Adrenal crisis: Difference between revisions
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==Background== | ==Background== | ||
*Consider in any | [[File:Gray1120-adrenal glands.png|thumb|Posterior view of the adrenal glands (colored) in relation to the viscera and large vessels of the abdomen (thoracic vertebra removed).]] | ||
* | [[File:HPA axis combined.jpg|thumb|Types of adrenal insufficiency (primary, secondary, and tertiary) compared to normal physiology. In its normal state, the hypothalamus secretes corticotropin-releasing hormone (CRH) to induce the pituitary gland to secrete adrenocorticotropic hormone (ACTH) to induce the adrenal gland to secrete cortisol. Cortisol then exerts negative feedback by inhibiting the secretion of CRH and ACTH in the hypothalamus and pituitary gland, respectively.]] | ||
**This is the reason crises occur much more frequently | *Adrenal insufficiency occurs when the adrenal glands fail to supply the physiologic demands of the body for glucocorticoids (cortisol) and/or mineralocorticoids (aldosterone). | ||
*Divided into primary adrenal insufficiency or secondary adrenal insufficiency | |||
*Adrenal crisis is the acute, life-threatening presentation of adrenal insufficiency<ref>Hahner S, Loeffler M, Bleicken B, et al. Epidemiology of adrenal crisis in chronic adrenal insufficiency: the need for new prevention strategies. Eur J Endocrinol. 2010;162(3):597-602. doi:10.1530/EJE-09-0884</ref> | |||
**8-47% of patients with primary adrenal insufficiency will have at least one adrenal crisis in their lives | |||
**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 | ===Causes of 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 | |||
**[[Congenital Adrenal Hyperplasia|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== | ===Precipitants=== | ||
*Increased demand | *Increased demand | ||
**Infection | **[[sepsis|Infection]] | ||
**MI | **[[MI]] | ||
**Surgery | **Surgery | ||
**Trauma | **[[Trauma]] | ||
*Decreased supply | *Decreased supply | ||
**Discontinuation of | **Discontinuation of [[steroid]] therapy | ||
==Clinical Features== | ==Clinical Features== | ||
* | [[File:AdrenalCrisis.jpg|thumb|Forty-nine year-old with an adrenal crisis. Appearance, showing lack of facial hair, dehydration, Queen Anne’s sign (panel A), pale skin, muscular and weight loss, and loss of body hair (panel B)..]] | ||
** | *Adrenal Crisis<ref>Rao RH, Vagnucci AH, Amico JA. Bilateral massive adrenal hemorrhage: early recognition and treatment. Ann Intern Med. 1989;110(3):227-235. doi:10.7326/0003-4819-110-3-227</ref> | ||
* | **[[Hypotension]] (refractory to fluids/pressors)(90%) | ||
*Abdominal tenderness | **[[Abdominal tenderness]] (86%) | ||
** | **[[Fever]] (66%) | ||
**[[AMS|Confusion/delirium/lethargy]](42%) | |||
* | **[[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> | ||
* | |||
** | |||
== | *Primary Adrenal Insufficiency<ref>Bancos I, Hahner S, Tomlinson J, Arlt W. Diagnosis and management of adrenal insufficiency. Lancet Diabetes Endocrinol. 2015;3(3):216-226. doi:10.1016/S2213-8587(14)70142-1</ref> | ||
**[[Anorexia]] (100%) | |||
**[[Weakness|Weakness/fatigue]] (84-100%) | |||
**Hyperpigmentation (41-94%) | |||
**[[Hypotension]] (41-94%) | |||
== | **[[Hyponatremia]] (57-88%) | ||
**[[Hyperkalemia]] (30-85%) | |||
**Azotemia (55%) | |||
**[[Dehydration]] | |||
*Secondary Adrenal Insufficiency | |||
**Similar to primary adrenal insufficiency | |||
**No hyperpigmentation | |||
**No hyperkalemia | |||
**Hypotension less common | |||
==Differential Diagnosis== | |||
{{Adrenal crisis ddx}} | |||
# | {{Shock DDX}} | ||
==Evaluation== | |||
*'''Labs''' | |||
**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]] | |||
*'''Imaging''' | |||
**Consider CXR to identify infectious triggers | |||
==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== | |||
*'''Admission''' | |||
**Admit all patients with acute adrenal insufficiency, especially if new diagnosis for the patient | |||
**Patients with adrenal crisis should receive ICU admission | |||
*'''Discharge''' | |||
**Consult endocrinology if discharge considered for mild cases w/ normal lab values | |||
==See Also== | ==See Also== | ||
*[[Congenital Adrenal Hyperplasia]] | *[[Congenital Adrenal Hyperplasia]] | ||
*[[Addison's disease]] | |||
==External Links== | |||
*[http://www.emdocs.net/core-em-adrenal-crisis/ emDocs - Adrenal Crisis] | |||
== | ==References== | ||
<references/> | |||
[[Category: | [[Category:Endocrinology]] |
Latest revision as of 16:37, 14 February 2024
Background
- Adrenal insufficiency occurs when the adrenal glands fail to supply the physiologic demands of the body for glucocorticoids (cortisol) and/or mineralocorticoids (aldosterone).
