Difference between revisions of "Adrenal crisis"

 
(39 intermediate revisions by 9 users not shown)
Line 1: Line 1:
 
==Background==
 
==Background==
*Consider in any pt w/ unexplained hypotension (esp if have HIV or take steroids)
+
*Consider in any patient with unexplained [[hypotension]] (especially in those with [[HIV]] or taking exogenous steroids)
*Main factor causing adrenal crisis is mineralocorticoid, not glucocorticoid, deficiency
+
*Generally caused by mineralocorticoid deficiency, not glucocorticoid deficiency
**Reason occurs much more frequently in primary adrenal insufficiency pts
+
**This is the reason crises occur much more frequently with primary adrenal insufficiency
*Major clinical problem is hypotension
 
**Most commonly presents as shock
 
  
==Causes (Adrenal Insufficiency)==
+
===Causes (Adrenal Insufficiency)===
#Primary adrenal insufficiency (decreased cortisol and aldosterone)
+
*Primary adrenal insufficiency (decreased cortisol and aldosterone)
##Autoimmune (70%)
+
**Autoimmune (70%)
##Adrenal hemorrhage
+
**Adrenal hemorrhage
###Coagulation disorders
+
***Coagulation disorders
###Sepsis (Waterhouse-Friderichsen syndrome)
+
***[[Sepsis]] (Waterhouse-Friderichsen syndrome)
##Meds
+
**Meds
##Infection (HIV, TB)
+
**Infection ([[HIV]], [[TB]])
##Sarcoidosis/amyloidosis
+
***TB is most common worldwide cause primary adrenal insuffiency
##Mets
+
**[[Sarcoidosis]]/[[amyloidosis]]
##CAH
+
**Metastases
#Secondary adrenal insufficiency (decreased ACTH -> decreased cortisol only)
+
**[[Congenital Adrenal Hyperplasia|CAH]]
##Withdrawal of steroid therapy
+
*Secondary adrenal insufficiency (decreased ACTH decreased cortisol only)
##Pituitary disease
+
**Withdrawal of [[steroid]] therapy
##Head trauma
+
**Pituitary disease
##Postpartum pituitary necrosis
+
**[[Head trauma]]
##Infiltrative disorders of pituitary or hypothalamus
+
**Postpartum pituitary necrosis
 +
**Infiltrative disorders of pituitary or hypothalamus
  
 
===Precipitants===
 
===Precipitants===
 
*Increased demand
 
*Increased demand
**Infection
+
**[[sepsis|Infection]]
**MI
+
**[[MI]]
 
**Surgery
 
**Surgery
**Trauma
+
**[[Trauma]]
 
*Decreased supply
 
*Decreased supply
**Discontinuation of steriod therapy
+
**Discontinuation of [[steroid]] therapy
  
 
==Clinical Features==
 
==Clinical Features==
*Hypotension
+
*[[Hypotension]] (refractory to fluids/pressors)
**Refractory to fluids/presors
+
*[[Hyponatremia]]/[[Hyperkalemia]] (hyperkalemia is not expected in secondary adrenal insufficiency)
*Dehydration
+
*[[Hypoglycemia]]
*Confusion/delirium/lethargy
+
*[[Dehydration]]
*Abdominal tenderness
+
*[[Abdominal tenderness]]
**Usually generalized
+
*[[AMS|Confusion/delirium/lethargy]]
*Hyponatremia/hyperkalemia
 
*Hypoglycemia
 
*Fever
 
**Usually caused by infection
 
  
==Workup==
+
==Differential Diagnosis==
#Chemistry
+
{{Shock DDX}}
#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
 
#Vasopressors
 
##Administered after steriod therapy in pts unresponsive to fluid resuscitation
 
#Treat underlying cause
 
  
==Source ==
+
==Evaluation==
Tintinalli's
+
*CBC - [[eosinophilia]]<ref>Nutman TB. Evaluation and differential diagnosis of marked, persistent eosinophilia. Immunol Allergy Clin North Am. 2007 Aug; 27(3): 529–549.</ref>
 +
*Chemistry
 +
*Random cortisol, renin, and ACTH levels
 +
**Do not wait for levels before starting treatment
 +
*[[ACTH (cosyntropin) stimulation test]]
  
