Coma mixedematoso : puntos de buena práctica
Las hormonas tiroideas son extremadamente importantes y tienen diversas acciones. Actúan en prácticamente todas las células del cuerpo para alterar la transcripción de genes: la producción insuficiente o excesiva de estas hormonas tiene efectos potentes. Los trastornos asociados con la secreción alt...
- Autores:
-
Zumaqué Carrascal, Antonio María
Aguado Torres, Luz Estefany
Saldarriaga Osuna, Luis Fernando
- Tipo de recurso:
- Article of journal
- Fecha de publicación:
- 2023
- Institución:
- Universidad de Antioquia
- Repositorio:
- Repositorio UdeA
- Idioma:
- spa
- OAI Identifier:
- oai:bibliotecadigital.udea.edu.co:10495/48403
- Acceso en línea:
- https://hdl.handle.net/10495/48403
- Palabra clave:
- Mixedema
Myxedema
Enfermedades de la Tiroides
Thyroid Diseases
Hipotiroidismo
Hypothyroidism
Tiroxina
Thyroxine
https://id.nlm.nih.gov/mesh/D009230
https://id.nlm.nih.gov/mesh/D013959
https://id.nlm.nih.gov/mesh/D007037
https://id.nlm.nih.gov/mesh/D013974
ODS 3: Salud y bienestar. Garantizar una vida sana y promover el bienestar de todos a todas las edades
- Rights
- openAccess
- License
- http://creativecommons.org/licenses/by-nc-sa/4.0/
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Coma mixedematoso : puntos de buena práctica |
| dc.title.translated.none.fl_str_mv |
Mixed hematous coma : Good practice points |
| title |
Coma mixedematoso : puntos de buena práctica |
| spellingShingle |
Coma mixedematoso : puntos de buena práctica Mixedema Myxedema Enfermedades de la Tiroides Thyroid Diseases Hipotiroidismo Hypothyroidism Tiroxina Thyroxine https://id.nlm.nih.gov/mesh/D009230 https://id.nlm.nih.gov/mesh/D013959 https://id.nlm.nih.gov/mesh/D007037 https://id.nlm.nih.gov/mesh/D013974 ODS 3: Salud y bienestar. Garantizar una vida sana y promover el bienestar de todos a todas las edades |
| title_short |
Coma mixedematoso : puntos de buena práctica |
| title_full |
Coma mixedematoso : puntos de buena práctica |
| title_fullStr |
Coma mixedematoso : puntos de buena práctica |
| title_full_unstemmed |
Coma mixedematoso : puntos de buena práctica |
| title_sort |
Coma mixedematoso : puntos de buena práctica |
| dc.creator.fl_str_mv |
Zumaqué Carrascal, Antonio María Aguado Torres, Luz Estefany Saldarriaga Osuna, Luis Fernando |
| dc.contributor.author.none.fl_str_mv |
Zumaqué Carrascal, Antonio María Aguado Torres, Luz Estefany Saldarriaga Osuna, Luis Fernando |
| dc.subject.decs.none.fl_str_mv |
Mixedema Myxedema Enfermedades de la Tiroides Thyroid Diseases Hipotiroidismo Hypothyroidism Tiroxina Thyroxine |
| topic |
Mixedema Myxedema Enfermedades de la Tiroides Thyroid Diseases Hipotiroidismo Hypothyroidism Tiroxina Thyroxine https://id.nlm.nih.gov/mesh/D009230 https://id.nlm.nih.gov/mesh/D013959 https://id.nlm.nih.gov/mesh/D007037 https://id.nlm.nih.gov/mesh/D013974 ODS 3: Salud y bienestar. Garantizar una vida sana y promover el bienestar de todos a todas las edades |
| dc.subject.meshuri.none.fl_str_mv |
https://id.nlm.nih.gov/mesh/D009230 https://id.nlm.nih.gov/mesh/D013959 https://id.nlm.nih.gov/mesh/D007037 https://id.nlm.nih.gov/mesh/D013974 |
| dc.subject.ods.none.fl_str_mv |
ODS 3: Salud y bienestar. Garantizar una vida sana y promover el bienestar de todos a todas las edades |
| description |
