Hypothermic Emergency

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Hypothermia is defined as a core temperature below 95℉. The causes for hypothermia can be divided into two categories, impaired thermoregulation and increased heat loss. Increased heat loss can result from disorders that impair the skin barrier, heat stroke, cold exposure, and shock. Central failure, peripheral failure, hypothyroidism, hypoglycemia, and neuromuscular compromise are examples of causes secondary to impaired thermoregulation. In a severe state of hypothyroidism, known as myxedema coma, low thyroid hormone levels lead to a decrease in basal metabolic rate impairing thermogenesis. CASE PRESENTATION: A 65 year old male was brought to the hospital after being found unresponsive, lying outdoors for an unknown amount of time while temperatures were below freezing. Upon presentation to the ED, the patient was found to be obtunded, hypothermic to 80.6 F, bradycardic, and hypotensive. The patient's presentation was assumed to be from extended cold exposure and rewarming was initiated. He was intubated for airway protection, started on vasopressors, and admitted to the medical intensive care unit.Further work up showed an acute kidney injury, hyperkalemia, lactic acidosis, and rhabdomyolysis. His endocrine studies showed an elevated thyroid stimulating hormone (TSH) of 28.14, an undetectable triiodothyronine (T3) and thyroxine (T4), and abnormally normal cortisol. The patient was diagnosed with myxedema coma (MC) and started on an IV of liothyronine and levothyroxine as well as stress dose steroids for presumed adrenal insufficiency. Eight days after this presentation and after the initiation of thyroid hormone therapy, his mental status improved and he was successfully extubated. He was ultimately discharged to a skilled nursing facility 5 weeks later. DISCUSSION: Given several mechanisms contributing to the development of hypothermia, it is imperative to be conscious of endocrine disorders which can impair thermoregulation. MC is a medical emergency with a reported incidence of 0.22 per million per year in the Western world and a mortality rate as high as 60%. Mortality decreases to 20%–40% in treated individuals mainly as a result of clinician awareness, improvements in diagnostic testing, and advances in intensive care. If diagnostic criteria for MC is met, initiation of appropriate therapy should not be delayed as results of endocrine testing may not be readily available. CONCLUSIONS: Despite the high mortality rate associated with MC, due to prompt management in the intensive care unit with appropriate therapy of glucocorticoids and thyroxine, this patient's condition improved. We wish to emphasize the need for early detection and treatment of endocrine emergencies. In patients with severe hypothermia, initial steps for resuscitation efforts should also include early treatment of MC due to the associated mortality benefit. Reference #1: Zafren, Ken. "Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia.” Emergency Medicine Clinics of North America, vol. 35, no. 2, 2017, pp. 261–279., https://doi.org/10.1016/j.emc.2017.01.003. Reference #2: Brown, Douglas J.a. "Accidental Hypothermia.” New England Journal of Medicine, vol. 367, no. 20, 2012, pp. 1930–1938., https://doi.org/10.1056/nejmra1114208. Reference #3: Wall CR. Myxedema coma: diagnosis and treatment. Am Fam Physician. 2000;62(11):2485-2490. DISCLOSURES: No relevant relationships by Michael Blaj, source=Web Response No relevant relationships by Priyanka Durai, source=Web Response No relevant relationships by Jennifer Lindsey, source=Web Response No relevant relationships by Daisy Ngwainmbi, source=Web Response No relevant relationships by Luis Rauseo Lopez, source=Web Response