Thyroid hormone replacement
›Thyroid hormone therapy
›Levothyroxine IV
›Initiate loading dose 200 to 400 mcg IV once
›Initiate loading dose 100 to 200 mcg IV once if elderly or coronary disease or arrhythmia risk
›Continuous ECG monitoring for ischemia and arrhythmia
›Continue maintenance dose 50 to 100 mcg IV daily
›Transition to oral levothyroxine when tolerating enteral intake
›Oral maintenance dose about 1.6 mcg per kg per day
›Liothyronine IV adjunct
›Initiate loading dose 5 to 20 mcg IV once
›Initiate loading dose 5 to 10 mcg IV once if elderly or coronary disease or arrhythmia risk
›Higher arrhythmia risk than T4 alone
›Continue maintenance dose 2.5 to 10 mcg IV every 8 hours
›Stop when mental status and hemodynamics improving
›Endocrinology or ICU protocol coordination
›Evidence and recommendations
›IV levothyroxine recommended for myxedema coma based on expert consensus
›Class I recommendation based on expert consensus
›Reduced dose strategy in cardiac disease
Empiric glucocorticoids and adrenal coverage
›Glucocorticoid therapy
›Hydrocortisone
›Initiate 100 mg IV every 8 hours
›Give before thyroid hormone when feasible
›Continue until adrenal insufficiency excluded
›Taper after stability and adequate cortisol evaluation
›Avoid abrupt cessation if chronic steroid exposure suspected
›Evidence and recommendations
›Empiric stress dose glucocorticoids recommended due to coexisting adrenal insufficiency risk
›Class I recommendation based on expert consensus
›Prevent adrenal crisis precipitated by thyroid hormone therapy
›Organ support and complications
›Airway and ventilation
›If hypoventilation or hypercapnia, initiate mechanical ventilation
›PaCO2 trajectory in mmHg to guide escalation
›Conservative tidal volume strategy per lung condition
›Aspiration precautions
›Elevate head of bed
›Gastric decompression if ileus
›Temperature management
›Passive rewarming only
›Active external rewarming can worsen hypotension
›Avoid heated blankets that cause vasodilation in shock
›Hemodynamic support
›Balanced crystalloid boluses if hypovolemic
›Small bolus strategy with reassessment
›POCUS guidance
›Norepinephrine infusion for shock
›Titrate every 2 to 5 minutes to MAP target
›Add vasopressin if escalating norepinephrine requirement
›Hyponatremia management
›Fluid restriction if euvolemic hyponatremia
›Avoid hypotonic fluids
›Frequent sodium monitoring mmol/L
›If seizure or severe symptoms, initiate hypertonic saline
›3 percent sodium chloride 100 mL IV bolus over 10 minutes
›Repeat up to 2 additional boluses if persistent severe symptoms
›Sodium correction target increase 4 to 6 mmol/L in first 6 hours
›Sodium correction limit 8 mmol/L per 24 hours
›Hypoglycemia management
›If symptomatic or glucose less than 3.0 mmol/L, initiate dextrose
›Dextrose 25 g IV
›Dextrose infusion to prevent recurrence
›Thiamine 100 mg IV if malnutrition risk
›Infection management
›Empiric antibiotics if infection suspected
›Blood cultures obtained when feasible
›Source control planning
›Early lactate guided resuscitation in septic shock
›Lactate mmol/L trend
›Reassess perfusion targets
›GI hypomotility and ileus
›Nasogastric decompression if vomiting or ileus
›Aspiration risk reduction
›Enteral meds absorption limitation
›Bowel regimen after stabilization
›Avoid severe constipation complications