1. Epidemiology and Incidence

Thyroid storm and myxedema coma are rare but high-mortality endocrine emergencies encountered in the intensive care unit (ICU). Early recognition hinges on awareness of their low incidence but profound impact on resource utilization and patient outcomes.

Incidence and Mortality

• Thyroid Storm:
  • Incidence: Approximately 0.2 cases per 100,000 population per year, representing less than 1% of endocrine emergencies in the ICU.
  • Mortality: Remains high at 10–20% even in modern series.
• Myxedema Coma:
  • Incidence: Approximately 0.1 cases per 100,000 population per year, with a strong predominance in elderly women.
  • Mortality: Ranges from 25–60%, reflecting the severity of metabolic collapse and frequent comorbidities.
• Resource Utilization: Both conditions typically necessitate an ICU length of stay of 7–14 days, driven by the need for prolonged mechanical ventilation and hemodynamic support.

Key Points

• Both syndromes are infrequent but demand urgent, decisive action when suspected.
• Maintain endocrine emergencies in the differential diagnosis for any patient with unexplained hyperthermia or hypothermia.
• Early consultation with endocrinology or clinical pharmacy specialists can significantly reduce diagnostic delays and optimize therapy.

2. Precipitating Factors and Risk Stratification

Thyroid emergencies are rarely spontaneous events. They are typically precipitated by major physiologic stresses, abrupt medication changes, chronic comorbidities, and social barriers to care. Identifying these factors is key to prevention and rapid intervention.

Common Triggers

1. Thyroid Storm Triggers:
   • Systemic infection (e.g., pneumonia, urosepsis)
   • Surgical stress (both thyroidectomy and non-thyroid procedures)
   • Significant trauma or burns
   • Abrupt withdrawal of thionamide medications
2. Myxedema Coma Triggers:
   • Cold exposure and environmental hypothermia
   • Infection, especially respiratory tract infections
   • Administration of CNS depressants (e.g., sedatives, opioids, anesthetics)
   • Noncompliance with levothyroxine therapy

Chronic Disease and Social Modifiers

• Chronic Comorbidities: Conditions like heart failure, diabetes, and COPD can significantly amplify the risks. Tachyarrhythmias in thyroid storm can precipitate acute decompensated heart failure, while the blunted respiratory drive in myxedema coma is worsened in patients with underlying COPD.
• Social Determinants of Health: Barriers such as poor medication access, limited health literacy, and socioeconomic constraints on routine medical monitoring are significant contributors to non-adherence and delayed presentation.

3. Pathophysiology

Thyroid storm arises from a hyperadrenergic, hypermetabolic surge driven by excessive thyroid hormone effects, whereas myxedema coma reflects a profound, systemic collapse from hormone deficiency and severe hypometabolism.

4. Clinical Presentation

The clinical presentation of thyroid emergencies is one of stark contrasts. Differentiating between the two syndromes relies on recognizing opposing patterns in vital signs, neurologic findings, and systemic manifestations. A high index of suspicion is required as presentations can mimic sepsis or primary neurologic disorders.

5. Clinical Pearls and Pitfalls

Effective management requires navigating diagnostic mimics and implementing timely, protocol-driven care bundles.

Key Pearls

• Think Thyroid: Do not dismiss unexplained, profound hyperthermia or hypothermia in an ICU patient as solely infectious or metabolic in origin. Actively consider thyroid storm or myxedema coma in the differential.
• Beta-Blocker Dual Benefit: In thyroid storm, non-selective beta-blockers (like propranolol) are crucial not only for controlling adrenergic symptoms but also for their ability to decrease the peripheral conversion of T4 to the more active T3.
• Protocolize Care: Implement protocol-driven order sets or “care bundles” to expedite the administration of critical therapies (e.g., thionamides, β-blockers, corticosteroids for storm; IV levothyroxine and stress-dose steroids for coma) and supportive care.

Common Pitfalls

• Misdiagnosis as Sepsis: The most common pitfall is misattributing the clinical picture to severe sepsis or septic shock, which can delay life-saving, specific endocrine therapy.
• Delayed Consultation: Failing to engage multidisciplinary teams (Endocrinology, Pharmacy, Critical Care) early can lead to suboptimal dosing, missed diagnoses, and delays in escalating care.