Hypothyroid coma

One of the most dangerous complications of hypothyroidism is the hypothyroid coma. Most often it appears in patients suffering from hypothyroidism, in elderly and senile age, while in most cases it affects women. Coma develops in patients with severe hypothyroidism who have not received the necessary treatment for a long time, or who have not received it in time.

[1], [2], [3], [4], [5], [6], [7]

Causes of hypothyroid coma

Untimely or inadequate treatment of hypothyroidism in most cases is due to late diagnosis of the disease. The worsening of the thyroid hormone deficiency is also observed due to the abolition of levothyroxine substitution (for example, in low-income patients), or as a result of a significant increase in the body's requirements for hormones due to certain causes, for example:

• because of hypothermia;
• because of concomitant diseases (pneumonia, heart attack, stroke, viral diseases, urogenital infection, etc.);
• due to injuries, massive bleeding, surgical interventions, radiation therapy;
• after the X-ray examination;
• after taking medications that depress the functions of the central nervous system;
• as a result of taking a large dose of alcohol;
• because of hypoglycemia;
• after the state of hypoxia.

A sharp drop in the level of thyroid hormones leads to a decrease in the activity of metabolic processes in the brain. As a result, hypoxia is increasing with a significant disruption of all types of metabolism and the functions of most organs.

[8], [9], [10], [11], [12], [13]

Symptoms of hypothyroid coma

Hypothyroid coma occurs slowly, gradually progressing and increasing. First there is a feeling of fatigue, inhibition, apathy, then you can observe the coldness of the limbs, blanching of the skin, puffiness and dryness of the feet. With time, breathing slows down, problems with urination begin (up to anuria), cardiac insufficiency develops, blood pressure lowers, tendon reflexes disappear.

During the examination of the patient, the doctor can pay attention to the following symptoms:

• deterioration of metabolic processes (increase in body weight, slowing of circulation with a decrease in temperature values below 35 ° C);
• disorders of the cardiovascular system (slowing heart rate, threadlike pulse, dropsy of the heart, lowering blood pressure);
• abnormalities on the part of the respiratory organs (decrease in the number of breaths, expiration of oxygen saturation, temporary respiratory arrest during sleep);
• dysfunction of the nervous system (progressive stupor, loss of tendon reflexes);
• dermatological symptoms (skin dryness, pallor and waxy shade, deterioration of hair and nails, joint hyperkeratoses);
• pronounced edema on the face and extremities, drop in the level of sodium in the blood;
• the increase in anemia and related symptoms;
• hypoglycemia;
• disorders of the digestive organs (enlargement of the liver, development of dynamic intestinal obstruction).

Diagnosis of the hypothyroid coma

The characteristic symptomatology of hypothyroid coma usually leaves no doubt when making the diagnosis, especially if the corresponding signs developed against the background of levothyroxine replacement therapy, radioiodine therapy, or after thyroid resection surgery.

Occasionally, the difficulties with diagnosis can be related to the general condition of patients, when there is no possibility to conduct a full-fledged examination and some studies. Often, the doctor is forced to begin emergency care before receiving the results of the survey.

In rare cases, the clinical picture of the disease may be atypical, which certainly complicates the diagnosis. For example, you may not have any of the key symptoms, for example, lowering the temperature or pressure - usually it happens in the presence of a simultaneous infectious disease or persistent hypertension.

There are additional tests that help to make the correct diagnosis. During the hypothyroid coma, they reveal:

• a decrease in the content of T4 and T3 in the bloodstream, an increase in TSH;
• anemia, leukopenia, an increase in hematocrit;
• hypoglycaemia, a decrease in the concentration of sodium in the blood, an increase in the cholesterol content;
• increased production of creatine phosphokinase, aminotransferase;
• development of respiratory acidosis;
• development of ascites, pulmonary edema, dropsy;
• when examined - a decrease in the thyroid gland in the volume, or its absence;
• decrease in the amount of cortisol.

Distinctive diagnostics is carried out:

• with kidney failure, heart failure;
• with cerebral circulation disorder;
• with general intoxication;
• with mechanical intestinal obstruction;
• with insufficient function of the adrenal cortex.

[14], [15], [16], [17]

Treatment of hypothyroid coma

Treatment of coma is carried out in stages, with exposure in all directions.