Las hormonas tiroideas son extremadamente importantes y tienen diversas acciones. Actúan en prácticamente todas las células del cuerpo para alterar la transcripción de genes: la producción insuficiente o excesiva de estas hormonas tiene efectos potentes. Los trastornos asociados con la secreción alterada de la hormona tiroidea son comunes y afectan aproximadamente al 5% de las mujeres y al 0,5% de los hombres. El coma mixedematoso (CM), es una complicación extrema del hipotiroidismo que pasa inadvertida y se asocia con anomalías estructurales alteraciones sensoriales y que puede ser fatal. Las personas con hipotiroidismo experimentan una gran variedad de cambios fisiológicos para compensar la deficiencia de hormona tiroidea. Dentro de la revisión de las emergencias endocrinas vamos a poder responder algunas preguntas que pueden cambiar la forma en que manejamos el (CM), dentro de las preguntas que surgen están las siguientes: ¿Cuáles son los factores causantes del coma mixedematoso? ¿Cómo se identifica un coma mixedematoso en su etapa inicial? ¿Cuál es el enfoque diagnóstico del paciente con coma mixedematoso? ¿Cómo iniciamos tratamiento farmacológico durante el ingreso a urgencias? |
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2023 |
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2023 |
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2025-11-26T16:42:33Z |
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Artículo de revista |
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Zumaqué AM, Aguado LE, Saldarriaga LF. Coma mixedematoso: Puntos de buena práctica [Internet]. Medellín: Perlas Clínicas, Facultad de Medicina, Universidad de Antioquia; 2023 acceso día de mes de año]. Disponible en: https://doi.org/10.59473/medudea.pc.2023.04 |
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10.59473/medudea.pc.2023.04 |
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Zumaqué AM, Aguado LE, Saldarriaga LF. Coma mixedematoso: Puntos de buena práctica [Internet]. Medellín: Perlas Clínicas, Facultad de Medicina, Universidad de Antioquia; 2023 acceso día de mes de año]. Disponible en: https://doi.org/10.59473/medudea.pc.2023.04 10.59473/medudea.pc.2023.04 |
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Perlas Clínicas |
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Nussey S, Whitehead S. The thyroid gland. Londres: Bios Scientific; 2001. Rodríguez I, Fluiters E, Pérez-Méndez LF, Luna R, Páramo C, García-Mayor RV. Factors associated with mortality of patients with myxoedema coma: prospective study in 11 cases treated in a single institution. J Endocrinol [Internet]. 2004 Feb;180(2):347-50. Available from: https://pubmed.ncbi.nlm.nih.gov/14765987/ Bridwell RE, Willis GC, Gottlieb M, Koyfman A, Long B. Decompensated hypothyroidism: A review for the emergency clinician. Am J Emerg Med [Internet]. 2021 Jan;39:207-212. Available from: https://pubmed.ncbi.nlm.nih.gov/33039222/ Vanderpump MP. The epidemiology of thyroid disease. Br Med Bull [Internet]. 2011;99:39-51. Available from: https://pubmed-ncbi-nlm-nih-gov.udea.lookproxy.com/21893493/ Chaudhary S, Das L, Sharma N, Sachdeva N, Bhansali A, Dutta P. Utility of myxedema score as a predictor of mortality in myxedema coma. J Endocrinol Invest [Internet]. 2023 Jan;46(1):59-65. Available from: https://link-springer-com.udea.lookproxy.com/article/10.1007/s40618-022-01884-6 Elshimy G, Chippa V, Correa R. Myxedema. En: StatPearls [Internet]. StatPearls Publishing; 2022. Jansen HJ, Doebé SR, Louwerse ES, van der Linden JC, Netten PM. Status epilepticus caused by a myxoedema coma. Neth J Med [Internet]. 2006 Jun;64(6):202-5. Available from: https://www.njmonline.nl/getpdf.php?id=426 Udovcic M, Pena RH, Patham B, Tabatabai L, Kansara A. Hypothyroidism and the Heart. Methodist Debakey Cardiovasc J [Internet]. 