Post on 14-Apr-2018
7/30/2019 Adrenal crisis.pptx
1/27
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.
7/30/2019 Adrenal crisis.pptx
2/27
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.
7/30/2019 Adrenal crisis.pptx
3/27
What do youexpect to find in
the serumelectrolyte report?
7/30/2019 Adrenal crisis.pptx
4/27
Moderate
hyperkalaemia, normalor decreased sodium
7/30/2019 Adrenal crisis.pptx
5/27
What is your mostlikely diagnosis?
7/30/2019 Adrenal crisis.pptx
6/27
Adrenal insufficiency
resulting inAddisonian crisis
7/30/2019 Adrenal crisis.pptx
7/27
What are the other
possible differentialdiagnoses?
7/30/2019 Adrenal crisis.pptx
8/27
Anorexia nervosa Acute abdomen Pregnancy relatedcomplications
7/30/2019 Adrenal crisis.pptx
9/27
What are your priorities on
clinical suspicion of thedisease?
7/30/2019 Adrenal crisis.pptx
10/27
It should be treatedpromptly without waitingfor laboratory
confirmation.
Still, blood can be takenfor essential investigationsprior to treatment.
7/30/2019 Adrenal crisis.pptx
11/27
What are the problemsthis patient might have?
7/30/2019 Adrenal crisis.pptx
12/27
Hypoglycaemia Electrolyte imbalance
Circulatory collapse Ongoing infection
7/30/2019 Adrenal crisis.pptx
13/27
How will you treat thepatient?
7/30/2019 Adrenal crisis.pptx
14/27
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
7/30/2019 Adrenal crisis.pptx
15/27
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.
7/30/2019 Adrenal crisis.pptx
16/27
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.
7/30/2019 Adrenal crisis.pptx
17/27
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
7/30/2019 Adrenal crisis.pptx
18/27
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.
7/30/2019 Adrenal crisis.pptx
19/27
What are the possible causes
for adrenal insufficiency in thispatient?
7/30/2019 Adrenal crisis.pptx
20/27
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)
7/30/2019 Adrenal crisis.pptx
21/27
How will you localize the
problem in thehypothalamo-pituitary-adrenal axis?
7/30/2019 Adrenal crisis.pptx
22/27
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;
7/30/2019 Adrenal crisis.pptx
23/27
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)
7/30/2019 Adrenal crisis.pptx
24/27
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.
7/30/2019 Adrenal crisis.pptx
25/27
What advice would you givethis patient on discharge?
7/30/2019 Adrenal crisis.pptx
26/27
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
7/30/2019 Adrenal crisis.pptx
27/27
Adrenalcrisis