- Divided into primary adrenal insufficiency or secondary adrenal insufficiency
- Adrenal crisis is the acute, life-threatening presentation of adrenal insufficiency[1]
- 8-47% of patients with primary adrenal insufficiency will have at least one adrenal crisis in their lives
- 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 of 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
- Adrenal Crisis[2]
- Hypotension (refractory to fluids/pressors)(90%)
- Abdominal tenderness (86%)
- Fever (66%)
- Confusion/delirium/lethargy(42%)
- Hypoglycemia
- Low bicarbonate, non-anion gap metabolic acidosis (due to decreased acid secretion in kidneys from aldosterone deficiency)[3]
- Primary Adrenal Insufficiency[4]
- Anorexia (100%)
- Weakness/fatigue (84-100%)
- Hyperpigmentation (41-94%)
- Hypotension (41-94%)
- Hyponatremia (57-88%)
- Hyperkalemia (30-85%)
- Azotemia (55%)
- Dehydration
- Secondary Adrenal Insufficiency
- Similar to primary adrenal insufficiency
- No hyperpigmentation
- No hyperkalemia
- Hypotension less common
Differential Diagnosis
Adrenal crisis
Shock
- Cardiogenic
- Acute valvular Regurgitation/VSD
- CHF
- Dysrhythmia
- ACS
- Myocardial Contusion
- Myocarditis
- Drug toxicity (e.g. beta blocker, CCB, or bupropion OD)
- Obstructive
- Distributive
- Hypovolemic
- Severe dehydration
- Hemorrhagic shock (traumatic and non-traumatic)
Evaluation
- Labs
- CBC - eosinophilia[5]
- Chemistry
- Random cortisol, renin, and ACTH levels
- Do not wait for levels before starting treatment
- ACTH (cosyntropin) stimulation test
- Imaging
- Consider CXR to identify infectious triggers
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[6]:
- Comparable steroid dosages
- Hydrocortisone (50-75mg/m2 or 1-2mg/kg)
- Methylprednisolone are 10-15mg/m2
- Dexamethasone 1-1.5mg/m2
- Hydrocortisone - 2mg/kg up to 100mg IV bolus
- 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
- Admission
- Admit all patients with acute adrenal insufficiency, especially if new diagnosis for the patient
- Patients with adrenal crisis should receive ICU admission
- Discharge
- Consult endocrinology if discharge considered for mild cases w/ normal lab values
See Also
External Links
References
- ↑ Hahner S, Loeffler M, Bleicken B, et al. Epidemiology of adrenal crisis in chronic adrenal insufficiency: the need for new prevention strategies. Eur J Endocrinol. 2010;162(3):597-602. doi:10.1530/EJE-09-0884
- ↑ Rao RH, Vagnucci AH, Amico JA. Bilateral massive adrenal hemorrhage: early recognition and treatment. Ann Intern Med. 1989;110(3):227-235. doi:10.7326/0003-4819-110-3-227
- ↑ Izumi Y et al. Renal tubular acidosis complicated with hyponatremia due to cortisol insufficiency. Oxf Med Case Reports. 2015 Nov; 2015(11): 360–363.
- ↑ Bancos I, Hahner S, Tomlinson J, Arlt W. Diagnosis and management of adrenal insufficiency. Lancet Diabetes Endocrinol. 2015;3(3):216-226. doi:10.1016/S2213-8587(14)70142-1
- ↑ Nutman TB. Evaluation and differential diagnosis of marked, persistent eosinophilia. Immunol Allergy Clin North Am. 2007 Aug; 27(3): 529–549.
- ↑ Wilson TA et al. Adrenal Hypoplasia Medication. eMedicine. Feb 11, 2013. http://emedicine.medscape.com/article/918967-medication.