ADRENAL CRISIS

Question 1

Essentials of diagnosis of a patient with Acute Adrenal Crisis- Adrenocortical Insufficiency

Answer 1

(a) Weakness, abdominal pain, fever, confusion, vomiting
(b) Low blood pressure, dehydration
(c) Skin pigmentation may be increased
(d) Insufficient aldosterone will result in elevated serum potassium and
low sodium.
(e) Insufficient cortisol may result in hypoglycemia
(f) Dehydration and hypotension may result in poor kidney perfusion
(may see elevated blood urea nitrogen and creatinine)

Question 2

General Considerations of a patient with Acute Adrenal Crisis- Adrenocortical Insufficiency

Answer 2

An emergency caused by insufficient mineralocorticoid (aldosterone)
and glucocorticoid (cortisol)

Question 3

Causes of a patient with Acute Adrenal Crisis- Adrenocortical Insufficiency

Answer 3

1) Primary and Secondary
a) Primary - resulting from destruction or dysfunction of the adrenal cortex.
b) Secondary- resulting from ACTH hyposecretion.
2) May occur during stress (e.g., trauma, surgery, infection,
hyperthyroidism, or prolonged fasting) in a patient with latent
insufficiency or treated adrenal insufficiency with sudden
withdrawal of adrenocortical hormones (e.g. prednisone or
fludrocortisone)
3) Drug-induced adrenal insufficiency
a) Steroid medications called glucocorticoids (e.g. prednisone and
dexamethasone) and mineralocorticoids (e.g. hydrocortisone and
fludrocortisone) are similar to natural hormones cortisol and
aldosterone produced in the adrenal gland
b) They are used to treat a variety of conditions, including many
inflammatory diseases such as asthma and some forms of
arthritis.
c) If steroids are stopped or decreased too quickly, the adrenal glands
may not begin making cortisol again fast enough to meet the body’s
needs.
d) Higher doses and longer treatments increase the risk of adrenal
insufficiency.
e) Steroid drugs should be slowly tapered under a physician’s supervision
4) Following bilateral adrenalectomy or removal of a functioning adrenal
tumor that had suppressed the other adrenal.
5) Following sudden destruction of the pituitary gland (pituitary
necrosis).
6) Thyroid hormone (endogenous or exogenous) increases the body’s
steroid demand, and if acutely elevated may result in a relative
adrenal insufficiency.
7) Following injury to both adrenals by trauma, hemorrhage,
anticoagulant therapy, thrombosis, infection or, rarely, metastatic carcinoma.

Question 4

Clinical Findings of a patient with Acute Adrenal Crisis- Adrenocortical Insufficiency
Symptoms:

Answer 4

1) Headaches
2) Lassitude (lethargy)
3) Nausea/Vomiting
4) Abdominal pain and diarrhea
5) Confusion or coma
6) Cyanosis
7) Dehydration
8) Sparse Axillary hair

Question 5

Clinical Findings of a patient with Acute Adrenal Crisis- Adrenocortical Insufficiency
Signs:

Answer 5

1) Skin hyperpigmentation
2) Fever
3) Hyperkalemia
4) Hyponatremia
5) Hypotension
6) Eosinophilia
a) Though eosinophils are generally associated with parasitic infections or
allergy, peripheral eosinophilia is also commonly seen in adrenal
insufficiency.

Question 6

Lab/imaging findings of a patient with Acute Adrenal Crisis- Adrenocortical Insufficiency

Answer 6

(a) Eosinophil count may be high
(b) Hyponatremia or hyperkalemia (or both) usually present
(c) Hypoglycemia common
(d) Hypercalcemia may be present (due to renal injury)
(e) Blood, sputum, and urine may be positive for bacteria (as source of
physiologic stress causing adrenal insufficiency)

Question 7

Diagnostic test of a patient with Acute Adrenal Crisis- Adrenocortical Insufficiency

Answer 7

(a) Cosyntropin stimulation test with serum ACTH level
1) Cosyntropin is synthetic ACTH. The goal is to determine if the adrenal
glands will respond to direct hormonal stimulation. This will help determine
rather the adrenal insufficiency is primary or secondary (this will be done by
Internal Medicine or Endocrinology).
(b) Early morning (0600-0800) serum cortisol
1) Cortisol undergoes diurnal variation and is at its highest in the
morning.Cortisol undergoes diurnal variation and is at its highest in the
morning

Question 8

Treatment of a patient with Acute Adrenal Crisis- Adrenocortical Insufficiency

Answer 8

(a) Refer to Medical Officer
1) Acute adrenal insufficiency is a medical emergency, and treatment
should not be delayed pending laboatory results.
(b) Medications
1) If adrenal crisis is suspected, obtain labs if possible such as
electrolytes, cortisol, ACTH.
2) If patient has been taking prescribed mineralocorticoid /
glucocorticoid ensure they have been compliant.
3) Screen for infection (PNA, UTI/pyelonephritis, etc.).
4) MEDEVAC as soon as possible
a) Patients treated for acute adrenal insufficiency and diagnosed with
Addison’s disease require lifelong replacement therapy with bothglucocorticoids and mineralocorticoids.
5) Discuss/Refer to Medical Officer.
a) If symptomatic adrenal insufficiency is suspected, immediately treat
with hydrocortisone 100-300 mg IV and saline
b) Then, continue hydrocortisone 50-100 mg IV q6h for first day, q8h
the second day, and taper as clinically appropriate
c) MEDEVAC

Question 9

Disposition of a patient with Acute Adrenal Crisis- Adrenocortical Insufficiency

Answer 9

MEDEVAC

Question 10

Complications of a patient with Acute Adrenal Crisis- Adrenocortical Insufficiency

Answer 10

(a) Shock and death if untreated

(b) Sequelae of infection that commonly precipitate adrenal crisis