[[Category:Endo]]
+
==Management==
 +
''Begin treatment immediately in any suspected case (prognosis related to rapidity of treatment)''
 +
*Treat underlying cause, if known
 +
*[[IVF]] - D5NS 2-3L (corrects fluid deficit and hypoglycemia)
 +
*[[Steroids]]
 +
**[[Hydrocortisone]] - 2mg/kg up to 100mg IV bolus
 +
***Drug of choice if K+>6 (provides glucocorticoid and mineralocorticoid effects)
 +
**[[Dexamethasone]] - 4mg IV bolus
 +
***Consider in hemodynamically stable patients if ACTH stimulation test will be performed (will not interfere with the test)
 +
***Along with methylprednisolone, dexamethasone has negligible mineralocorticoid effect, so '''choose hydrocortisone in'''<ref>Wilson TA et al. Adrenal Hypoplasia Medication. eMedicine. Feb 11, 2013. http://emedicine.medscape.com/article/918967-medication.</ref>:
 +
****[[Hypotension]]
 +
****[[Hyponatremia]] or [[hyperkalemia]]
 +
**Comparable steroid dosages
 +
***[[Hydrocortisone]] (50-75mg/m2 or 1-2mg/kg)
 +
***[[Methylprednisolone]] are 10-15mg/m2
 +
***[[Dexamethasone]] 1-1.5mg/m2
 +
*[[Vasopressors]]
 +
**Administer after steroid therapy in patients unresponsive to fluid resuscitation
 +
 
 +
===Stress-Dose Steroids in Illness===
 +
''To aid in mounting stress response in those with adrenal insufficiency lacking endogenous cortisol''
 +
{| {{table}}
 +
| align="center" style="background:#f0f0f0;"|'''Illness Type'''
 +
| align="center" style="background:#f0f0f0;"|'''Steroid Administration'''
 +
|-
 +
| Minor, with fever < 38°C||Double dose of chronic maintenance steroids
 +
|-
 +
| Severe, with fever > 38°C||Triple dose of chronic maintenance steroids
 +
|-
 +
| Vomiting, listless, or hypotensive||[[Hydrocortisone]] at 1-2mg/kg (as above in adrenal crisis)
 +
|}
 +
 
 +
==Disposition==
 +
*Admit
 +
 
 +
==See Also==
 +
*[[Congenital Adrenal Hyperplasia]]
 +
*[[Addison's disease]]
 +
 
 +
==References==
 +
<references/>
 +
 
 +
[[Category:Endocrinology]]

Latest revision as of 15:20, 28 September 2019

Background

  • Consider in any patient with unexplained hypotension (especially in those with HIV or taking exogenous steroids)
  • Generally caused by mineralocorticoid deficiency, not glucocorticoid deficiency
    • This is the reason crises occur much more frequently with primary adrenal insufficiency

Causes (Adrenal Insufficiency)

  • Primary adrenal insufficiency (decreased cortisol and aldosterone)
    • Autoimmune (70%)
    • Adrenal hemorrhage
      • Coagulation disorders
      • Sepsis (Waterhouse-Friderichsen syndrome)
    • Meds
    • Infection (HIV, TB)
      • TB is most common worldwide cause primary adrenal insuffiency
    • Sarcoidosis/amyloidosis
    • Metastases
    • 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

Clinical Features

Differential Diagnosis

Shock

Evaluation

Management

Begin treatment immediately in any suspected case (prognosis related to rapidity of treatment)

  • Treat underlying cause, if known
  • IVF - D5NS 2-3L (corrects fluid deficit and hypoglycemia)
  • Steroids
    • Hydrocortisone - 2mg/kg up to 100mg IV bolus
      • Drug of choice if K+>6 (provides glucocorticoid and mineralocorticoid effects)
    • Dexamethasone - 4mg IV bolus
      • Consider in hemodynamically stable patients if ACTH stimulation test will be performed (will not interfere with the test)
      • Along with methylprednisolone, dexamethasone has negligible mineralocorticoid effect, so choose hydrocortisone in[2]:
    • Comparable steroid dosages
  • Vasopressors
    • Administer after steroid therapy in patients unresponsive to fluid resuscitation

Stress-Dose Steroids in Illness

To aid in mounting stress response in those with adrenal insufficiency lacking endogenous cortisol

Illness Type Steroid Administration
Minor, with fever < 38°C Double dose of chronic maintenance steroids
Severe, with fever > 38°C Triple dose of chronic maintenance steroids
Vomiting, listless, or hypotensive Hydrocortisone at 1-2mg/kg (as above in adrenal crisis)

Disposition

  • Admit

See Also

References

  1. Nutman TB. Evaluation and differential diagnosis of marked, persistent eosinophilia. Immunol Allergy Clin North Am. 2007 Aug; 27(3): 529–549.
  2. Wilson TA et al. Adrenal Hypoplasia Medication. eMedicine. Feb 11, 2013. http://emedicine.medscape.com/article/918967-medication.