Hypothyroid coma

One of the most dangerous complications of hypothyroidism is considered to be hypothyroid coma. Most often, it appears in patients suffering from hypothyroidism in old and senile age, and 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 have received it untimely.

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Causes of hypothyroid coma

Untimely or inadequate treatment of hypothyroidism is in most cases explained by late diagnosis of the disease. Aggravation of thyroid hormone deficiency is also observed due to the cancellation of levothyroxine replacement therapy (for example, in low-income patients), or as a result of a significant increase in the body's need for hormones due to certain reasons, such as:

• due to hypothermia;
• due to concomitant diseases (pneumonia, heart attack, stroke, viral diseases, urogenital infection, etc.);
• due to injuries, massive bleeding, surgeries, radiation therapy;
• after an 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;
• due to hypoglycemia;
• after a 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 increases with significant disruption of all types of metabolism and functions of most organs.

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Symptoms of hypothyroid coma

Hypothyroid coma occurs slowly, gradually progressing and increasing. At first, there is a feeling of fatigue, lethargy, apathy, then one can observe cold extremities, pale skin, swelling and dry feet. Over time, breathing slows down, problems with urination begin (up to anuria), cardiac insufficiency develops, blood pressure decreases, tendon reflexes disappear.

During the examination of the patient, the doctor may pay attention to the following signs:

• deterioration of metabolic processes (increase in body weight, slowing of blood circulation with a decrease in temperature below 35°C);
• disorders of the cardiovascular system (slow heart rate, thready pulse, cardiac dropsy, decreased blood pressure);
• respiratory disorders (reduction in the number of inhalations and exhalations, decrease in blood oxygen saturation, temporary cessation of breathing during sleep);
• dysfunction of the nervous system (progressive stupor, loss of tendon reflexes);
• dermatological symptoms (skin dryness, paleness and waxy hue, deterioration of hair and nails, articular hyperkeratosis);
• pronounced swelling of the face and limbs, a drop in the sodium level in the blood;
• increasing anemia and associated symptoms;
• hypoglycemia;
• disorders of the digestive organs (enlargement of the liver, development of dynamic intestinal obstruction).

Diagnosis of hypothyroid coma

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

Sometimes difficulties with diagnostics may be related to the general condition of patients, when it is not possible to conduct a full examination and some studies. Often, the doctor is forced to start providing emergency care even before receiving the results of the examination.

In rare cases, the clinical picture of the disease may be atypical, which certainly complicates the diagnosis. For example, some of the key symptoms may be absent, such as a decrease in temperature or pressure - this usually happens in the presence of a simultaneous infectious disease or persistent hypertension.

Additional examinations are carried out to help make the correct diagnosis. During hypothyroid coma, the following is revealed:

• decrease in the content of T4 and T3 in the bloodstream, increase in TSH;
• anemia, leukopenia, increased hematocrit;
• hypoglycemia, decreased sodium concentration in the blood, increased cholesterol levels;
• increased production of creatine phosphokinase, aminotransferase;
• development of respiratory acidosis;
• development of ascites, pulmonary edema, cardiac dropsy;
• upon examination – a decrease in the volume of the thyroid gland, or its absence;
• decrease in the amount of cortisol.

Distinctive diagnostics are carried out:

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

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Treatment of hypothyroid coma

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

• Hormone replacement therapy with glucocorticoids is the main method of treating patients. Usually, a combination of thyroid and glucocorticoid agents is prescribed, starting 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-thyroxine becomes noticeable only after several hours, so triiodothyronine is additionally prescribed in an amount of up to 50 mcg. Prednisolone or hydrocortisone hemisuccinate are used at the same time. After the patient regains consciousness and his condition improves, glucocorticoid drugs are discontinued.
• Treatment of hypoglycemia is also an important step in improving the patient's condition, since normalizing blood sugar levels helps restore the functioning of the brain, heart, and urinary system. To treat hypoglycemia, an intravenous injection of 20-30 ml of glucose solution (40%) and drip administration of 500-1000 ml of glucose solution (5%) are used, with mandatory monitoring of blood pressure and urination.
• Treatment of respiratory disorders is a mandatory stage of therapy, because the breathing of patients in a coma becomes weak and rare. Oxygen inhalations through the nose are used, and in severe situations - artificial ventilation of the lungs. If the patient's condition has sharply worsened, then he is administered intravenously up to 4 ml of cordiamine - a stimulant of respiratory function. Injections of cordiamine are repeated 3-4 times if necessary, while monitoring blood pressure indicators.
• Treatment of cardiovascular disorders, in particular, low blood pressure, is carried out using rheopolyglucin, 10% albumin. The use of sympathotonics is highly discouraged, since together with treatment with thyroid agents, this can cause myocardial infarction. To normalize blood pressure, angiotensinamide is administered dropwise, which increases peripheral vascular resistance. If heart failure develops against the background of low blood pressure, then cardiac agents, such as strophanthin, are administered.
• Normalization of temperature is very important for improving the condition of a patient who has survived a thyrotoxic coma. To begin with, the patient should be warmed up: it is better to use blankets for this. Active warming with heating pads is not recommended. Over time, when the effect of thyroid hormones appears, temperature indicators will normalize.
• Normalization of the blood picture, elimination of anemia consists of blood or red blood cell mass transfusion, 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

In case of hypothyroid coma, the patient is urgently hospitalized in the endocrinology department or intensive care unit.

As an emergency aid, urgent administration of triiodothyronine in the amount of 100 mcg is carried out during the first hour. Oxygen therapy is additionally prescribed. Intravenous injections of hydrocortisone (100 mg), prednisolone (up to 50 mg), as well as the administration of cardiovascular drugs are recommended.

After half an hour or an hour, ATP, B vitamins, and a solution of vitamin C (5% to 4 ml) are administered. If systolic pressure exceeds 90 mm Hg, lasix is administered. If systolic pressure is less than 90 mm Hg, cordiamine, mesaton, corazol, and cardiac medications are used.

Then, every 4 hours, triiodothyronine is administered intravenously in the amount of 25 mcg (in case of myocardial ischemia or cardiac insufficiency - no more than 10 mcg twice a day). After the temperature indicators have normalized and the heart rate has stabilized, the dosage of triiodothyronine is reduced. Oxygen therapy, the use of sodium oxybutyrate, and passive warming of the patient are continued.

If convulsive syndrome occurs, intravenous administration of seduxen (2 ml) is recommended.

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Prevention of hypothyroid coma

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

If hypothyroidism has already developed in the body, then it is important to strictly follow all the doctor's instructions and recommendations. Replacement therapy with thyroid hormones 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 your treatment for any reason, you cannot do without a doctor’s advice, because the development of a comatose state 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 procedure for intensive care and emergency care during coma has long been developed, the number of fatal outcomes reaches 40-60%, regardless of the timeliness of the treatment measures.

The prognosis worsens in older patients, as well as in individuals with persistently decreased heart rate and increasing hypothermia.

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