Adrenal crisis: Difference between revisions

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==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
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***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]]
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===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==
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*[[Dehydration]]
*[[Dehydration]]
*[[Abdominal tenderness]]
*[[Abdominal tenderness]]
*Confusion/delirium/lethargy
*[[AMS|Confusion/delirium/lethargy]]


==Differential Diagnosis==
==Differential Diagnosis==
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==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
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*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==

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.
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