Adrenal crisis

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