Hypothyroidism is a dangerous disease. One of its frequent complications is hypothyroid coma. It most often occurs in older patients, especially women. Coma develops in the group of patients who, suffering from hypothyroidism, did not receive the necessary treatment, or it was carried out out of 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.
In violation of the stimulating and regulating effects of pituitary thyrotropin, as well as thyreoliberin (or hypothalamic releasing factor), secondary hypothyroidism occurs. The frequency of its occurrence is largely inferior to the primary. In both cases, with insufficient treatment, a hypothyroid coma can develop.
About peripheral hypothyroidism, the issue has not yet been resolved in many respects. Does it occur due to metabolic disorders inthe periphery of thyroid hormones or due to a decrease in the sensitivity in organs and tissues of nuclear receptors to thyroid hormones?
It remains a controversial question whether age-related degradation of thyroid hormone levels occurs in violation of peripheral metabolism. And are irreversible phenomena observed in the thyroid gland during aging?
Hypothyroid coma. Reasons
The pathogenesis of hypothyroid coma in most cases indicates that inadequate or untimely treatment of hypothyroidism was carried out. Often the explanation can be a belated diagnosis. Thyroid hormone deficiency can be exacerbated by the withdrawal of levothyroxine or the body's need for an increase in the dose of replacement hormones. Several factors may contribute to hypothyroid coma:
- Hypercooling.
- Comorbidities (heart attack, pneumonia, stroke, viral, urogenital infections).
- Massive blood loss, trauma, radiotherapy, surgery.
- X-ray examinations.
- Taking drugs that depress the central nervous system.
- High 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 are significantly disturbed.most organs.
Symptoms of hypothyroid coma
The phenomenon of coma occurs slowly, increases, progresses gradually. Initially, fatigue, apathy, lethargy appear, after which there is a coldness of the extremities, dryness, swelling of the feet, pallor of the skin - these signs are characterized by hypothyroid coma. The status of localis indicates slow breathing, problems with urination, manifestations of heart failure. Arterial pressure decreases, the absence of tendon reflexes is stated. When examining a patient, the doctor observes the following symptoms of hypothyroid coma:
- Metabolism worsens, body weight increases, blood circulation slows down, temperature indicators drop to 35 degrees.
- There are disturbances in the cardiovascular system. The heart rate slows down, there is a thready pulse, a decrease in blood pressure, dropsy of the heart.
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Respiratory dysfunction. The number of breaths decreases, the level of oxygen in the blood drops, breathing stops are possible during sleep.
- Disturbances in the functions of the nervous system. Inhibition of tendon reflexes, progressive stupor.
- Skin symptoms. Paleness, dryness, waxy skin tones, articular hyperkeratosis. Brittle nails. Hair loss.
- The level of sodium in the blood falls. Severe swelling of the face and limbs.
- Anemia and all its symptoms.
- Hypoglycemia.
- Disordersdigestion. Intestinal obstruction. Liver enlargement.
Clinic
The clinic of a hypothyroid coma is as follows: weakness, drowsiness appear, the temperature drops to 35 degrees. Speech slows down, words are slurred, vision and hearing decrease. Arterial pressure is lowered, pulse - up to 30 beats per minute. Breathing is shallow and rare. From the gastrointestinal tract - flatulence, constipation, pain, vomiting. The development of oliguria is observed. The skin is pale yellow, dry. Swelling of the face, limbs. Confusion of consciousness, lethargy. Tendon reflexes are absent. Hypothyroid coma sets in.
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 Algorithm
If a person has a hypothyroid coma, the emergency care algorithm is as follows:
1. Prehospital:
- Call a doctor. Provide first aid.
- Wrap your body in blankets to reduce heat transfer.
- To eliminate hypoxia, give humidified oxygen through nasal catheters.
- Get access to the veins, place a catheter in the vein.
If a hypothyroid coma is established, the tactics of the nurse should be clear, joint work with the doctor should be quick,well-coordinated:
- To diagnose complications, take blood for the content of thyroxine, thyrotropin, triiodothyronine, glucose, cortisol, chlorides, sodium, KShchR, gas composition.