2017 Apr-Jun;13(2):55-59. doi: 10.14797/mdcj-13-2-55. Available from: https://journal.houstonmethodist.org/articles/10.14797/mdcj-13-2-55 Constant EL, de Volder AG, Ivanoiu A, Bol A, Labar D, Seghers A, Et al. Cerebral blood flow and glucose metabolism in hypothyroidism: a positron emission tomography study. J Clin Endocrinol Metab [Internet]. 2001 Aug;86(8):3864-70. Available from: https://academic-oup-com.udea.lookproxy.com/jcem/article/86/8/3864/2849004?login=false MacKerrow SD, Osborn LA, Levy H, Eaton RP, Economou P. Myxedema-associated cardiogenic shock treated with intravenous triiodothyronine. Ann Intern Med [Internet]. 1992 Dec 15;117(12):1014-5. Available from: https://www.acpjournals.org/doi/10.7326/0003-4819-117-12-1014?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed Majid-Moosa A, Schussler JM, Mora A. Myxedema coma with cardiac tamponade and severe cardiomyopathy. Proc (Bayl Univ Med Cent) [Internet]. 2015 Oct;28(4):509-11. Available from: https://www-ncbi-nlm-nih-gov.udea.lookproxy.com/pmc/articles/PMC4569241/ Massumi RA, Winnacker JL. Severe depression of the respiratory center in myxedema. Am J Med [Internet]. 1964 [citado el 21 de noviembre de 2022];36(6):876–82. Available from: https://www.amjmed.com/article/0002-9343(64)90117-2/pdf Ji JS, Chae HS, Cho YS, Kim HK, Kim SS, Kim CW, et al. Myxedema ascites: case report and literature review. J Korean Med Sci [Internet]. 2006;21(4):761–4Available from: http://dx.doi.org/10.3346/jkms.2006.21.4.761. Gregory A. Brent P. Weetman. Hipotiroidismo y Tiroiditis. En: Melmed S, Polonsky KS, Reed Larsen P, Kronenberg HM. Williams textbook of endocrinology. 13a ed. Filadelfia, PA, Estados Unidos de América: Elsevier – Health Sciences Division; 2015. Página 416-448. Checchi S, Montanaro A, Pasqui L, Ciuoli C, De Palo V, Chiappetta MC, et al. L-thyroxine requirement in patients with autoimmune hypothyroidism and parietal cell antibodies. J Clin Endocrinol Metab [Internet]. 2008;93(2):465–9. Available from: http://dx.doi.org/10.1210/jc.2007-1544 Ylli D, Klubo-Gwiezdzinska J, Wartofsky L. Thyroid emergencies. Pol Arch Intern Med [Internet]. 2019;129(7–8):526–34. Available from: http://dx.doi.org/10.20452/pamw.14876. Chaker L, Bianco AC, Jonklaas J, Peeters RP. Lancet [Internet]. 2017 [citado el 24 de noviembre de 2022];390(10101):1550–62. Available from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30703-1/fulltext Carlé A, Pedersen IB, Knudsen N, Perrild H, Ovesen L, Laurberg P. Hypothyroid symptoms and the likelihood of overt thyroid failure: a population-based case-control study. Eur J Endocrinol [Internet]. 2014;171(5):593–602. Available from: http://dx.doi.org/10.1530/EJE-14-0481 Popoveniuc G, Chandra T, Sud A, Sharma M, Blackman MR, Burman KD, et al. A diagnostic scoring system for myxedema coma. Endocr Pract [Internet]. 2014;20(8):808–17. Available from: http://dx.doi.org/10.4158/EP13460.OR. Kwaku MP, Burman KD. Myxedema coma. J Intensive Care Med [Internet]. 2007;22(4):224–31. Available from: http://dx.doi.org/10.1177/0885066607301361 Jonklaas J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, et al. Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid [Internet]. 2014;24(12):1670–751. Available from: http://dx.doi.org/10.1089/thy.2014.0028 |
