Hypothyroid coma: how to provide emergency care?

Hypothyroidism is a dangerous disease. One of its frequent complications is a hypothyroid coma. Most often it happens in elderly patients, especially in women. The coma develops in that group of patients who, suffering from hypothyroidism, did not receive the necessary treatment, or it was carried out untimely.

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 thyroidiborin (or hypothalamic releasing factor), secondary hypothyroidism occurs . The frequency of its occurrence is largely inferior to the primary one. And in that, and in other cases with insufficient treatment, a hypothyroid coma can develop.

On peripheral hypothyroidism, the question has not been solved in many respects. Does it arise in connection with metabolic disorders in the periphery of thyroid hormones or because of a decrease in sensitivity in the organs and tissues of nuclear receptors to thyroid hormones?

The question remains whether the age-related degradation of the level of thyroid hormones occurs in disorders of peripheral metabolism. And are there irreversible phenomena in the thyroid gland in the aging process?

Hypothyroid coma. Causes

The pathogenesis of hypothyroid coma in most cases indicates that an inadequate or untimely treatment of hypothyroidism has been performed. Often the explanation may be a belated diagnosis. Deficiency of thyroid hormones can be exacerbated by withdrawal of levothyroxine or the body's need for an increase in the dose of replacement hormones. Hypothyroid coma may contribute to several factors:

• Subcooling.

• Concomitant diseases (heart attack, pneumonia, stroke, viral, urogenital infections).

• Massive blood loss, trauma, radiation therapy, surgical interventions.

• X-ray examinations.

• Taking medications that depress the central nervous system.

• Large alcoholic doses.

• Hypoglycemia.

• Hypoxia.

If the level of thyroid hormones falls sharply, the activity of metabolic processes decreases in the brain. As a consequence, hypoxia is increasing, all types of metabolism and many functions of most organs are significantly impaired.

Symptoms of hypothyroid coma

The phenomenon of coma appears slowly, increases, progresses gradually. At first, fatigue, apathy, inhibition appears, then the coldness of the limbs, dryness, puffiness of the feet, pallor of the skin - these signs are characterized by hypothyroid coma. Status localis indicates slowed breathing, trouble with urination, manifestations of heart failure. The arterial pressure is lowered, the absence of tendon reflexes is ascertained. When examining a patient, the doctor observes the following symptoms of a hypothyroid coma:

• The metabolism worsens, the body weight increases, the circulation slows down, the temperature drops to 35 degrees.

• There are violations in the cardiovascular system. The heart rate slows down, a thread-like pulse, a decrease in blood pressure, a dropsy of the heart are observed.

• Dysfunction of the respiratory system. The number of breaths-exhalations is reduced, the level of oxygen in the blood drops, during the sleep, breathing stops are possible.

• Violations of the functions of the nervous system. Inhibition of tendon reflexes, progressive stupor.

• Skin symptoms. Pale, dry, waxy skin tones, articular hyperkeratosis. Fragility of nails. Hair loss.

• The sodium level in the blood drops. Pronounced edema of the face and extremities.

• Anemia and all its inherent symptoms.

• Hypoglycemia.

• Digestive disorders. Intestinal obstruction. Enlarged liver.

Clinic

The clinic of the hypothyroid coma is as follows: weakness, drowsiness, the temperature drops to 35 degrees. Speech is slowed down, words are uttered indistinctly, vision and hearing decrease. Arterial pressure is lowered, pulse - up to 30 beats per minute. Breath is superficial and rare. From the digestive tract - flatulence, constipation, pain, vomiting. There is a development of oliguria. The skin is pale yellow, dry. Swelling of the face, limbs. Confusion, inhibition. Tendon reflexes are absent. Comes with a hypothyroid coma.

Blood. Hypoxia, hypercapnia, hyponatremia, hypoglycemia, acidosis, hematocrit, TTG, T3 and T4 are lowered, cholesterol is elevated.

Complications: pneumonia, acute left ventricular failure, encephalopathy, arthritis, heart rhythm disturbances, ONMI, dementia, intestinal obstruction.

