Difference between revisions of "Adrenal crisis"

(Text replacement - "==Diagnosis==" to "==Evaluation==")
 
(7 intermediate revisions by 3 users not shown)
Line 1: Line 1:
 
==Background==
 
==Background==
*Consider in any patient with unexplained hypotension (especially in those with HIV or taking exogenous steroids)
+
*Consider in any patient with unexplained [[hypotension]] (especially in those with [[HIV]] or taking exogenous steroids)
 
*Generally caused by mineralocorticoid deficiency, not glucocorticoid deficiency
 
*Generally caused by mineralocorticoid deficiency, not glucocorticoid deficiency
 
**This is the reason crises occur much more frequently with primary adrenal insufficiency
 
**This is the reason crises occur much more frequently with primary adrenal insufficiency
Line 14: Line 14:
 
***TB is most common worldwide cause primary adrenal insuffiency
 
***TB is most common worldwide cause primary adrenal insuffiency
 
**[[Sarcoidosis]]/[[amyloidosis]]
 
**[[Sarcoidosis]]/[[amyloidosis]]
**Mets
+
**Metastases
 
**[[Congenital Adrenal Hyperplasia|CAH]]
 
**[[Congenital Adrenal Hyperplasia|CAH]]
*Secondary adrenal insufficiency (decreased ACTH -> decreased cortisol only)
+
*Secondary adrenal insufficiency (decreased ACTH decreased cortisol only)
**Withdrawal of steroid therapy
+
**Withdrawal of [[steroid]] therapy
 
**Pituitary disease
 
**Pituitary disease
 
**[[Head trauma]]
 
**[[Head trauma]]
Line 25: Line 25:
 
===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==
Line 38: Line 38:
 
*[[Dehydration]]
 
*[[Dehydration]]
 
*[[Abdominal tenderness]]
 
*[[Abdominal tenderness]]
*Confusion/delirium/lethargy
+
*[[AMS|Confusion/delirium/lethargy]]
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
Line 44: Line 44:
  
 
==Evaluation==
 
==Evaluation==
*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>
+
*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
 
*Chemistry
 
*Random cortisol, renin, and ACTH levels
 
*Random cortisol, renin, and ACTH levels
Line 54: Line 54:
 
*Treat underlying cause, if known
 
*Treat underlying cause, if known
 
*[[IVF]] - D5NS 2-3L (corrects fluid deficit and hypoglycemia)
 
*[[IVF]] - D5NS 2-3L (corrects fluid deficit and hypoglycemia)
*Steroids
+
*[[Steroids]]
 
**[[Hydrocortisone]] - 2mg/kg up to 100mg IV bolus
 
**[[Hydrocortisone]] - 2mg/kg up to 100mg IV bolus
***Drug of choice if K+>6 (provides glucocorticoid and mineralcorticoid effects)
+
***Drug of choice if K+>6 (provides glucocorticoid and mineralocorticoid effects)
 
**[[Dexamethasone]] - 4mg IV bolus
 
**[[Dexamethasone]] - 4mg IV bolus
 
***Consider in hemodynamically stable patients if ACTH stimulation test will be performed (will not interfere with the test)
 
***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>:
+
***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
+
****[[Hypotension]]
 
****[[Hyponatremia]] or [[hyperkalemia]]
 
****[[Hyponatremia]] or [[hyperkalemia]]
 
**Comparable steroid dosages
 
**Comparable steroid dosages
***Hydrocortisone (50-75mg/m2 or 1-2mg/kg)
+
***[[Hydrocortisone]] (50-75mg/m2 or 1-2mg/kg)
***Methylprednisolone are 10-15mg/m2
+
***[[Methylprednisolone]] are 10-15mg/m2
***Dexamethasone 1-1.5mg/m2
+
***[[Dexamethasone]] 1-1.5mg/m2
 
*[[Vasopressors]]
 
*[[Vasopressors]]
 
**Administer after steroid therapy in patients unresponsive to fluid resuscitation
 
**Administer after steroid therapy in patients unresponsive to fluid resuscitation
  
 
===Stress-Dose Steroids in Illness===
 
===Stress-Dose Steroids in Illness===
*To aid in mounting stress response in those with adrenal insufficiency lacking endogenous cortisol
+
''To aid in mounting stress response in those with adrenal insufficiency lacking endogenous cortisol''
*Minor illness, with fever < 38°C
+
{| {{table}}
**Administer double the dose of chronic maintenance steroids
+
| align="center" style="background:#f0f0f0;"|'''Illness Type'''
*Severe illness, with fever > 38°C
+
| align="center" style="background:#f0f0f0;"|'''Steroid Administration'''
**Admin triple dose of chronic maintenance steroids
+
|-
*Vomiting, listless, or hypotensive
+
| Minor, with fever < 38°C||Double dose of chronic maintenance steroids
**Administer hydrocortisone at 1-2mg/kg as above in adrenal crisis
+
|-
 +
| 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==
 
==Disposition==

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.