Hypothyroidism is a dangerous disease. One of its frequent complications is hypothyroid coma. Most often, it happens in elderly patients, especially in women. Coma develops in that group of patients who, suffering from hypothyroidism, did not receive the necessary treatment, or it was not performed on time.
Causes of Hypothyroidism
In the vast majority of patients (up to 95%), hypothyroidism is caused by pathological processes occurring in the thyroid gland. The level of hormone production decreases, primary hypothyroidism develops.
With violations of the stimulating and regulatory effects of pituitary thyrotropin, as well as thyroliberin (or hypothalamic releasing factor), secondary hypothyroidism occurs. The frequency of its occurrence is significantly inferior to the primary. In both cases, with inadequate treatment, hypothyroid coma can develop.
On peripheral hypothyroidism, the question has not yet been largely resolved. Does it arise in connection with metabolic disorders in the periphery of thyroid hormones or because of a decrease in the sensitivity of thyroid hormones in the organs and tissues of nuclear receptors?
The question remains whether age-related degradation of the level of thyroid hormones occurs in cases of peripheral metabolic disturbances. And are irreversible thyroid events observed during aging?
Hypothyroid coma. Causes
The pathogenesis of hypothyroid coma in most cases indicates that an inadequate or untimely treatment of hypothyroidism was carried out. Often the explanation may be a delayed diagnosis. Deficiency of thyroid hormones can be aggravated by the abolition of levothyroxine or the need of the body to increase the dose of replacement hormones. Some factors can contribute to hypothyroid coma:
Hypothermia.
Concomitant diseases (heart attack, pneumonia, stroke, viral, urogenital infections).
Massive blood loss, injuries, radiation therapy, surgical interventions.
X-ray examination.
Taking drugs that inhibit the central nervous system.
Large alcohol doses.
Hypoglycemia.
Hypoxia
If the level of thyroid hormones drops sharply, the activity of metabolic processes in the brain decreases. As a result, hypoxia increases, all types of metabolism and many functions of most organs are significantly impaired.
Symptoms of hypothyroid coma
The coma phenomenon occurs slowly, increases, progresses gradually. At first, fatigue, apathy, lethargy appear, after which there is a cooling of the extremities, dryness, swelling of the feet, pallor of the skin - these signs are characterized by hypothyroid coma. Localis status indicates slowed breathing, problems with urination, manifestations of heart failure. Blood pressure decreases, the absence of tendon reflexes is noted. When examining a patient, the doctor observes the following symptoms of hypothyroid coma:
Metabolism worsens, body weight increases, blood circulation slows down, temperature indicators decrease to 35 degrees.
Disorders in the cardiovascular system occur. The heart rate slows, a filamentous pulse, a decrease in blood pressure, dropsy of the heart are observed.
Impaired respiratory function. The number of inspirations-expirations is reduced, the level of oxygen in the blood drops, while breathing is possible during sleep.
Violations of the functions of the nervous system. Oppression of tendon reflexes, progressive stupor.
Skin symptoms. Pallor, dryness, waxy skin tones, articular hyperkeratosis. Fragility of nails. Hair loss.
The level of sodium in the blood drops. Severe swelling of the face and limbs.
Anemia and all its inherent symptoms.
Hypoglycemia.
Digestive disorders. Bowel obstruction. Liver enlargement.
Clinic
The clinic of hypothyroid coma is as follows: weakness appears, drowsiness, temperature drops to 35 degrees. Speech slows down, words are slurred, vision and hearing are reduced. Blood pressure is lowered, pulse - up to 30 beats per minute. Breath is superficial and rare. From the digestive tract - flatulence, constipation, pain, vomiting. The development of oliguria is observed. The skin is pale yellow, dry. Swelling of the face, limbs. Confusion, inhibition. Tendon reflexes are absent. There is a hypothyroid coma.
Blood. Hypoxia, hypercapnia, hyponatremia, hypoglycemia, acidosis, hematocrit, TSH, T3 and T4 are lowered, cholesterol is increased.
Complications: pneumonia, acute left ventricular failure, encephalopathy, acute renal failure, cardiac arrhythmias, stroke, dementia, intestinal obstruction.
Emergency care algorithm
If a person has hypothyroid coma, the emergency care algorithm has the following:
1. Prehospital phase:
Call a doctor. Provide first aid.
Wrap the body with blankets to reduce heat transfer.
To eliminate hypoxia through nasal catheters, give moistened oxygen.
Provide access to veins, insert a catheter into a vein.