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Zumaqué Carrascal, Antonio MaríaAguado Torres, Luz EstefanySaldarriaga Osuna, Luis Fernando2025-11-26T16:42:33Z2023Zumaqué AM, Aguado LE, Saldarriaga LF. Coma mixedematoso: Puntos de buena práctica [Internet]. Medellín: Perlas Clínicas, Facultad de Medicina, Universidad de Antioquia; 2023 acceso día de mes de año]. Disponible en: https://doi.org/10.59473/medudea.pc.2023.04https://hdl.handle.net/10495/4840310.59473/medudea.pc.2023.04Las hormonas tiroideas son extremadamente importantes y tienen diversas acciones. Actúan en prácticamente todas las células del cuerpo para alterar la transcripción de genes: la producción insuficiente o excesiva de estas hormonas tiene efectos potentes. Los trastornos asociados con la secreción alterada de la hormona tiroidea son comunes y afectan aproximadamente al 5% de las mujeres y al 0,5% de los hombres. El coma mixedematoso (CM), es una complicación extrema del hipotiroidismo que pasa inadvertida y se asocia con anomalías estructurales alteraciones sensoriales y que puede ser fatal. Las personas con hipotiroidismo experimentan una gran variedad de cambios fisiológicos para compensar la deficiencia de hormona tiroidea. Dentro de la revisión de las emergencias endocrinas vamos a poder responder algunas preguntas que pueden cambiar la forma en que manejamos el (CM), dentro de las preguntas que surgen están las siguientes: ¿Cuáles son los factores causantes del coma mixedematoso? ¿Cómo se identifica un coma mixedematoso en su etapa inicial? ¿Cuál es el enfoque diagnóstico del paciente con coma mixedematoso? ¿Cómo iniciamos tratamiento farmacológico durante el ingreso a urgencias?25 páginasapplication/pdfspaUniversidad de Antioquia, Facultad de MedicinaMedellín, ColombiaPerlas ClínicasNussey S, Whitehead S. The thyroid gland. Londres: Bios Scientific; 2001.Rodríguez I, Fluiters E, Pérez-Méndez LF, Luna R, Páramo C, García-Mayor RV. Factors associated with mortality of patients with myxoedema coma: prospective study in 11 cases treated in a single institution. J Endocrinol [Internet]. 2004 Feb;180(2):347-50. Available from: https://pubmed.ncbi.nlm.nih.gov/14765987/Bridwell RE, Willis GC, Gottlieb M, Koyfman A, Long B. Decompensated hypothyroidism: A review for the emergency clinician. Am J Emerg Med [Internet]. 2021 Jan;39:207-212. Available from: https://pubmed.ncbi.nlm.nih.gov/33039222/Vanderpump MP. The epidemiology of thyroid disease. Br Med Bull [Internet]. 2011;99:39-51. Available from: https://pubmed-ncbi-nlm-nih-gov.udea.lookproxy.com/21893493/Chaudhary S, Das L, Sharma N, Sachdeva N, Bhansali A, Dutta P. Utility of myxedema score as a predictor of mortality in myxedema coma. J Endocrinol Invest [Internet]. 2023 Jan;46(1):59-65. Available from: https://link-springer-com.udea.lookproxy.com/article/10.1007/s40618-022-01884-6Elshimy G, Chippa V, Correa R. Myxedema. En: StatPearls [Internet]. StatPearls Publishing; 2022.Jansen HJ, Doebé SR, Louwerse ES, van der Linden JC, Netten PM. Status epilepticus caused by a myxoedema coma. Neth J Med [Internet]. 2006 Jun;64(6):202-5. Available from: https://www.njmonline.nl/getpdf.php?id=426Udovcic M, Pena RH, Patham B, Tabatabai L, Kansara A. Hypothyroidism and the Heart. Methodist Debakey Cardiovasc J [Internet]. 2017 Apr-Jun;13(2):55-59. doi: 10.14797/mdcj-13-2-55. Available from: https://journal.houstonmethodist.org/articles/10.14797/mdcj-13-2-55Constant EL, de Volder AG, Ivanoiu A, Bol A, Labar D, Seghers A, Et al. Cerebral blood flow and glucose metabolism in hypothyroidism: a positron emission tomography study. J Clin Endocrinol Metab [Internet]. 2001 Aug;86(8):3864-70. Available from: https://academic-oup-com.udea.lookproxy.com/jcem/article/86/8/3864/2849004?login=falseMacKerrow SD, Osborn LA, Levy H, Eaton RP, Economou P. Myxedema-associated cardiogenic shock treated with intravenous triiodothyronine. Ann Intern Med [Internet]. 