adrenal crisis.pptx emergency medicine pdf

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1. ACUTE ADRENAL CRISIS

2. CONTENTS Definition Causes Clinical features Signs and symptoms Investigation Management

3. DEFINITION It is sudden deterioration of adrenocortical functions leading to insufficient cortisol. It occurs commonly due to rapid and overwhelming intensification of chronic adrenal insufficiency but occurs uncommonly due to acute adrenal destruction secondary to hemorrhage, sepsis or sudden withdrawl of steroids, etc. It is a medical emergency needs immediate attention and treatment

4. CAUSES Precipitation of chronic adrenal insufficiency by hyperthyroidism, sepsis, surgical stress or intercurrent infection, prolonged fasting, etc. Acute bilateral destruction of adrenal glands by hemorrhage (anticoagulation or a coagulation disorder) embolization or sepsis in previously healthy subjects In children, it may be associated with septicaemia Sudden withdrawal of steroids from patient with adrenal atrophy due to chronic steroid use It may occur in patient with congenital adrenal hyperplasia or those with poor adrenal reserve

5. AETIOLOGY Adrenal causes Sudden precipitation of Addison’s disease Bilateral adrenal haemorrhage Adrenal necrosis due to sepsis Pituitary causes Postpartum pituitary necrosis Pituitary microadenoma Pituitary or adrenal surgery for cushing’s syndrome

6. CLINICAL FEATURES Glucocorticoids and mineralocorticoids and androgen deficiency with excess ACTH. Also includes symptoms of Addison’s disease such as acute circulatory failure or shock with severe hypotension, dehydration, hyponatraemia , hyperkalaemia and in some instances hypoglycemia and hypercalcaemia Muscle cramps, intractable nausea, vomiting and diarrhoea , and unexplained fever may be present. This crisis often precipitated by surgery or sepsis

7. SIGNS AND SYMPTOMS Glucocorticoid deficiency Weight loss, weakness Lack of energy Nausea, vomiting Hypotension Joint pain, Myalgia Hypoglycemia, hyponatraemia Mineralocorticoid deficiency Hypotension Low BP Shock Hyponatraemia Hyperkalemia

8. INVESTIGATIONS Eosinophil count may be high Plasma cortisol (morning & evening) – will be low (Less than 3mcg/dl at 8 am) Short one hour ACTH stimulation test ACTH levels will help to diagnose whether adrenal insufficiency is primary or secondary Serum DHEA levels less than 1000ng/ml in all patient with Addison’s disease Serum Na+ and K+ levels – Serum sodium will be normal to low and Potassium is high Screening for steroid auto antibodies CT scan Blood sputum or urine culture may be positive of bacterial infection

9. MANAGEMENT Aims : Rapid elevation of glucocorticoid levels Replacement of sodium and water deficits Hyponatraemia is itself an emergency. This may lead to delirium, coma and seizures

10. TREATMENT Fluid replacement : Large volume of 5% dextrose in saline or 0.9% normal saline should be infused immediately Steroid replacement therapy : Intravenous hydrocortisone 100mg IV as a bolus or dexamethasone 4mg IV stat - after every 6 hrs for first day Treatment of hypotension : Glucocorticoid replacement, Vasoactive agents ( e.g.dopamine ) No need for mineralocorticoid replacement Identification of precipitating cause and its treatment – bacterial infection – broad spectrum antibiotic should be administered

11. PREVENTION OF FURTHER ILLNESS Concurrent illness To add salt to the diet During an episode of febrile illness, patient should double the dose of steroids for 3-5 days Surgery Minor procedures – under local anaesthesia do not need any change in steroid intake Moderate stressful procedure ( e.g.endoscopy , bronchoscopy, arteriography) need to be covered with an additional dose of 100mg of hydrocortisone I.V

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