Algorithm for emergency care

If a person has a hypothyroid coma, an urgent help algorithm has the following:

1. Pre-hospital stage:

• Call a doctor. Provide first medical assistance.

• Wrap the body with blankets to reduce heat dissipation.

• To eliminate hypoxia through nasal catheters give moistened oxygen.

• Provide access to the veins, establish a vein catheter.

If a hypothyroid coma is established, the tactics of the nurse should be clear, working together with the doctor - fast, well-coordinated:

• To diagnose complications, take blood for the content of thyroxine, thyrotropin, triiodothyronine, glucose, cortisol, chlorides, sodium, KCHR, gas composition.

• To monitor diuresis, the bladder is catheterized.

• To prevent aspiration of vomiting, a probe is inserted into the stomach.

• For the diagnosis of complications - ECG, monitoring of HDR, temperature, hemodynamics. "Reopoliglyukin" intravenously-dropping 500 ml.

• Detoxification - glucose 40% in / in jet - 20-30 ml; Then iv glucose 5% (500 ml) is injected intravenously.

2. In the hospital:

• To replace the deficiencies of hormones in / in struino every 6 hours 250-500 μg of thyroxin (or through the stomach probe 100 μg of Triiodothyronine) is injected, then after 12 hours the dose is reduced to 25-100 μg.

• For relief of adrenal insufficiency in / in the hydrocortisone is injected hydrocortisone hemisuccinate (50-100 mg).

• For the prevention of encephalopathy 1 ml of vitamin B1.

• To arrest bradycardia, subcutaneously injected "Atropine" 0.1% (0.5-1 ml).

• Stimulation of the respiratory center - "Cordiamin" (2-4 ml).

• To stop the hypoxia of the brain - "Mildronate" (250 mg).

• For the prevention of infections - antibiotics.

• To eliminate hypoxia - artificial ventilation.

Hypothyroid coma: emergency care

Providing emergency help, in no case can warming the patient use warmers - this is due to the deterioration of 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 prone position in the intensive care unit or endocrinology department.

If a hypothyroid coma is established, urgent help in the first hour is provided by the introduction of "Triiodothyronine". Oxygen therapy is prescribed. Intravenously administered drugs prednisolone, hydrocortisone. It is also necessary to introduce cardiovascular drugs.

After half an hour-hour, it is necessary to introduce ATP, vitamins C, B. If the pressure is above 90 mm Hg. The introduction of "Lasix" is made. If the blood pressure is less than this indicator, "Corazol", "Mezaton", "Cordiamin" are used.

Then, every 4 hours, depending on the condition of the heart, in the amount of 25 μg introduce "Triiodothyronine". Once the cardiac contractions and the temperature stabilize, the dosage is lowered. It is necessary to continue passively warming the patient, oxygen therapy, use sodium oxybutyrate.

If there is a convulsive syndrome, "Seduxen" is injected intravenously.

Treatment: Stage 1

Treatment of a 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 proper effect and can even threaten the life of the patient

Maintenance of respiratory functions. If the patient himself is able to breathe and the parameters of the KSHN are compensated, the O ₂ supply (oxygen therapy) is made through the nasal cannula or face mask. As a rule, patients experience self-breathing disorders, carbon dioxide accumulates in the blood. It is required to use the device for artificial ventilation. This stabilizes the level of oxygen and carbon dioxide in the blood, prevents the development of hypoxia, eliminates its negative impact on all tissues and organs.

Adjustment of vollemic losses . Hypothyroid (myxedematous) 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 deficiency of fluid, for this reason, blood pressure may drop. Correction is made with hypertonic solution of NaCl, colloidal and salt solutions. During the procedure it is important to take into account the level of central venous pressure. The indicator within the limits of the norm or the overestimated allows to enter per day no more than one liter of solution. Otherwise, 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 increasing the air temperature in the room by 1 degree. In no case can the active heating of the patient with various hot wraps, heaters. This will lead to aggravation of peripheral vasodilation, vasodilation will occur. Arterial pressure may decrease even more with relative hypovolemia.

