Adrenal crisis

Backgrounds

• Major factor precipitating adrenal crisis is mineralocorticoid, not glucocorticoid, deficiency
  • Major clinical problem is hypotension
• Most commonly presents as shock

Diagnosis

Clinical Picture

• Hypotension
  • Refractory to fluids
• Volume depletion
• Abdominal tenderness
  • Usually generalized
• Fever
  • Usually caused by infection (source must be identified and treated)

1. fever, hypoTN (refractory to fluids), hyperpigmentation by increased ACTH
2. cushingoid look by chronic steroid use
3. think about in kids with congenital adrenal hyperplasia (CAH) who present with shock

Lab tests

• Hyperkalemia
• Hyponatremia

Workup

1. Chemistry/glucose
   1. Guides therapy
2. Cortisol level
   1. Confirms diagnosis
3. Renin, ACTH
   1. For evaluating differential diagnosis if cortisol level normal

Treatment

1. Do not wait for lab results to start treatment
2. Fluids
   1. Infuse 2-3L of NS or D5NS (to correct hypoglycemia)
   2. Avoid hypotonic fluids (may worsen hyponatremia)
3. Glucocorticoids
   1. Patient without previous diagnosis of adrenal insufficiency
      1. Dexamethasone 4mg IV bolus is preferred tx
   2. Patient with known primary adrenal insufficiency w/ potassium > 6
      1. Hydrocortisone 100mg IV bolus (preferred due to its mineralcorticoid activity)
4. Mineralocorticoids are not indicated in acute management
5. Treat underlying cause

Source

7/2/09 PANI (Adapted from Mistry), UpToDate