Adrenal crisis: Difference between revisions

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===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 22:48, 18 December 2018

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
    • 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

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 mineralcorticoid 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
      • 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

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.