Adrenal crisis
Background
- 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 (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
Clinical Features
- Hypotension (refractory to fluids/pressors)
- Hyponatremia/Hyperkalemia (hyperkalemia is not expected in secondary adrenal insufficiency)
- Hypoglycemia
- Dehydration
- Abdominal tenderness
- Confusion/delirium/lethargy
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
- Hypovolemic
- Severe dehydration
- Hemorrhagic shock (traumatic and non-traumatic)
Evaluation
- CBC - eosinophilia[1]
- Chemistry
- Random cortisol, renin, and ACTH levels
- Do not wait for levels before starting treatment
- ACTH (cosyntropin) stimulation test
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[2]:
- 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
- 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
- Admit
References
- 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.
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