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)

• 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

• Hypotension
  • Refractory to fluids/presors
• Dehydration
• Abdominal tenderness
  • Usually generalized
• Hyponatremia/hyperkalemia
• Hypoglycemia
• Confusion/delirium/lethargy
• Fever
  • Usually caused by infection

Workup

• Chemistry
• Random cortisol, renin, and ACTH levels
  • Do not wait for levels before starting treatment

Differential Diagnosis

Shock

• Cardiogenic
  • Acute valvular Regurgitation/VSD
  • CHF
  • Dysrhythmia
  • ACS
  • Myocardial Contusion
  • Myocarditis
  • Drug toxicity (e.g. beta blocker, CCB, or bupropion OD)
• Obstructive
  • Air embolism
  • Aortic Stenosis
  • Cardiac Tamponade
  • PE
  • Tension pneumothorax
• Distributive
  • Adrenal crisis
  • Anaphylaxis
  • Neurogenic shock
  • Sepsis
  • Toxicologic
• Hypovolemic
  • Severe dehydration
  • Hemorrhagic shock (traumatic and non-traumatic)

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)
    • 2mg/kg up to 100mg IV bolus
  • Dexamethasone
    • Consider in stable patients if ACTH stim test will be performed (won't interfere w/ the test)
    • 4mg IV bolus
• Vasopressors
  • Administered after steriod therapy in pts unresponsive to fluid resuscitation
• Treat underlying cause

See Also

• Congenital Adrenal Hyperplasia

Source

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