Adrenal crisis

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)

1. Primary adrenal insufficiency (decreased cortisol and aldosterone)
   1. Autoimmune (70%)
   2. Adrenal hemorrhage
      1. Coagulation disorders
      2. Sepsis (Waterhouse-Friderichsen syndrome)
   3. Meds
   4. Infection (HIV, TB)
   5. Sarcoidosis/amyloidosis
   6. Mets
   7. CAH
2. Secondary adrenal insufficiency (decreased ACTH -> decreased cortisol only)
   1. Withdrawal of steroid therapy
   2. Pituitary disease
   3. Head trauma
   4. Postpartum pituitary necrosis
   5. 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
• Abdominal tenderness
  • Usually generalized
• Hyponatremia/hyperkalemia
• Hypoglycemia
• Confusion/delirium/lethargy
• Fever
  • Usually caused by infection

Workup

1. Chemistry
2. Random cortisol, renin, and ACTH levels
   1. Do not wait for levels before starting treatment

Treatment

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

See Also

• Congenital Adrenal Hyperplasia

Source

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