• Replacement hormonal treatment with glucocorticoids is the main therapy for patients. Usually, a combination of thyroid and glucocorticoid agents is prescribed, starting treatment with L-thyroxine, which is administered intravenously at 250 mg every 6 hours. On the second day, maintenance therapy is carried out at a dose of up to 100 mg / day. The effect of L-thyroxin becomes visible only after a few hours, so additionally prescribed triiodothyronine in an amount up to 50 mcg. At the same time, prednisolone or hydrocortisone hemisuccinate is used. After the patient regains consciousness, and his condition improves, glucocorticoid drugs are canceled.
• Treatment of hypoglycemia is also an important stage for improving the patient's condition, since bringing the blood sugar level to normal helps restore the functioning of the brain, heart, and urinary system. For the treatment of hypoglycemia, intravenous injection of 20-30 ml of glucose solution (40%) and drip injection of 500-1000 ml of glucose solution (5%), under mandatory control of blood pressure and urination, are used.
• Treatment of respiratory disorders is an obligatory stage of therapy, because the breathing of patients in a coma becomes weak and rare. Oxygen inhalation through the nose is applied, and in severe situations - artificial ventilation of the lungs. If the patient's condition deteriorates sharply, then inject it intravenously with 4 ml of cordiamine, a stimulant of the respiratory function. Injections of cordiamine are repeated 3-4 times, if necessary, while monitoring blood pressure.
• Treatment of violations of the cardiovascular system, in particular, lowering blood pressure, is carried out using rheopolyglucin, 10% albumin. The use of sympathotons is highly discouraged, since together with thyroid treatment it can cause myocardial infarction. To normalize the blood pressure indicators, angiotensinamide is injected drastically, which enhances peripheral vascular resistance. If, against a background of lowering blood pressure, cardiac insufficiency develops, then the introduction of cardiac agents, for example, strophanthin, is used.
• Normalization of temperature is very important for improving the condition of the patient who survived thyrotoxic coma. To start the patient should be warmed: for this it is better to use blankets. Active heating with heaters is not recommended. Over time, when the action of thyroid hormones manifests itself, the temperature values are normalized.
• Normalization of the picture of blood, the elimination of anemia is a blood transfusion or erythrocyte mass, and such procedures can be carried out more than once. Getting rid of anemia reduces the state of hypoxia of body tissues, including brain structures.

Emergency care for hypothyroid coma

When hypothyroid coma, the patient is urgently hospitalized in the endocrinology department or in intensive care.

As an emergency, during the first hour, an immediate introduction of triiodothyronine in the amount of 100 μg is carried out. In addition, oxygen therapy is prescribed. Intravenously recommended injections of hydrocortisone (100 mg), prednisolone (up to 50 mg), as well as the introduction of cardiovascular drugs.

After half an hour-hour, ATP, vitamins gr. B, a solution of vitamin C (5% to 4 ml). If the systolic pressure exceeds 90 mm Hg. The introduction of lasix is used. At a systolic pressure less than 90 mm Hg. Art. Use cordiamin, mezaton, corazole, cardiac drugs.

Further, every 4 hours, a dropwise injection of triiodothyronine in an amount of 25 μg (with myocardial ischemia or cardiac insufficiency - no more than 10 μg twice a day). After normalization of temperature parameters and stabilization of cardiac contractions, the dose of triiodothyronine is lowered. Oxygen therapy continues, use of sodium oxybutyrate, passive warming of the patient.

When there is a convulsive syndrome, intravenous seduksen (2 ml) is recommended.

[18], [19], [20], [21], [22], [23]

Prevention of hypothyroid coma

The living conditions of many modern people, polluted ecology, radiation, malnutrition, lead to the fact that there are more patients with thyroid diseases. However, most people, unfortunately, are in no hurry to engage in prevention until the disease begins to progress and cause feelings of discomfort and pain. Of course, this is wrong, because the prevention of thyroid disease is of great importance at any age.

If hypothyroidism has already developed in the body, then an important point is the strict implementation of all prescriptions and recommendations of the doctor. Substitution therapy with thyroid hormonal drugs should be carried out strictly according to the scheme developed by the doctor for each patient individually. Deviations from this scheme, as well as independent cancellation or replacement of drugs are unacceptable, because all these actions predispose to the occurrence of hypothyroid coma.

If you want to change the treatment for any reason, then you can not do without the advice of a doctor, because the development of a coma is too high a price for our carelessness.

Prognosis of hypothyroid coma

Hypothyroid coma is one of the most critical situations, difficult to treat. Despite the fact that the order of intensive therapy and emergency care during coma has long been developed, the number of deaths reaches 40-60%, regardless of the timeliness of the medical measures taken.

The prognosis worsens in patients of the older age group, as well as in individuals with a persistent decrease in the frequency of cardiac activity and with increasing hypothermia.

Hypothyroid coma in most cases is a consequence of violations in the treatment of hypothyroidism, so patients with this disease should carefully monitor compliance with the treatment regimen, and if necessary - seek the advice of a doctor.