Adrenal crisis

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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

Differential Diagnosis

Shock

Diagnosis

Treatment

Begin treatment 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
      • 4mg IV bolus
      • Consider in hemodynamically stable patients if ACTH stim test will be performed (won't interfere w/ the test)
      • Along with methylprednisolone, dexamethasone has negligible mineralocorticoid effect, so choose hydrocortisone in[2]:
    • Comparable stress-dose steroids
      • Hydrocortisone (50-75 mg/m2 or 1-2 mg/kg)
      • Methylprednisolone are 10-15 mg/m2
      • Dexamethasone 1-1.5 mg/m2
  3. Vasopressors
    • Administered after steriod therapy in pts unresponsive to fluid resuscitation
  4. Treat underlying cause

See Also

References

  • ACEP Critical Decisions in Emergency Medicine July 2012 issue
  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.