- Bladder catheterization is performed to control diuresis.
- To prevent aspiration of vomit, a probe is inserted into the stomach.
- For the diagnosis of complications - ECG, control of respiratory rate, temperature, hemodynamics. "Reopoliglyukin" intravenous drip 500 ml.
- Detoxification - glucose 40% IV bolus - 20-30 ml; then glucose 5% (500 ml) is injected intravenously.
2. Inpatient:
- To replace the deficiencies of hormones, 250-500 mcg of "Thyroxin" is administered 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.
- For the relief of adrenal insufficiency, hydrocortisone hemisuccinate (50-100 mg) is injected intravenously.
- For the prevention of encephalopathy 1 ml of vitamin B1.
- For the relief of bradycardia, "Atropine" 0.1% (0.5-1 ml) is injected subcutaneously.
- Stimulation of the respiratory center - "Cordiamin" (2-4 ml).
- For the relief of cerebral hypoxia - "Mildronate" (250 mg).
- For the prevention of infections - antibiotics.
- To eliminate hypoxia - artificial ventilation of the lungs.
Hypothyroid coma: emergency care
When providing emergency care, in no case should you use heating pads to warm the patient - this is due to a deterioration in hemodynamics. "Triiodothyronine" is not administered immediately intravenously to avoid the risk 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 the endocrinology department.
If a hypothyroid coma is established, emergency care in the first hour is provided by the introduction of "Triiodothyronine". Oxygen therapy is prescribed. Prednisolone, hydrocortisone preparations are administered intravenously. The introduction of cardiovascular drugs is also necessary.
After half an hour or an hour, it is necessary to introduce ATP, vitamins C, B. If the pressure is above 90 mm Hg. Art., the introduction of "Lasix". If blood pressure is less than this indicator, Corazol, Mezaton, Cordiamin are used.
Further, every 4 hours, depending on the condition of the heart, "Triiodothyronine" is administered in the amount of 25 mcg. As soon as heart contractions and temperature stabilize, the dosage is reduced. It is necessary to continue passive warming of the patient, oxygen therapy, use sodium oxybutyrate.
If a convulsive syndrome occurs, Seduxen is administered intravenously.
Treatment: Stage 1
Treatmenthypothyroid coma, as a rule, includes several stages, 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
Maintaining respiratory functions. If the patient is able to breathe on his own, and the indicators of CSF are compensated, then the supply of O2 (oxygen therapy) is performed through nasal cannulas or a face mask. As a rule, patients have violations of spontaneous breathing, carbon dioxide accumulates in the blood. The use of a ventilator is required. This stabilizes the level of oxygen and carbon dioxide in the blood, prevents the development of hypoxia, and eliminates its negative impact on all tissues and organs.
Volemic loss correction. Hypothyroid (myxedematous) coma is characterized by fluid retention. But the fact is that it accumulates in the interstitial spaces, the vascular bed suffers at this time, and there is a shortage of fluid, for this reason, blood pressure may decrease. Correction is performed using a hypertonic solution of NaCl, colloidal and saline solutions. When carrying out the procedure, it is important to take into account the level of central venous pressure. The indicator within the normal range or overestimated allows you to enter no more than one liter of solution per day. ATotherwise, it is possible to provoke an increased cardiac load, while sodium in the blood will decrease significantly.
Passive heating of the patient's body with blankets or raising the air temperature in the room by 1 degree. In no case should the patient be actively heated with the help of various hot wraps, heating pads. This will lead to aggravation of peripheral vasodilation, vasodilation will occur. Blood pressure can drop further through relative hypovolemia.
Correction of the cardiovascular system. Hypothyroid coma causes a serious blow to the cardiovascular system. At the first stage, it is necessary to treat bradycardia and stabilize blood pressure. For the treatment of bradycardia, M-anticholinergics are used (for example, Atropine), it is possible to use Eufillin. If blood pressure cannot be stabilized by correcting vascular hypovolemia, medical support is needed. Adrenaline, mezaton, norepinephrine are used. Here you need to exercise extreme care, since the sensitivity of the receptors increases during therapy with thyroid hormones. Possible heart rhythm disturbance, symptoms of atrial fibrillation or tachycardia.
