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ruptured ectopic) Metabolic/endocrine/environmental Hyperkalemia Hypothermia (Osborn waves on ECG) Hypothyroidism Myxedema coma Hypoglycemia (neonates) Toxicologic B-blocker Ca-channel blocker Clonidine Digoxin toxicity Ethanol Opioids Organophosphates Xylazine toxicity Infectious/Postinfectious Chagas disease Lyme disease Syphilis Other Brash syndrome Evaluation Work-up TSH Total and Free T4 Total and Free T3 Thyroid Binding Globulin (TBG) Auto-antibodies (anti-TPO, anti-microsomal, anti-Tg) Thyroid ultrasound ECG - bradycardia, low voltage VBG - hypercapnia from hypoventilation, possibly compensated if chronic Categorization Management Depends on etiology [1] [2] If treatment started, initiate low dose as daily doses too high may lead to thyroid storm Primary (Central) Hypothyroidism Consider starting low dose levothyroxine at 25mcg daily Close follow-up with primary care or endocrinology Subclinical Hypothyroidism TSH 10 mU/L Start low dose levothyroxine at 25mcg daily with close outpatient follow up Patients are at higher risk for atherosclerosis, myocardial infarction, and risk of progression to overt hypothyroidism The American Thyroid Association (ATA), American Association of Clinical Endocrinologists (AACE) and the European Thyroid Association guidelines recommend initiating treatment [3] [4] TSH 7.0 to 9.9 mU/L 65 years old Risk of over treatment vs

69.4%) but did not reach statistical significance ( P =0.052)

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