1992 Dec 15;117(12):1014-5. Available from: https://www.acpjournals.org/doi/10.7326/0003-4819-117-12-1014?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmedMajid-Moosa A, Schussler JM, Mora A. Myxedema coma with cardiac tamponade and severe cardiomyopathy. Proc (Bayl Univ Med Cent) [Internet]. 2015 Oct;28(4):509-11. Available from: https://www-ncbi-nlm-nih-gov.udea.lookproxy.com/pmc/articles/PMC4569241/Massumi RA, Winnacker JL. Severe depression of the respiratory center in myxedema. Am J Med [Internet]. 1964 [citado el 21 de noviembre de 2022];36(6):876–82. Available from: https://www.amjmed.com/article/0002-9343(64)90117-2/pdfJi JS, Chae HS, Cho YS, Kim HK, Kim SS, Kim CW, et al. Myxedema ascites: case report and literature review. J Korean Med Sci [Internet]. 2006;21(4):761–4Available from: http://dx.doi.org/10.3346/jkms.2006.21.4.761.Gregory A. Brent P. Weetman. Hipotiroidismo y Tiroiditis. En: Melmed S, Polonsky KS, Reed Larsen P, Kronenberg HM. Williams textbook of endocrinology. 13a ed. Filadelfia, PA, Estados Unidos de América: Elsevier – Health Sciences Division; 2015. Página 416-448.Checchi S, Montanaro A, Pasqui L, Ciuoli C, De Palo V, Chiappetta MC, et al. L-thyroxine requirement in patients with autoimmune hypothyroidism and parietal cell antibodies. J Clin Endocrinol Metab [Internet]. 2008;93(2):465–9. Available from: http://dx.doi.org/10.1210/jc.2007-1544Ylli D, Klubo-Gwiezdzinska J, Wartofsky L. Thyroid emergencies. Pol Arch Intern Med [Internet]. 2019;129(7–8):526–34. Available from: http://dx.doi.org/10.20452/pamw.14876.Chaker L, Bianco AC, Jonklaas J, Peeters RP. Lancet [Internet]. 2017 [citado el 24 de noviembre de 2022];390(10101):1550–62. Available from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30703-1/fulltextCarlé A, Pedersen IB, Knudsen N, Perrild H, Ovesen L, Laurberg P. Hypothyroid symptoms and the likelihood of overt thyroid failure: a population-based case-control study. Eur J Endocrinol [Internet]. 2014;171(5):593–602. Available from: http://dx.doi.org/10.1530/EJE-14-0481Popoveniuc G, Chandra T, Sud A, Sharma M, Blackman MR, Burman KD, et al. A diagnostic scoring system for myxedema coma. Endocr Pract [Internet]. 2014;20(8):808–17. Available from: http://dx.doi.org/10.4158/EP13460.OR.Kwaku MP, Burman KD. Myxedema coma. J Intensive Care Med [Internet]. 2007;22(4):224–31. Available from: http://dx.doi.org/10.1177/0885066607301361Jonklaas J, Bianco AC, Bauer AJ, Burman KD, Cappola AR, Celi FS, et al. Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid [Internet]. 2014;24(12):1670–751. Available from: http://dx.doi.org/10.1089/thy.2014.0028http://creativecommons.org/licenses/by-nc-sa/4.0/info:eu-repo/semantics/openAccessAttribution-NonCommercial-ShareAlike 4.0 Internationalhttp://purl.org/coar/access_right/c_abf2Coma mixedematoso : puntos de buena prácticaMixed hematous coma : Good practice pointsArtículo de revistahttp://purl.org/coar/resource_type/c_6501http://purl.org/coar/resource_type/c_2df8fbb1http://purl.org/redcol/resource_type/ARTOTRTexthttp://purl.org/coar/version/c_b1a7d7d4d402bcceinfo:eu-repo/semantics/articleinfo:eu-repo/semantics/draftMixedemaMyxedemaEnfermedades de la TiroidesThyroid DiseasesHipotiroidismoHypothyroidismTiroxinaThyroxinehttps://id.nlm.nih.gov/mesh/D009230https://id.nlm.nih.gov/mesh/D013959https://id.nlm.nih.gov/mesh/D007037https://id.nlm.nih.gov/mesh/D013974ODS 3: Salud y bienestar. 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