication or have been untreated.

04:30 So we would expect very low thyroid hormone levels if they're in a state of going into a myxedema coma.

04:36 So you should see a low T3 and T4.

04:40 The TSH, why would that be elevated? Oh well, we know this is probably a primary hypothyroidism.

04:46 So the hypothalamus and anterior pituitary anterior pituitary gland will be dumping out TSH and the thyroid gland just can't respond.

04:56 Now there's some other things you might think, not think of um, sodium and glucose. Both of these will be low on their lab work. And finally the respiratory labs you're going to see hypoxia and hypercapnia or elevated CO2.

05:12 Now some other things you might keep in mind.

05:15 This often presents in the winter months.

05:17 Remember because severe cold can be a trigger.

05:19 It's more common in elderly women than other clients.

05:23 There's usually some type of event that set this off, and it can also have an associated adrenal insufficiency.

05:30 So keep in mind this is a medical emergency and they need immediate ICU care. So they'll have this altered mental status.

05:39 Plus they'll be cold. And somebody with known hypothyroidism should raise immediate concern for any health care provider.

05:46 So if you have a client who has a diagnosis of hypothyroidism and you know that they've had either a triggering event or they seem somewhat confused or they have a really low temperature, this should put you on high alert to know they're at risk for developing a myxedema coma.