Adrenal crisis.pptx

7/30/2019 Adrenal crisis.pptx

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Miss D, 36 year old female was admittedwith a sudden collapse following a viralflu. She had complained of weakness

and lethargy over the last few days. Immediately before collapsing she had

complained of severe abdominal pain

and had a bout of vomiting. Onadmission her blood pressure was60/40mmHg, and the pulse was weakand rapid. CBS was 56mg/dl.


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On further questioning it wasrevealed that the patient had beentaking 8 tablets of prednisolone

daily without a prescription for jointpains.

Recently, she had decided to go off

the drugs as she was feeling well. The attending doctor requested an

urgent serum electrolyte report.


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What do youexpect to find in

the serumelectrolyte report?


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Moderate

hyperkalaemia, normalor decreased sodium


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What is your mostlikely diagnosis?


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Adrenal insufficiency

resulting inAddisonian crisis


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What are the other

possible differentialdiagnoses?


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Anorexia nervosa Acute abdomen Pregnancy relatedcomplications


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What are your priorities on

clinical suspicion of thedisease?


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It should be treatedpromptly without waitingfor laboratory

confirmation.

Still, blood can be takenfor essential investigationsprior to treatment.


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What are the problemsthis patient might have?


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Hypoglycaemia Electrolyte imbalance

Circulatory collapse Ongoing infection


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How will you treat thepatient?


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Establish IV access with two widebore cannulae

Take blood at time of insertion ofcannulae for FBC, BU/SE, bloodculture, RBS Take 10ml of blood in a

heparinized tube for later analysis ofcortisol levels Order urine full report, urineculture, inward CXR and an ECG as

other investigations Correct hypoglycaemia with 50%dextrose 50 ml IV and repeat ifnecessary


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Correct fluid deficit by

o Correcting deficit

o Replacing ongoing losses

o Providing maintenance requirement until thepatient takes orally

As the blood pressure is below 90mmHg in thispatient, she needs one unit of colloids infusedfast.

If the blood pressure is still low, 20ml/kg bolusescan be given until it picks up.


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Iffacilitiesare available, fluid replacement is best guided byinsertionofa CVPline. Whenblood pressure is above 90mmHgfurtherfluids canbe givenat a rate of500mlevery4to 6hours judged bythe clinical

When blood pressure is above 90 mmHgfurther fluids can be given at a rate of500 ml every 4 to 6 hours judged by theclinical signs of overload or deficit.

Replace ongoing losses: Ongoinglosses as vomiting and diarrhea has tobe replaced with normal saline or as oralfluids if the patient is taking orally

Maintenance fluid requirement:Maintenance requirement also needs tobe supplemented intravenously if thepatient is not taking orally.


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Replacement of corticosteroids: HydrocortisoneIV is the drug of choice as it has bothglucocorticoid and mineralocorticoid activities.

It should be given as IV hydrocortisone 100mgstat and as an infusion of 100mg, 8 hourly for2448 hours.

Then convert to 50mg 8 hourly for 48 hours and

later 30mg total dose PO per day. (20mg maneand 10mg vesper).

Fludrocortisone can be added 50300 g POdaily


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Assess need for antibiotics.

The patient may have infection.

Look for features of infection, andstart appropriate antibiotics, usuallybroad spectrum IV antibiotics until

culture results are available.


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What are the possible causes

for adrenal insufficiency in thispatient?


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The most apparent cause is sudden

withdrawal of steroid therapyOther causes to consider are, Autoimmune (polyglandularautoimmune diseases, antibodies

against adrenal cortex) Neoplastic conditions (primary,metastatic) Infective conditions (tuberculosis,

meningococcal sepsis) Metabolic disorders (amyloidosis) Vascular events (infarction,haemorrhage)


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How will you localize the

problem in thehypothalamo-pituitary-adrenal axis?


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The defect can either be in the

adrenal gland (primary) or inpituitary gland (secondary).First establish adrenalinsufficiency by doing a morning

cortisol level at 9.00 a.m.Values less than 3g/dl confirmthe diagnosis while values above

19ug/dl exclude the diagnosis.If it is inconclusive, three tests areused to confirm adrenalinsufficiency;


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A) Short synacthen test (measuring serumcortisol after

synthetic corticotrophin dose, serum cortisol is

measured

after 30 and 60 minutes and values below13ug/dl are

diagnostic of adrenal insufficiency) B) Metyrapone test (read)

C) Insulin tolerance test (read)


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Once adrenal insufficiency is established furthertests are needed to find the site of malfunctionin hypothalamo-- pituitaryadrenal axis.

A) A serum ACTH level > 100 pg/ml is diagnostic

of primary adrenal insufficiencyB) Longsynacthen test to confirm primary adrenalinsufficiency in inconclusive situations

C) CRH test to diagnose secondary (pituitary)

from tertiary (hypothalamic) adrenalinsufficiency

D) CT / MRI, tissue culture and histologicaldiagnosis would be useful in finding anaetiology for adrenal insufficiency.


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What advice would you givethis patient on discharge?


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Explain regarding theaetiology of the condition

Advice regarding theimportance of not stoppingsteroids suddenly.

Give a time plan on tailing offof steroids No dietary restrictions,

increase salt intake No activity restrictions Avoid unnecessary

medication


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Adrenalcrisis

Adrenal crisis.pptx

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