Correction of the cardiovascular system . Hypothyroid coma is a serious blow to the cardiovascular system. At the first stage, it is necessary to treat bradycardia, stabilize blood pressure. For treatment of bradycardia, M-holinoblokatory (for example, "Atropin") is used, it is possible to use "Eufillina". If blood pressure can not be stabilized by correction of vascular hypovolemia, drug support is necessary. Apply epinephrine, mezaton, noradrenaline. Here it is necessary to show extreme attention, since the sensitivity of receptors is increased by the therapy with hormones of the thyroid gland. Possible disturbance of the heart rhythm, the manifestation of symptoms of atrial fibrillation or tachycardia.

Correction of electrolyte indices (chlorine, sodium, calcium, potassium), as well as blood glucose levels.

Use (GCS) of glucocorticosteroids. Stress doses are needed when the functions of the adrenal cortex are depleted 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. Typically, hydrocortisone is administered every six hours in the calculation of a daily dose of 200 to 400 mg. After the patient's condition is stabilized, a dose reduction occurs in two to three days.

Acute hemodialysis, or renal therapy. It is shown in patients with advanced oligoanuria, with the growth of creatinine, the level of urea, potassium.

The patient should be treated immediately. The earlier it passes the first stage, vital functions are restored, the faster it will be possible to begin hormone replacement therapy. The chances of recovery increase many times.

2 stage

At the 2 stage of treatment, the hypothyroid coma status already has another. Here, thyroid hormone replacement therapy is required.

The main components are preparations of T4. "Levothyroxine" is usually administered at a dose of 1.8 μg / kg per day. After 6 hours, the action begins, and a full effect is achieved in a day. Initially within an hour shown from 100 to 500 μg of the drug. Further during the day, the remaining daily dose is administered. After that, the maintenance dose per day is 75-100 μg. After stabilizing the patient, "Levothyroxine" is prescribed in tablet form.

In severe condition, T3 drugs are administered from 0.1 to 0.6 μg / kg per day. At diurnal 75-100 mcg every 12 hours, 12.5-25 mcg is injected. If the patient has cardiovascular pathologies, the daily dose is applied minimum - 25-50 mcg.

Stage 3

At stage 3, after stabilization of the patient's condition, treatment of the underlying disease begins, which led to the development of coma. It can be any 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 threatening life may occur. Self-medication in this case is strictly prohibited. If you suspect any signs of coma, seek medical help immediately.

Thyrotoxic coma

Hypothyroid coma, or thyrotoxic crisis, can occur against a background of severe thyrotoxicosis in untreated thyrotoxic goiter. More often it occurs on a background of neuropsychic strains, after the surgical removal of the thyroid gland. The main links of pathogenesis are:

• A sharp jump in thyroid hormones in the blood.

• Hypoxia.

• Endotoxicosis.

• Toxic defeat of the cardiovascular and nervous system, supratrices, liver.

• Disturbance of cellular metabolism and water-electrolyte balance.

The thyrotoxic crisis precedes the development of coma. The patient has the following symptoms: mental overexcitation, often accompanied by hallucinations, delirium. Tremor of extremities, tachycardia (up to 200 beats per minute). The body temperature rises to 38-41 degrees. Severe sweating. Diarrhea, vomiting. There may be jaundice.

If there is no adequate therapy, the patient's condition worsens dramatically:

• Lowering blood pressure;

• dry skin;

• Atrial fibrillation;

• Mydriasis;

• cyanosis;

• Bulbar disorders.

There is a depression of reflexes, muscle tone is reduced, uncontrolled urination, frustration of consciousness, coma. Diagnostic value has data in the history, indicating the presence of thyrotoxicosis: tachycardia, fever, weight loss, vomiting, an agitated state, profuse diarrhea.

When analyzing blood, there are: increased thyroid hormone associated with the protein of iodine, bilirubin (due to damage to liver toxins), 17-oxyketosteroid, metabolic acidosis.

In this condition, the patient must provide emergency care. It includes the following activities:

• Intravenously injected isotonic sodium chloride solution in an amount of 1 liter.

• Glucose solution 5%.

• "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.

• "Mercazolil" (antithyroid drug) - 60-80 mg per day.

If a patient has the above symptoms, it is urgent to call an "ambulance" and hospitalize the patient in the endocrinology department.