Adrenal crisis: Difference between revisions
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==Backgrounds==
==Background==
* Major factor precipitating adrenal crisis is mineralocorticoid, not glucocorticoid, deficiency
*Consider in any pt w/ unexplained hypotension (esp if have HIV or take steroids)
** Major clinical problem is hypotension
*Main factor causing adrenal crisis is mineralocorticoid, not glucocorticoid, deficiency
* Most commonly presents as shock
**Reason occurs much more frequently in primary adrenal insufficiency
**Major clinical problem is hypotension
***Most commonly presents as shock


==Diagnosis==
==Causes==
===Clinical Picture===
#Primary adrenal insufficiency (decreased cortisol and aldosterone)
* Hypotension
##Autoimmune (70%)
** Refractory to fluids
##Adrenal hemorrhage
* Volume depletion
###Coagulation disorders
* Abdominal tenderness
###Sepsis (Waterhouse-Friderichsen syndrome)
** Usually generalized
##Meds
* Fever
##Infection (HIV, TB)
** Usually caused by infection (source must be identified and treated)
##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


#fever, hypoTN (refractory to fluids), hyperpigmentation by increased ACTH
===Precipitants===
#cushingoid look by chronic steroid use
*Increased demand
#think about in kids with congenital adrenal hyperplasia (CAH) who present with shock
**Infection
**MI
**Surgery
**Trauma
*Decreased supply
**Discontinuation of steriod therapy


===Lab tests===
==Clinical Features==
* [[Hyperkalemia]]
*Hypotension
* [[Hyponatremia]]
**Refractory to fluids/presors
*Dehydration
*Confusion/delirium/lethargy
*Abdominal tenderness
**Usually generalized
*Hyponatremia/hyperkalemia
*Hypoglycemia
*Fever
**Usually caused by infection


==Workup==
==Workup==
# Chemistry/glucose
#Chemistry
## Guides therapy
#?ACTH stim test
# Cortisol level
##Step 1: Draw cortisol level
## Confirms diagnosis
##Step 2: Give ACTH 0.25mg IV
# Renin, ACTH
##Step 3: Draw cortisol level 30min and 1hr later
## For evaluating differential diagnosis if cortisol level normal 
###If cortisol levels rise at least by 7 and peak value >18 adrenal insufficiency r/o
 
   
   
==Treatment==
==Treatment==
# Do not wait for lab results to start treatment
#Begin tx immediately in any suspected case(prognosis related to rapidity of tx)
# Fluids
#IVF
## Infuse 2-3L of NS or D5NS (to correct hypoglycemia)
##D5NS is fluid of choice
## Avoid hypotonic fluids (may worsen hyponatremia)
#Steroids
# Glucocorticoids
##Hydrocortisone
## Patient without previous diagnosis of adrenal insufficiency
###Drug of choice (provides glucocorticoid and mineralcorticoid effects)
### Dexamethasone 4mg IV bolus is preferred tx
###100mg IV bolus
## Patient with known primary adrenal insufficiency w/ potassium > 6
##Dexamethasone
### Hydrocortisone 100mg IV bolus (preferred due to its mineralcorticoid activity)
###Consider if ACTH stim test will be performed (doesn't interfere w/ the test)
# Mineralocorticoids are not indicated in acute management
###4mg IV bolus
# Treat underlying cause  
#Vasopressors
##Administered after steriod therapy in pts unresponsive to fluid resuscitation
#Treat underlying cause  


==Source ==
==Source ==
7/2/09 PANI (Adapted from Mistry), UpToDate
Tintinalli's


[[Category:Endo]]
[[Category:Endo]]

Revision as of 05:41, 28 September 2011

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
    • Reason occurs much more frequently in primary adrenal insufficiency
    • Major clinical problem is hypotension
      • Most commonly presents as shock

Causes

  1. Primary adrenal insufficiency (decreased cortisol and aldosterone)
    1. Autoimmune (70%)
    2. Adrenal hemorrhage
      1. Coagulation disorders
      2. Sepsis (Waterhouse-Friderichsen syndrome)
    3. Meds
    4. Infection (HIV, TB)
    5. Sarcoidosis/amyloidosis
    6. Mets
    7. CAH
  2. Secondary adrenal insufficiency (decreased ACTH -> decreased cortisol only)
    1. Withdrawal of steroid therapy
    2. Pituitary disease
    3. Head trauma
    4. Postpartum pituitary necrosis
    5. 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
  • Confusion/delirium/lethargy
  • Abdominal tenderness
    • Usually generalized
  • Hyponatremia/hyperkalemia
  • Hypoglycemia
  • Fever
    • Usually caused by infection

Workup

  1. Chemistry
  2. ?ACTH stim test
    1. Step 1: Draw cortisol level
    2. Step 2: Give ACTH 0.25mg IV
    3. Step 3: Draw cortisol level 30min and 1hr later
      1. If cortisol levels rise at least by 7 and peak value >18 adrenal insufficiency r/o


Treatment

  1. Begin tx immediately in any suspected case(prognosis related to rapidity of tx)
  2. IVF
    1. D5NS is fluid of choice
  3. Steroids
    1. Hydrocortisone
      1. Drug of choice (provides glucocorticoid and mineralcorticoid effects)
      2. 100mg IV bolus
    2. Dexamethasone
      1. Consider if ACTH stim test will be performed (doesn't interfere w/ the test)
      2. 4mg IV bolus
  4. Vasopressors
    1. Administered after steriod therapy in pts unresponsive to fluid resuscitation
  5. Treat underlying cause

Source

Tintinalli's

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