If a hypothyroid coma is established, the tactics of the nurse should be clear, the collaboration with the doctor should be quick, well-coordinated:
To diagnose complications, take blood for the content of thyroxine, thyrotropin, triiodothyronine, glucose, cortisol, chlorides, sodium, CSR, gas composition.
Catheterization of the bladder is performed to control diuresis.
To prevent aspiration of vomiting, a probe is inserted into the stomach.
For the diagnosis of complications - ECG, monitoring of NPV, temperature, hemodynamics. "Reopoliglyukin" intravenously dropwise 500 ml.
Detoxification - glucose 40% iv in-stream - 20-30 ml; then 5% glucose (500 ml) is administered intravenously.
2. In the hospital:
To replace the deficiencies of hormones, 250-500 mcg of Thyroxine is injected intravenously every 6 hours (or 100 mcg of Triiodothyronine through a gastric tube), then after 12 hours the dose is reduced to 25-100 mcg.
To stop adrenal insufficiency, hydrocortisone hemisuccinate (50-100 mg) is injected intravenously.
For the prevention of encephalopathy, 1 ml of vitamin B1.
To stop bradycardia, Atropine 0.1% (0.5-1 ml) is administered subcutaneously.
Stimulation of the respiratory center - "Cordiamine" (2-4 ml).
For stopping brain hypoxia - "Mildronate" (250 mg).
For the prevention of infections - antibiotics.
To eliminate hypoxia - mechanical ventilation.
Hypothyroid coma: emergency care
Providing emergency care, in no case can you use a heating pad to warm the patient - this is due to the deterioration of hemodynamics. Triiodothyronine is not administered immediately intravenously to avoid the risks of cardiovascular complications. A large dose of Levothyroxine can provoke acute adrenal insufficiency.
Hospitalization is performed in the supine position in the intensive care unit or in the endocrinological department.
If a hypothyroid coma is established, emergency care in the first hour is provided by the administration of Triiodothyronine. Oxygen therapy is prescribed. Preparations of prednisone, hydrocortisone are administered intravenously. The introduction of cardiovascular drugs is also necessary.
After half an hour or an hour, you need to enter ATP, vitamins C, B. If the pressure is above 90 mm RT. Art., is the introduction of "Lasix". If blood pressure is less than this indicator, "Corazole", "Mesatone", "Cordiamine" are used.
Then, every 4 hours, depending on the state of the heart, Triiodothyronine is administered in an amount of 25 μg. As soon as the heart rate and temperature stabilize, the dosage is reduced. It is necessary to continue passive warming of the patient, oxygen therapy, use sodium oxybutyrate.
If convulsive syndrome occurs, Seduxen is administered intravenously.
Treatment: Stage 1
Treatment of hypothyroid coma, as a rule, includes several stages, it does not begin immediately with hormone replacement therapy. Treatment of patients is carried out strictly under the supervision of a resuscitator in the intensive care unit.
At the first stage, general measures are taken to stabilize important vital functions in the first day or two, without them, further use of hormone replacement therapy will not have the desired effect and may even threaten the patient’s life
Maintenance of respiratory functions. If the patient himself is able to breathe, and KSCH indicators are compensated, then the supply of O 2 (oxygen therapy) is performed through the nasal cannula or face mask. As a rule, patients have impaired spontaneous breathing, carbon dioxide accumulates in the blood. Requires the use of a ventilator. This stabilizes the level of oxygen and carbon dioxide in the blood, prevents the development of hypoxia, and eliminates its negative effect on all tissues and organs.
Correction of vollemic losses . Hypothyroid (myxedema) coma is characterized by fluid retention. But the fact is that it accumulates in the interstitial spaces, the vascular bed at this time suffers, and there is a shortage of fluid, for this reason blood pressure may decrease. Correction is carried out using hypertonic NaCl, colloidal and saline solutions. During the procedure, it is important to consider the level of central venous pressure. The indicator within normal limits or too high allows you to enter no more than one liter of solution per day. Otherwise, it is possible to provoke an increased heart load, while sodium in the blood will significantly decrease.
Passive heating of the patient's body with the help of blankets or increase the air temperature in the room by 1 degree. In no case can you conduct active heating of the patient using various hot wraps, heating pads. This will lead to aggravation of peripheral vasodilation, vasodilation will occur. Blood pressure can decrease even more through relative hypovolemia.
