Adrenal crisis: Difference between revisions
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==Treatment== | ==Treatment== | ||
;Begin tx immediately in any suspected case(prognosis related to rapidity of treatment) | |||
#[[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== | ==See Also== | ||
Revision as of 23:56, 20 February 2015
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
- Hyperkalemia is not expected in Secondary Adrenal Insuffiency
- 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
- Distributive
- Hypovolemic
- Severe dehydration
- Hemorrhagic shock (traumatic and non-traumatic)
Treatment
- Begin tx immediately in any suspected case(prognosis related to rapidity of treatment)
- 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
- Hydrocortisone
- Vasopressors
- Administered after steriod therapy in pts unresponsive to fluid resuscitation
- Treat underlying cause
See Also
Source
- Tintinalli's
- ACEP Critical Decisions in Emergency Medicine July 2012 issue