Adrenal crisis: Difference between revisions
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*Consider in any pt w/ unexplained hypotension (esp if have HIV or take steroids) | *Consider in any pt w/ unexplained hypotension (esp if have HIV or take steroids) | ||
*Main factor causing adrenal crisis is mineralocorticoid, not glucocorticoid, deficiency | *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 | *Major clinical problem is hypotension | ||
**Most commonly presents as shock | **Most commonly presents as shock |
Revision as of 02:20, 23 October 2011
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)
- 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
- Hypotension
- Refractory to fluids/presors
- Dehydration
- Confusion/delirium/lethargy
- Abdominal tenderness
- Usually generalized
- Hyponatremia/hyperkalemia
- Hypoglycemia
- Fever
- Usually caused by infection
Workup
- Chemistry
- 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
- Hydrocortisone
- Vasopressors
- Administered after steriod therapy in pts unresponsive to fluid resuscitation
- Treat underlying cause
Source
Tintinalli's