Adrenal crisis: Difference between revisions
m (moved Adrenal Insufficiency to Adrenal Crisis) |
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*Consider in any pt w/ unexplained hypotension (esp if have HIV or take steroids) | *Consider in any pt w/ unexplained hypotension (esp if have HIV or take steroids) | ||
*Main factor causing adrenal crisis is mineralocorticoid, not glucocorticoid, deficiency | *Main factor causing adrenal crisis is mineralocorticoid, not glucocorticoid, deficiency | ||
**Reason occurs much more frequently in primary adrenal insufficiency | **Reason occurs much more frequently in primary adrenal insufficiency pts | ||
*Major clinical problem is hypotension | |||
**Most commonly presents as shock | |||
==Causes== | ==Causes (Adrenal Insufficiency)== | ||
#Primary adrenal insufficiency (decreased cortisol and aldosterone) | #Primary adrenal insufficiency (decreased cortisol and aldosterone) | ||
##Autoimmune (70%) | ##Autoimmune (70%) | ||
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==Workup== | ==Workup== | ||
#Chemistry | #Chemistry | ||
# | #Cortisol and ACTH levels | ||
##Do not wait for levels before starting treatment | |||
## | |||
==Treatment== | ==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 | ##D5NS IV 2-3L (corrects fluid deficit and hypoglycemia) | ||
#Steroids | #Steroids | ||
##Hydrocortisone | ##Hydrocortisone | ||
###Drug of choice (provides glucocorticoid and mineralcorticoid effects) | ###Drug of choice if K+>6 (provides glucocorticoid and mineralcorticoid effects) | ||
###100mg IV bolus | ###100mg IV bolus | ||
##Dexamethasone | ##Dexamethasone | ||
###Consider if ACTH stim test will be performed ( | ###Consider if ACTH stim test will be performed (won't interfere w/ the test) | ||
###4mg IV bolus | ###4mg IV bolus | ||
#Vasopressors | #Vasopressors | ||
Revision as of 05:48, 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 pts
- 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
- Confusion/delirium/lethargy
- Abdominal tenderness
- Usually generalized
- Hyponatremia/hyperkalemia
- Hypoglycemia
- Fever
- Usually caused by infection
Workup
- Chemistry
- Cortisol and ACTH levels
- Do not wait for levels before starting treatment
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)
- 100mg IV bolus
- Dexamethasone
- Consider if ACTH stim test will be performed (won't interfere w/ the test)
- 4mg IV bolus
- Hydrocortisone
- Vasopressors
- Administered after steriod therapy in pts unresponsive to fluid resuscitation
- Treat underlying cause
Source
Tintinalli's