Adrenal crisis: Difference between revisions

Revision as of 08:07, 18 February 2015

Background

Consider in any pt w/ unexplained hypotension (esp if have HIV or take steroids)
Main factor causing adrenal crisis is mineralocorticoid, not glucocorticoid, deficiency
- This is the reason crises occur much more frequently w/ primary adrenal insufficiency
Major clinical problem is hypotension
- Most commonly presents as shock

Causes (Adrenal Insufficiency)

Primary adrenal insufficiency (decreased cortisol and aldosterone)
- Autoimmune (70%)
- Adrenal hemorrhage
  - Coagulation disorders
  - Sepsis (Waterhouse-Friderichsen syndrome)
- Meds
- Infection (HIV, TB)
- Sarcoidosis/amyloidosis
- Mets
- CAH
Secondary adrenal insufficiency (decreased ACTH -> decreased cortisol only)
- Withdrawal of steroid therapy
- Pituitary disease
- Head trauma
- Postpartum pituitary necrosis
- Infiltrative disorders of pituitary or hypothalamus

Precipitants

Increased demand
- Infection
- MI
- Surgery
- Trauma
Decreased supply
- Discontinuation of steriod therapy

Clinical Features

Hypotension
- Refractory to fluids/presors
Dehydration
Abdominal tenderness
- Usually generalized
Hyponatremia/hyperkalemia
Hypoglycemia
Confusion/delirium/lethargy
Fever
- Usually caused by infection

Workup

Chemistry
Random cortisol, renin, and ACTH levels
- Do not wait for levels before starting treatment

Differential Diagnosis

Shock

Cardiogenic
- Acute valvular Regurgitation/VSD
- CHF
- Dysrhythmia
- ACS
- Myocardial Contusion
- Myocarditis
- Drug toxicity (e.g. beta blocker, CCB, or bupropion OD)
Obstructive
Distributive
Hypovolemic
- Severe dehydration
- Hemorrhagic shock (traumatic and non-traumatic)

Treatment

Begin tx immediately in any suspected case(prognosis related to rapidity of tx)
IVF
- D5NS IV 2-3L (corrects fluid deficit and hypoglycemia)
Steroids
- Hydrocortisone
  - Drug of choice if K+>6 (provides glucocorticoid and mineralcorticoid effects)
  - 2mg/kg up to 100mg IV bolus
- Dexamethasone
  - Consider in stable patients if ACTH stim test will be performed (won't interfere w/ the test)
  - 4mg IV bolus
Vasopressors
- Administered after steriod therapy in pts unresponsive to fluid resuscitation
Treat underlying cause

Source

Tintinalli's
ACEP Critical Decisions in Emergency Medicine July 2012 issue

Authors:

@@ Line 6: / Line 6: @@
 **Most commonly presents as shock
-==Causes (Adrenal Insufficiency)==
+===Causes (Adrenal Insufficiency)===
-#Primary adrenal insufficiency (decreased cortisol and aldosterone)
+*Primary adrenal insufficiency (decreased cortisol and aldosterone)
-##Autoimmune (70%)
+**Autoimmune (70%)
-##Adrenal hemorrhage
+**Adrenal hemorrhage
-###Coagulation disorders
+***Coagulation disorders
-###Sepsis (Waterhouse-Friderichsen syndrome)
+***[[Sepsis]] (Waterhouse-Friderichsen syndrome)
-##Meds
+**Meds
-##Infection (HIV, TB)
+**Infection ([[HIV]], [[TB]])
-##Sarcoidosis/amyloidosis
+**[[Sarcoidosis]]/[[amyloidosis]]
-##Mets
+**Mets
-##[[Congenital Adrenal Hyperplasia|CAH]]
+**[[Congenital Adrenal Hyperplasia|CAH]]
-#Secondary adrenal insufficiency (decreased ACTH -> decreased cortisol only)
+*Secondary adrenal insufficiency (decreased ACTH -> decreased cortisol only)
-##Withdrawal of steroid therapy
+**Withdrawal of steroid therapy
-##Pituitary disease
+**Pituitary disease
-##Head trauma
+**[[Head trauma]]
-##Postpartum pituitary necrosis
+**Postpartum pituitary necrosis
-##Infiltrative disorders of pituitary or hypothalamus
+**Infiltrative disorders of pituitary or hypothalamus
-==Precipitants==
+===Precipitants===
 *Increased demand
 **Infection
-**MI
+**[[MI]]
 **Surgery
 **Trauma
@@ Line 34: / Line 34: @@
 ==Clinical Features==
-*Hypotension
+*[[Hypotension]]
 **Refractory to fluids/presors
-*Dehydration
+*[[Dehydration]]
-*Abdominal tenderness
+*[[Abdominal tenderness]]
 **Usually generalized
-*Hyponatremia/hyperkalemia
+*[[Hyponatremia]]/[[hyperkalemia]]
-*Hypoglycemia
+*[[Hypoglycemia]]
-*Confusion/delirium/lethargy
+*Confusion/[[delirium]]/lethargy
-*Fever
+*[[Fever]]
 **Usually caused by infection
 ==Workup==
-#Chemistry
+*Chemistry
-#Random cortisol, renin, and ACTH levels
+*Random cortisol, renin, and ACTH levels
-##Do not wait for levels before starting treatment
+**Do not wait for levels before starting treatment
+==Differential Diagnosis==
+{{Shock DDX}}
 ==Treatment==
-#Begin tx immediately in any suspected case(prognosis related to rapidity of tx)
+*Begin tx immediately in any suspected case(prognosis related to rapidity of tx)
-#IVF
+*[[IVF]]
-##D5NS IV 2-3L (corrects fluid deficit and hypoglycemia)
+**D5NS IV 2-3L (corrects fluid deficit and hypoglycemia)
-#Steroids
+*Steroids
-##Hydrocortisone
+**Hydrocortisone
-###Drug of choice if K+>6 (provides glucocorticoid and mineralcorticoid effects)
+***Drug of choice if K+>6 (provides glucocorticoid and mineralcorticoid effects)
-###2mg/kg up to 100mg IV bolus
+***2mg/kg up to 100mg IV bolus
-##Dexamethasone
+**[[Dexamethasone]]
-###Consider in stable patients if ACTH stim test will be performed (won't interfere w/ the test)
+***Consider in stable patients if ACTH stim test will be performed (won't interfere w/ the test)
-###4mg IV bolus
+***4mg IV bolus
-#Vasopressors
+*[[Vasopressors]]
-##Administered after steriod therapy in pts unresponsive to fluid resuscitation
+**Administered after steriod therapy in pts unresponsive to fluid resuscitation
-#Treat underlying cause
+*Treat underlying cause
 ==See Also==
@@ Line 69: / Line 72: @@
 ==Source ==
-Tintinalli's
+*Tintinalli's
-ACEP Critical Decisions in Emergency Medicine July 2012 issue
+*ACEP Critical Decisions in Emergency Medicine July 2012 issue
 [[Category:Endo]]