Adrenal crisis: Difference between revisions

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==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
*Low bicarbonate, non-anion gap [[metabolic acidosis]] (due to decreased acid secretion in kidneys from aldosterone deficiency)<ref>Izumi Y et al. Renal tubular acidosis complicated with hyponatremia due to cortisol insufficiency. Oxf Med Case Reports. 2015 Nov; 2015(11): 360–363.</ref>
*Abdominal tenderness
*[[Dehydration]]
**Usually generalized
*[[Abdominal tenderness]]
*Hyponatremia/hyperkalemia
*[[AMS|Confusion/delirium/lethargy]]
*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]]

Revision as of 11:42, 3 May 2020

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[3]:
    • 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. Izumi Y et al. Renal tubular acidosis complicated with hyponatremia due to cortisol insufficiency. Oxf Med Case Reports. 2015 Nov; 2015(11): 360–363.
  2. Nutman TB. Evaluation and differential diagnosis of marked, persistent eosinophilia. Immunol Allergy Clin North Am. 2007 Aug; 27(3): 529–549.
  3. Wilson TA et al. Adrenal Hypoplasia Medication. eMedicine. Feb 11, 2013. http://emedicine.medscape.com/article/918967-medication.