Severe hypothyroid decompensation with altered consciousness, hypoventilation, hypothermia, bradycardia, hyponatremia or shock requiring immediate ICU therapy before confirmatory testing is complete.
Suspect myxedema coma in severe hypothyroidism with altered consciousness plus hypothermia, bradycardia, hypoventilation/hypercapnia, hyponatremia, hypoglycemia, hypotension or a precipitating infection/drug exposure. Coma is not required. Draw TSH/free T4, cortisol, electrolytes, glucose, blood gas and cultures as indicated, but do not wait for results when the syndrome is compelling.
Give empiric stress-dose IV glucocorticoid before or with thyroid hormone (commonly hydrocortisone 100 mg IV every 8 hours) until clinically important adrenal insufficiency is excluded, because thyroid replacement can increase cortisol clearance and precipitate adrenal collapse.
Give IV levothyroxine with an age/cardiac-risk-adjusted loading strategy followed by daily replacement. Use lower loading doses in older patients, coronary disease, arrhythmia or low body mass. Liothyronine is not routine and should be reserved for selected severe/refractory cases with specialist input because of cardiac risk.
Caution
Do not warm aggressively with external heat that causes peripheral vasodilation and hypotension, and do not give thyroid hormone without first protecting against possible adrenal insufficiency.
Current consensus for ICU myxedema-coma resuscitation, glucocorticoid and thyroid-hormone therapy.
Evidence status
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Recognize high-risk shock → draw cortisol/ACTH if feasible → immediate hydrocortisone + fluids/glucose → reassess competing shock causes.
ICU recognition and treatment of severe decompensated hypothyroidism with hypothermia, hypoventilation, bradycardia, hyponatremia and altered consciousness.
Recognition and ICU treatment of decompensated profound hypothyroidism with altered mental status and multiorgan dysfunction.
Time-critical recognition and empiric treatment of acute cortisol deficiency causing shock, electrolyte disturbance and hypoglycemia.