Adrenal crisis
Diagnosis
- Major factor precipitating adrenal crisis is mineralocorticoid, not glucocorticoid, deficiency
- Major clinical problem is hypotension
- Most commonly presents as shock
Clinical Manifestations
- Hypotension
- Refractory to fluids
- Volume depletion
- Abdominal tenderness
- Usually generalized
- Fever
- Usually caused by infection (source must be identified and treated)
Lab tests
- Hyperkalemia
- Hyponatremia
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
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)
- Mineralocorticoids are not indicated in acute management
- Treat underlying cause
Source
7/2/09 PANI (Adapted from Mistry), UpToDate