Addisonian crisis Flashcards
What are 4 types of causes of Addisonian crisis?
- Stress e.g. sepsis or surgery causing an acute exacerbation of chronic insufficiency (Addison’s, hypopituitarism)
- Adrenal haemorrhage e.g. Waterhouse-Friderichsen syndrome (fulminant meningococcaemia)
- Steroid withdrawal
- Pituitary apoplexy
What is the definition of Addisonian crisis?
serious medical condition caused by body’s inability to produce a sufficient amount of cortisol
What are 5 examples of stress which may precipitate Addisonian crisis in patients with a background of chronic insufficiency?
- Gastrointestinal illness (most common)
- Other infections including sepsis
- Perioperative period
- Physical stress or pain
- Psychological stress
What is the commonest cause of stress leading to Addisonian crisis on a background of chronic insufficiency?
Gastrointestinal illness
What are 7 signs and symptoms of Addisonian crisis?
- Hypotension, shock
- Imapired consciousness
- Coma
- Fever
- Vomiting
- Diarrhoea
- Severe abdominal pain (which can resemble peritoniitis)
What are 3 areas of investigations in suspected Addisonian crisis?
- Based on clinical suspicion: low threshold in at-risk patients e.g. shock refractory to fluids and/or vasopressors
- Routine bloods
- Endocrine testing
What are 3 types of routine tests which can help confirm a diagnosis of Addisonian crisis?
- U+Es: hyponatraemia, hyperkalaemia, hypocalcaemia
- Glucose: Hypoglycaemia
- Blood gas: Normal anion gap metabolic acidosis
What are the cardinal 3 electrolyte abnormalities in Addisonian crisis?
- Hyponatraemia
- Hypoglycaemia
- Hyperkalaemia
What are 2 forms of endocrine testing to perform if the diagnosis of Addisonian crisis is uncertain?
- Random cortisol level (prior to hydrocortisone administration)
- ACTH stimulation test: once patient stable
When are more specific endocrine tests peformed to confirm a diagnosis of Addisonian crisis?
if diagnosis is uncertain
What are the 4 aspects of management of Addisonian crisis?
- 1L fluid resuscitation if hypotensive
- IV hydrocortisone 100mg (or IM)
- IV glucose if hypoglycaemic
- Swab back to their oral steroids after 3 days
What are the 2 routes that hydrocortisone can be given in Addisonian crisis and what is the dose?
IM or IV, 100mg
Which fluids should be given in a patient with Addisonian criis?
1L 0.9% NaCl over 30-60 min or with dextrose if hypoglycaemic
How frequently is hydrocortisone given after the initial dose in Addisonian crisis?
continue 6 hourly until patient is stable
Why is no fludrocortisone initially needed for the management of Addisonian crisis?
high cortisol exerts weak mineralocorticoid action
Within what time period can oral replacement of hydrocortisone begin following Addisonian crisis and when can the dose be reduced to maintenance levels?
after 24h
can be reduced to maintenance over 3-4 days
What are the 5 Ss of management of Addisonian crisis?
salt (0.9% saline), sugar (50% dextrose), steroids (100mg hydrocortisone IV), support (normal saline to correct hypotension and electroytes), search for underlying disorder
What are 6 complicatoins of Addisonian crisis?
- Low blood pressure
- Vomiting and diarrhoea
- Dehydration
- Shock
- Coma
- Death
