Dr Alex Mcleod Best Case Ever

1. BCE – The
Confused Old
Man from rural
community

2. Presentation
› Ambulance to home late afternoon for
confusion/unwell/weak, ? 24hrs duration,
found T 34°, given antibiotics for possible
sepsis, no apparent trauma
› Arrival ED:
› T 34.5 P 48 BP 82/66 R 19 O2 96%RA
› Sitting on bed, interacting verbally but
disorientated +/- hallucinating,
oedematous, no focal neuro deficit

3. Workup & Initial Course
› Background trawled:
› AF, Chronic RHF & Left pEF, Possible Chronic Cognitive Impairment, Acquired
Hypothyroidism (Thyroidectomy/Radioiodine for Ca 2010)
› Meds: Spironolactone, Frusemide, Thyroxine
› Not anticoagulated
› SOCIAL HISTORY - Lives alone. Has a carer for meal prep. Independent with all other ADLs.
Drives. Can mobilise round supermarket and round town without issue.
› ED Investigations:
› Bloods – WCC 4.3, CRP 0.9, Hb 110, plt 88, Na 135, K 3.9, Ur 9.8, Cr 93, Glu 4.2,
VBG pH 7.36/Lact 1.85/CO2 5.62/HCO3 24
› ECG
› CXR
› Initial Interventions:
› Monitoring – physiologically stable
› IV fluid for hypotension

4. ECG

5. CXR

6. Impression/Management
› ??
› Further labs received 2200hrs – TSH 108, T4 2.0
› Progress in ED:
› Oral thyroxine dose,
› Observed/monitored overnight with view to
transfer to definitive care following morning
› Checks overnight – seemingly stable
› 0830hrs following morning – HR 34, SBP 100,
obtunded, hypothermic, Gluc 3.8 (given IV
Dextrose)
› 0930hrs ABG pH 7.37/CO2 5.28/Lact 0.61

7. Hypothyroid Coma
› High mortality – 30%, worse if elderly
› Evidence base for treatment:

8. Clinical Features
› Confusion/obtundation
› Hypothermia
› +/- bradycardia,
hypotension, low
Na/Gluc, respiratory
failure, preceeding
systemic upset
› TFTs confirm, plus absence
of other causes of coma

9. An approach to tx

10. Treatment challenges
› Only T3 available for parenteral tx in NZ
› Impaired T4-to-T3 conversion when
hypothyroid, +/- when systemically ill
› CVS instability during early treatment
› Concurrent hormonal dysfunction (e.g HPA
axis, immune system, glucose metabolism)
› Monitoring and adherence to maintenance
thyroid hormone supplementation!

11. Reflections for the doctor
› Anchoring bias
› Night shift brain failure - don’t forget the
basics
› Handovers and expectations – especially
acutely unwell patients in holding pattern