In suspected myxedema coma presenting with hypothermia, hypoventilation, bradycardia, and altered mental status, what is the initial management?

• A. IV thyroid hormone replacement (levothyroxine, often with liothyronine) and hydrocortisone after adrenal coverage; supportive care
• B. Oral thyroid hormone replacement alone
• C. IV fluids and vasopressors only
• D. Antibiotics and antipyretics

Answer: (A)

In suspected myxedema coma, the priority is rapid reversal of the hypothyroid state and stabilization of the patient. The thyroid hormone needs to be given IV because oral absorption is unreliable when a patient is comatose or not tolerating oral intake, and a quick, reliable effect is essential. Administer IV thyroid hormone replacement—levothyroxine—with the addition of liothyronine for faster T3 activity because T3 acts more rapidly on cellular processes. To cover potential concurrent adrenal insufficiency, give hydrocortisone after initiating adrenal coverage; starting steroids empirically prevents a possible adrenal crisis when thyroid hormone is started in a stressed patient. Supportive care is also crucial: secure the airway and provide ventilation if needed, actively rewarm for hypothermia, give IV fluids to treat circulatory collapse and electrolyte disturbances, and monitor and correct hypoglycemia or hyponatremia as they arise. Antibiotics and antipyretics aren’t routine unless there is a concurrent infection or fever, but they aren’t substitutes for thyroid hormone replacement.