Adrenal crisis: Difference between revisions
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== | ==Backgrounds== | ||
* Major factor precipitating adrenal crisis is mineralocorticoid, not glucocorticoid, deficiency | * Major factor precipitating adrenal crisis is mineralocorticoid, not glucocorticoid, deficiency | ||
* Major clinical problem is hypotension | ** Major clinical problem is hypotension | ||
* Most commonly presents as shock | * Most commonly presents as shock | ||
==Diagnosis== | |||
===Clinical Picture=== | |||
* Hypotension | * Hypotension | ||
* Refractory to fluids | ** Refractory to fluids | ||
* Volume depletion | * Volume depletion | ||
* Abdominal tenderness | * Abdominal tenderness | ||
* Usually generalized | ** Usually generalized | ||
* Fever | * Fever | ||
* Usually caused by infection (source must be identified and treated) | ** Usually caused by infection (source must be identified and treated) | ||
#fever, hypoTN (refractory to fluids), hyperpigmentation by increased ACTH | |||
#cushingoid look by chronic steroid use | |||
#think about in kids with congenital adrenal hyperplasia (CAH) who present with shock | |||
===Lab tests=== | |||
* Hyperkalemia | * Hyperkalemia | ||
* Hyponatremia | * Hyponatremia | ||
==Workup== | ==Workup== | ||
# Chemistry/glucose | |||
## Guides therapy | |||
# Cortisol level | |||
## Confirms diagnosis | |||
# Renin, ACTH | |||
## For evaluating differential diagnosis if cortisol level normal | |||
==Treatment== | |||
Treatment== | # Do not wait for lab results to start treatment | ||
# Fluids | |||
## Infuse 2-3L of NS or D5NS (to correct hypoglycemia) | |||
## Avoid hypotonic fluids (may worsen hyponatremia) | |||
# Glucocorticoids | |||
## Patient without previous diagnosis of adrenal insufficiency | |||
### Dexamethasone 4mg IV bolus is preferred tx | |||
## Patient with known primary adrenal insufficiency w/ potassium > 6 | |||
### Hydrocortisone 100mg IV bolus (preferred due to its mineralcorticoid activity) | |||
# Mineralocorticoids are not indicated in acute management | |||
# Treat underlying cause | |||
==Source == | ==Source == | ||
7/2/09 PANI (Adapted from Mistry), UpToDate | 7/2/09 PANI (Adapted from Mistry), UpToDate | ||
[[Category:Endo]] | [[Category:Endo]] | ||
Revision as of 05:17, 13 March 2011
Backgrounds
- Major factor precipitating adrenal crisis is mineralocorticoid, not glucocorticoid, deficiency
- Major clinical problem is hypotension
- Most commonly presents as shock
Diagnosis
Clinical Picture
- Hypotension
- Refractory to fluids
- Volume depletion
- Abdominal tenderness
- Usually generalized
- Fever
- Usually caused by infection (source must be identified and treated)
- fever, hypoTN (refractory to fluids), hyperpigmentation by increased ACTH
- cushingoid look by chronic steroid use
- think about in kids with congenital adrenal hyperplasia (CAH) who present with shock
Lab tests
- Hyperkalemia
- Hyponatremia
Workup
- Chemistry/glucose
- Guides therapy
- Cortisol level
- Confirms diagnosis
- Renin, ACTH
- For evaluating differential diagnosis if cortisol level normal
Treatment
- Do not wait for lab results to start treatment
- Fluids
- Infuse 2-3L of NS or D5NS (to correct hypoglycemia)
- Avoid hypotonic fluids (may worsen hyponatremia)
- Glucocorticoids
- Patient without previous diagnosis of adrenal insufficiency
- Dexamethasone 4mg IV bolus is preferred tx
- Patient with known primary adrenal insufficiency w/ potassium > 6
- Hydrocortisone 100mg IV bolus (preferred due to its mineralcorticoid activity)
- Patient without previous diagnosis of adrenal insufficiency
- Mineralocorticoids are not indicated in acute management
- Treat underlying cause
Source
7/2/09 PANI (Adapted from Mistry), UpToDate