Correction of electrolyte parameters (chlorine, sodium, calcium, potassium), as well as blood glucose levels.
Use (GCS) of glucocorticosteroids. Stress doses are necessary when the functions of the adrenal cortex are depleted in patients with thyroiditis, which arose against the background of long-term use of hormones, with a decrease inlevels of indicators T3 and T4, with disorders in the hypothalamic-pituitary system. Hydrocortisone is usually administered every six hours in the calculation of a daily dose of 200 to 400 mg. After the patient's condition stabilizes, the dose is reduced after two to three days.
Acute hemodialysis, or kidney therapy. It is indicated for patients with developed oligoanuria, with an increase in creatinine, urea, potassium.
Treatment of the patient must begin immediately. The sooner he passes the first stage, the necessary vital functions are restored, the sooner it will be possible to start hormone replacement therapy. The chances of recovery increase many times over.
2 stage
At the 2nd stage of treatment, hypothyroid coma already has a different status. Thyroid replacement therapy is required here.
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 after a day the full effect is achieved. Initially, from 100 to 500 mcg of the drug is shown within an hour. Then, throughout the day, the remaining daily dose is administered. After that, the maintenance dose per day is 75-100 mcg. After stabilization of the patient, "Levothyroxine" is prescribed in tablet form.
In severe condition, T3 drugs are administered at 0.1 to 0.6 mcg/kg per day. With daily 75-100 mcg, 12.5-25 mcg is administered every 6 hours. If the patient has cardiovascular pathologies, the daily doseminimum applied - 25-50 mcg.
3 stage
At the 3rd stage, after the stabilization of the patient's condition, the 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 the patient. Medical recommendations must be strictly observed and implemented. Otherwise, serious complications that threaten life can occur. Self-medication in this case is strictly prohibited. Seek immediate medical attention if you suspect symptoms of a coma.
Thyrotoxic coma
Hypothyroid coma, or thyroid crisis, can occur against the background of severe thyrotoxicosis with untreated thyrotoxic goiter. More often this occurs against the background of neuropsychic stress, after surgical removal of the thyroid gland. The main links of pathogenesis are:
- A sharp jump in thyroid hormones in the blood.
- Hypoxia.
- Endotoxicosis.
- Toxic damage to the cardiovascular and nervous system, adrenal glands, liver.
- Impaired cell metabolism and water and electrolyte balance.
Thyrotoxic crisis precedes the development of coma. The patient has the following symptoms: mental overexcitation, often accompanied by hallucinations, delusions. Tremor of the extremities, tachycardia (up to 200 beats per minute). Body temperaturerises to 38-41 degrees. Strong sweating. Diarrhea, vomiting. Possible jaundice.
If there is no adequate therapy, the patient's condition deteriorates sharply:
- lowering blood pressure;
- dry skin;
- atrial fibrillation;
- mydriasis;
- cyanosis;
- bulbar disorders.
Reflexes are inhibited, muscle tone is reduced, uncontrolled urination, mental disorders, coma are observed. Of diagnostic value are the data in the anamnesis, indicating the presence of thyrotoxicosis: tachycardia, fever, weight loss, vomiting, agitation, profuse diarrhea.
Blood test reveals: elevated levels of thyroid hormone bound to iodine protein, bilirubin (due to damage by liver toxins), 17-hydroxyketosteroids, metabolic acidosis.
In this condition, the patient needs emergency care. It includes the following activities:
- Intravenously administered isotonic sodium chloride solution in the amount of 1 l.
- Glucose solution 5%.
- "Hydrocortisone" at a dosage of 350 to 600 mg.
- "Prednisolone" from 120 to 180 mg.
- "Korglikon" or "StrophanthinK" 0, 5-1 ml.
- Seduxen or other anticonvulsants.
- "Mercazolil" (antithyroid drug) - 60-80 mgper day.
If a patient has the above symptoms, it is urgent to call an ambulance and hospitalize the patient in the endocrinology department.
