Adrenal crisis: Difference between revisions
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==Workup== | ==Workup== | ||
#Chemistry | #Chemistry | ||
# | #Random cortisol, renin, and ACTH levels | ||
##Do not wait for levels before starting treatment | ##Do not wait for levels before starting treatment | ||
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##Hydrocortisone | ##Hydrocortisone | ||
###Drug of choice if K+>6 (provides glucocorticoid and mineralcorticoid effects) | ###Drug of choice if K+>6 (provides glucocorticoid and mineralcorticoid effects) | ||
###100mg IV bolus | ###2mg/kg up to 100mg IV bolus | ||
##Dexamethasone | ##Dexamethasone | ||
###Consider 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 | ||
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==Source == | ==Source == | ||
Tintinalli's | Tintinalli's | ||
ACEP Critical Decisions in Emergency Medicine July 2012 issue | |||
[[Category:Endo]] | [[Category:Endo]] | ||
Revision as of 18:31, 15 August 2012
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
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
- Hydrocortisone
- Vasopressors
- Administered after steriod therapy in pts unresponsive to fluid resuscitation
- Treat underlying cause
See Also
Source
Tintinalli's ACEP Critical Decisions in Emergency Medicine July 2012 issue