Adrenal crisis

Question 1

What is adrenal crisis? Signs/symptoms

Answer 1

Insufficient levels of cortisol –> severe adrenal insuficiency

Shock (Tachycardia, vasoconstriction, postural hypotension, oliguria, weak, confused, comatose)
Sudden pain in legs/lower back or abdomen
Hyperkalaemia, hypercalcaemia, hypoglycaemia, hyponatraemia, hypotension, severe vomiting and diarrhoea, fever, convulsions, lethargy, confusion.

Known Addison’s (e.g. when oral steroid has not been increased to cover stress such as pneumonia or pt on long term steroids who has forgotten tablets)
Bilateral adrenal haemorrhage - Waterhouse-Friderichsen)

Question 2

What are precipitating factors for adrenal crisis?

Answer 2

Infection, trauma, surgery, missed medication in Addison’s or congenital adrenal hyperplasia

Question 3

Immediate management? Investigations?

Answer 3

Hydrocortisone 100mg IV stat
IV fluid bolus 500ml 0.9% aline to support BP - repeat as necessary
Fludrocortisone is not required because high dose hydrocortisone has mineralocorticoid effect.

Bloods for cortisol and ACTH - U&Es (hyperkalaemia (ECG -calcium gluconate if required) and hyponatraemia))

Blood, urine, sputum culture - antibiotics if necessary

Question 4

Cause of hyponatraemia in adrenal crisis?

Answer 4

Lack of aldosterone/cortisol leading to reduced mineralocorticoid activity on the principal cells of DCT and CD to retain NA and excrete K.
Aldosterone: uptregulatea NaK ATPase which creates gradient to reabsorb sodium and water and secrete potassium.
Upredulates ENaC in CD increasing absorption of NA in CD and colon
Stimulates sodium and water reabsorption from the gut.

Question 5

What should you monitor?

Answer 5

Blood glucose - danger is hypoglycaemia

Question 6

What should be done in continued treatment?

Answer 6

Glucose IV if hypoglycaemic
IV fluids guided by clinical state and U&E
Continue hydrocortisone e.g. 100mg/8h IV or IM
Change to oral steroids after 72h if patients condition is good

Question 7

What advice to prevent future adrenal crisis?

Answer 7

Self-care advice
Providing hydrocortisone injection with needles and syringes
Ensure that if person is undergoing surgery/ dental treatment/endoscopy, team are aware that extra glucocorticoid replacement may be retried.
Increase corticosteroid cover if under physical stress such as illness or strenuous exercise, fever, nausea, vomiting, diarrhoea.

Addison’s disease emergency - IM hydrocrotinsone if vomit.
After major injury

Question 8

What evidence to let people know pt is on long-term steroids

Answer 8

Bracelet

Card in wallet