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
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