26 year old Male

PC: 2 day history

Fever, Nausea, Vomiting and Diarrhoea

Postural syncopal episode

No Past medical history/medications

Low energy Levels

Clinical – Looks ill, distressed

T 37.8

PR 120

BP 65/40

RR 26

Chest: Clear

Abdomen: SNT

ABG

pH 7.32

pCO2 45

pO2 50

HCO3- 17.1

BE -6.9

Na+ 121

K+ 6.1

Cl- 92

BSL 3.0

Creat. 110

Urine Dipstick: Clear

ECG: NSR, Sinus Tachy.

CXR: Clear

DON’T MIND ME…I’M JUST STRESSED!

An overview of Adrenal Insufficency in the Emergency

Department

Dr Kyle Kophamel

1st May 2014

SCGH - CME

Aims Define Adrenal Insufficiency/Crisis

Outline Approach specific to Emergency

Setting

Highlight Adrenal Insufficiency as a diagnostic

Consideration

Function Glucocorticoids

Cortisol

“facilitates stress response”

Increase Glucose

Fat, Protein, Carbohydrate Metabolism

Immunosuppression

Vascular tone + Cardiac Contractility

Mineralocorticoids

Aldosterone

Reabsorption of Na+ and Water

Excretion K+

Adrenal Failure

Basal Failure results in Adrenal Insufficiency

Insidious wasting disease

Stress failure results in Adrenal Crisis

Life Threatening

Adrenal Insufficiency Primary

Failure of Adrenal glands

Most common:

Autoimmune Adrenalitis - Addison’s (70-80%)

Infectious TB

Results in Cortisol AND Aldosterone

Secondary

Failure of HPA axis

Exogenous glucocorticoid administration

Results in Cortisol

Adrenal Insufficiency

1 in 500

Chronic Insufficiency Hyponatremia

Hypernatremia

Only in 2 Failure

Hyperkalemia

Only 1 Failure

Nonspecific

Fatigue, Anorexia

Neurologicial

Headaches, Visual changes

Gastrointestinal

Pain, N+V, Diarrhoea

Orthostatic Hypotension

Hypoglycemia

Hyperpigmentation

Adrenal Crisis Supply Demand

Adrenal Crisis STRESS

Normal Response

Increases glucocorticoid and mineralocorticoid levels 5-10 fold

Adrenal Insufficient individuals

High risk for Adrenal Crisis

Stressors

AMI, Febrile Illness, Trauma, Surgery, V+D.

Adrenal CrisisClinical Presentation

Profound Shock

Resistant to IVF resuscitation and

Vasopressors

Electrolyte Disturbance

Pallor/Dizziness/Headache/

Altered Mental state

Lethargy/Weakness

Abdominal Pain

N+V

Hypoglycemia

Adrenal CrisisManagement

Attend ABC’s

IV Fluid Resuscitation

Normal Saline – Resus and correct Na+

Dextrose – correct BSL

Treat Hyperkalemia

IV Hydrocortisone 100-150mg

OR Dexamethasone 4mg IV

Vasopressors

Norepinephrine

Investigate and Treat underlying stress

Adrenal CrisisInvestigation

Vitals

Blood Gas

WCC, Urea, Creatinine, Calcium, Serum Cortisol

ECG

CXR, MSU, Blood Cultures

CT Abdomen

CT Head

Short Synacthen Test

Considering the Diagnosis Unexplained Hypotension

Especially in high risk populations

Characteristic Electrolyte abnormalities

Primary vs Secondary

Disposition Critically Ill

ICU/HDU

Patients with Chronic Adrenal Insufficiency with Acute Illness or Injury

Patients with Past Corticosteroid Treatment

References Arlt W. The approach to the adult with newly diagnosed adrenal

insufficiency. J Clin Endocrinol Metab. 2009 Apr;94(4):1059-67. PMID: 19349469.

Arlt W, Allolio B. Adrenal insufficiency. Lancet. 2003 May 31;361(9372):1881-93. PMID: 12788587

Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7e. Judith E. Tintinalli

Adrenal Crisis in Emergency Medicine Workup Author: Kevin M Klauer, DO, FACEP; Chief Editor: Erik D Schraga, MD http://emedicine.medscape.com/article/765753-overview

http://lifeinthefastlane.com/education/ccc/adrenal-insufficency/