Adrenal crisis

Adrenal crisis

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  By- Prem MohanJha Jr3 (medicine)
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   Life-threatening emergency Triggered by anything that increases the person’s normal stress level  The body is unable to release sufficient cortisol to respond appropriately  May lead to shock & vascular collapse  Typically resistant to catecholamine and IVF resuscitation
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  The Adrenal Gland releases…Androgens (sex hormones) Mineralocorticoids Glucocorticoids Glucocortoicoids (most potent is cortisol) Action: anti-inflammatory, growth suppressing, affects sleep patterns & awareness, stress response Mineralcorticoids (Aldosterone) Action: Manages sodium/potassium balance Internet.
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  Kronenberg - WilliamsTextbook of Endocrinology 11th ed
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   Dehydration, hypotension,or shock out of proportion to severity of current illness  Nausea and vomiting with a history of weight lost and anorexia  Abdominal pain, so-called acute abdomen  Unexplained hypoglycemia  Unexplained fever  Hyponatremia, hyperkalemia, azotemia, hypercalcemia, or eosinophilia  Hyperpigmentation or vitiligo  Other autoimmune endocrine deficiencies, such as hypothyroidism or gonadal failure Kronenberg - Williams Textbook of Endocrinology 11th ed
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   Abrupt adrenalfailure usually from  Bilateral adrenal infarction  Bilateral adrenal Hemorrhage  Primary Adrenal Insufficiency  Serious infection  Acute stress in previously undiagnosed cases  No extra glucocorticoid therapy during infection  Secondary adrenocortical insufficiency -Abrupt withdrawal from glucocorticoids  Catastrophic HPA axis failure  Head trauma  Hemorrhage of pituitary adenoma  Post-partum herniation (Sheehan syndrome) Kronenberg - Williams Textbook of Endocrinology 11th ed
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  Immediate Laboratory Workup  Electrolytes, glucose  Baseline Cortisol and ACTH  Send immediately (before steroid administration)  Send in early morning sample if pt is stable with suspected chronic adrenal insufficiency  Can measure urinary 17-OHCS  Renin(+/- aldosterone- less sensitive)Random Cortisol Kronenberg - Williams Textbook of Endocrinology 11th ed
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   Cosyntropin(synthetic ACTH)stimulation test is (used in all patients in whom adrenal insufficiency is being considered  Cortisol levels measured at 0 and 30 minutes following cosyntropin administration  Normal response is defined by a peak plasma cortisol of > 20mcg/dl.  Primary adrenal insufficiency has a low or no rise in cortisol following ACTH stimulation  Secondary or Tertiary causes due to deficient endogenous ACTH have an increase in cortisol (sub sub-normal) following ACTH stimulation. Kronenberg - Williams Textbook of Endocrinology 11th ed
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   Imaging:  AbdominalCT to evaluate for adrenal findings (ie. Infection, calcification, hemorrhage)  Head CT or MRI if secondary AI is diagnosed  Other Labs:  Anti-adrenal antibodies  VLCFA (very long chain fatty acids)(acids)  Especially in young males with negative antibodies  Evaluate for other autoimmune disorders as indicated  PPD if TB is suspected  Metyrapone test: : ↓↓cortisol synthesis, should see a resultant ↑↑in ACTH. Used to diagnosis partial ACTH Kronenberg - Williams Textbook of Endocrinology 11th ed
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   EMERGENCY MEASURES 1)Establish intravenous access with a large-gauge needle 2) Draw blood for stat serum electrolytes and glucose and routine measurement of plasma cortisol and ACTH. Do not wait for laboratory results. 3) Infuse 2 to 3 L of 0.9% saline solution or 5% dextrose in 0.9% saline solution as quickly as possible. Monitor for signs of fluid overload by measuring central or peripheral venous pressure and listening for pulmonary rales. Reduce infusion rate if indicated. 4) Inject intravenous hydrocortisone (100 mg immediately and every 6 hr) 5) Use supportive measures as needed. Kronenberg - Williams Textbook of Endocrinology 11th ed
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   Continue iv0.9% saline solution at a slower rate for next 24 to 48 hr  Search for and treat possible infectious precipitating causes of the adrenal crisis  Perform a short ACTH stimulation test to confirm the diagnosis of adrenal insufficiency, if he is not a known case .  Determine the type of adrenal insufficiency and its cause if not already known.  Taper glucocorticoids to maintenance dosage over 1 to 3 days, if precipitating or complicating illness permits.  Begin mineralocorticoid replacement with fludrocortisone (0.1 mg by mouth daily) when saline infusion is stopped. Kronenberg - Williams Textbook of Endocrinology 11th ed
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   Glucocorticoid replacement Dexamethasone or prednisone (longer-acting or once daily acting) daily  Alternative therapy with hydrocortisone BID -TID  Mineralocorticoid replacement  Fludrocortisone  Liberal salt intake  Patient Education  Recognition and treatment of minor and major stress/ illness  Instructions to triple the dose of steroid in the event of an intercurrent illness, accident or mental stress  Emergency precautions  Medic-alert bracelet, pre alert pre--filled dexamethasone syringes Kronenberg - Williams Textbook of Endocrinology 11th ed
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   Tuberculosis isknown to affect adrenal glands directly.  Adrenal destruction by tuberculosis may lead to overt or subclinical adrenal insufficiency  In India it is the most common cause of Addison’s disease .  CT abdomen shows typically shrunken and calcified adrenals in chronic stage and enlarged in the active stage. Confirmed by FNAC  ATT increase the degratdation of corticosteroids, may precipitate the adrenal crisis & has been reported with rifampicin therapy INT. J. DIAB. DEV. COUNTRIES (1999), VOL. 19
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   “Unexplained hyponatremiaand hyperkalemia in the setting of hypotension unresponsive to catecholamine and fluid administration… should receive 100mg hydrocortisone intravenously.”  Prevention through careful titration of steroids  Patient, family, friends aware of signs/symptoms of crisis Thank You