Difference between revisions of "Adrenal crisis"

(Treatment)
(See Also)
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==See Also==
 
==See Also==
 
*[[Congenital Adrenal Hyperplasia]]
 
*[[Congenital Adrenal Hyperplasia]]
 +
*[[Addison's disease]]
  
 
==Source ==
 
==Source ==

Revision as of 22:31, 17 May 2015

Background

  • Consider in any pt w/ unexplained hypotension (esp if have HIV or take steroids)
  • Main factor causing adrenal crisis is mineralocorticoid, not glucocorticoid, deficiency
    • This is the reason crises occur much more frequently w/ primary adrenal insufficiency
  • Major clinical problem is hypotension
    • Most commonly presents as shock

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
    • Mets
    • 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

  • Increased demand
    • Infection
    • MI
    • Surgery
    • Trauma
  • Decreased supply
    • Discontinuation of steriod therapy

Clinical Features

Workup

  • Chemistry
  • Random cortisol, renin, and ACTH levels
    • Do not wait for levels before starting treatment

Differential Diagnosis

Shock

Treatment

Begin tx immediately in any suspected case(prognosis related to rapidity of treatment)
  1. IVF
    • D5NS IV 2-3L (corrects fluid deficit and hypoglycemia)
  2. Steroids
    • Hydrocortisone
      • Drug of choice if K+>6 (provides glucocorticoid and mineralcorticoid effects)
      • 2mg/kg up to 100mg IV bolus
    • Dexamethasone
      • Consider in stable patients if ACTH stim test will be performed (won't interfere w/ the test)
      • 4mg IV bolus
  3. Vasopressors
    • Administered after steriod therapy in pts unresponsive to fluid resuscitation
  4. Treat underlying cause

See Also

Source

  • Tintinalli's
  • ACEP Critical Decisions in Emergency Medicine July 2012 issue