Correction of the cardiovascular system . Hypothyroid coma causes a serious blow to the cardiovascular system. At the first stage, treatment of bradycardia, stabilization of blood pressure is necessary. For the treatment of bradycardia, M-anticholinergics (for example, Atropine) are used, the use of Eufillin is possible. If blood pressure cannot be stabilized by correction of vascular hypovolemia, drug support is needed. Apply adrenaline, mesatone, norepinephrine. Extreme care must be taken here, as the sensitivity of the receptors increases with therapy with thyroid hormones. Perhaps a violation of the heart rhythm, the manifestation of symptoms of atrial fibrillation or tachycardia.
Correction of electrolyte indicators (chlorine, sodium, calcium, potassium), as well as blood glucose levels.
Use (GCS) of glucocorticosteroids. Stress doses are necessary for the depletion of the functions of the adrenal cortex in patients with thyroiditis, which arose against the background of prolonged use of hormones, with a decrease in the levels of T3 and T4, with violations in the hypothalamic-pituitary system. Hydrocortisone is usually administered every six hours in a daily dose calculation of 200 to 400 mg. After the patient's condition stabilizes, a dose reduction occurs in two to three days.
Acute hemodialysis, or renal therapy. It is indicated for patients with advanced oligoanuria, with an increase in creatinine, level of urea, potassium.
Patient treatment should be started immediately. The sooner he passes the first stage, the necessary vital functions are restored, the faster it will be possible to begin hormone replacement therapy. The chances of recovery increase many times over.
2 stage
At the 2nd stage of treatment, the hypothyroid coma status already has a different one. It requires therapy with thyroid replacement hormones.
The main components are T4 preparations. "Levothyroxine" is usually prescribed at a dose of 1.8 mcg / kg per day. After 6 hours, the action begins, and in a day the full effect is achieved. Initially, from 100 to 500 micrograms of the drug are indicated within an hour. Then, the remaining daily dose is administered throughout the day. After that, the maintenance dose per day is 75-100 mcg. After stabilization of the patient, Levothyroxine is prescribed in tablet form.
In serious condition, T3 drugs are administered from 0.1 to 0.6 μg / kg per day. With a daily allowance of 75-100 mcg, 12.5-25 mcg is administered every 6 hours. If the patient has cardiovascular pathologies, the minimum daily dose is 25-50 mcg.
3 stage
At the 3rd stage, after stabilization of the patient’s condition, treatment of the underlying disease begins, which led to the development of coma. This may be some kind of infectious or inflammatory process of the thyroid gland, trauma and other factors.
Hypothyroid coma is a life-threatening condition for a patient. Medical recommendations should be strictly observed and followed. Otherwise, serious life-threatening complications may occur. Self-medication in this case is strictly prohibited. If you suspect coma symptoms, seek medical attention immediately.
Thyrotoxic coma
Hypothyroid coma, or thyrotoxic crisis, can occur against the background of severe thyrotoxicosis with untreated thyrotoxic goiter. More often this occurs against the background of neuropsychic stresses after surgical removal of the thyroid gland. The main links of pathogenesis are:
A sharp jump in thyroid hormones in the blood.
Hypoxia
Endotoxemia.
Toxic damage to the cardiovascular and nervous system, adrenal glands, liver.
Violation of cellular metabolism and water-electrolyte balance.
Thyrotoxic crisis precedes the development of coma. The patient has the following symptoms: mental overexcitation, often accompanied by hallucinations, delirium. Tremor of the extremities, tachycardia (up to 200 beats per minute). Body temperature rises to 38-41 degrees. Heavy sweating. Diarrhea, vomiting. The appearance of jaundice is possible.
If there is no adequate therapy, the patient sharply worsens:
lowering blood pressure;
dry skin;
atrial fibrillation;
mydriasis;
cyanosis;
bulbar disorders.
Inhibition of reflexes occurs, muscle tone decreases, uncontrolled urination, impaired consciousness, coma are observed. Diagnostic significance is given in the history of evidence of the presence of thyrotoxicosis: tachycardia, fever, weight loss, vomiting, excited state, profuse diarrhea.
When a blood test is found: increased levels of thyroid hormone associated with the protein of iodine, bilirubin (due to damage by liver toxins), 17-hydroxyketosteroids, metabolic acidosis.
In this condition, the patient must be given emergency care. It includes the following activities:
An isotonic solution of sodium chloride in an amount of 1 liter is administered intravenously.
5% glucose solution.
"Hydrocortisone" in a dosage of 350 to 600 mg.
"Prednisolone" from 120 to 180 mg.
"Korglikon" or "StrofantinK" 0.5-1 ml.
Seduxen or other anticonvulsants.
"Merkazolil" (antithyroid drug) - 60-80 mg per day.
If the patient identifies the above symptoms, it is urgent to call an ambulance and hospitalize the patient in the endocrinology department.