Thyroid storm vs myxoedema coma

Storm is hypermetabolic decompensation: fever above 38.5, disproportionate tachycardia/AF, delirium through coma, heart failure, GI-hepatic signs, precipitant. No lab is specific — treat promptly across all hormone steps; BWPS below 25 unlikely, 25-44 impending, 45+ highly suggestive. Sequence: beta-blocker, thionamide, iodine 1 hour later, glucocorticoid; cooling plus paracetamol; treat precipitant; ICU.^[2][17]

Myxoedema coma is hypometabolic decompensation: altered status in 88.9 percent with hypothermia, bradycardia, hypoventilation, hyponatraemia in 58.3 percent. Resuscitate with early steroids, thyroid replacement and precipitant therapy; hydrocortisone before T4 (T4 raises cortisol clearance); 500 mcg load safe in younger, lower in elderly; passive rewarming; ventilate — some for weeks. Mortality 38.8 percent; sepsis predominant; SOFA above 6 predicts; oral equals IV route.^[8][13]

Pitfalls examiners love: iodine-first in storm (extra substrate, Jod-Basedow); T4-without-steroid in myxoedema; high-dose T4 in the elderly (OR 2.414); waiting for the lab; missing amiodarone (15-20% dysfunction) as context.^[2][13][17]