adrenal crisis

Question 1

Adrenal insuffeincy are classified according to their etiology such as ?

Answer 1

Disorder of the adrenal cortex - primary

Disorder of anterior pituitary gland - secondary

Disorder of hypothalamus - tertiary

Question 2

etiology of primary adrenal insufficiency ADDISON DISEASE?

Answer 2

Autoimmune adrenalitis
- characterised by destruction of the adrenal cortex

Hemorrhagic infraction
Associated with meningococcemia ( Waterhouse fredrichsen syndrome )
Pseudomonas aeurginosa

Infectious adrenalitis
Tuberculosis , hiv

Drug / adrenal enzyme inhibitors
Etomidate

infiltration of adrenal glands
metastasis
amyloidosis

Genetic disorder
Adrenoleukodystrophy
Congenital adrenal hypoplasia

Question 3

etiology of secondary and tertiary adrenal insufficiency?

Answer 3

Pituitary or hypothalamic :
tumors 
Or surgery 
Or irradiation  
Trauma
Infections
Drug induced - glucocorticoid therapy

Question 4

clinical manifestation of adrenal insufficiency ?

Answer 4

deficiency of cortisol , aldosterone , and androgens = all three

causing hypogonadism : decreased libido and impaired spermatogenesis

hypocortisolism :
hypoglycemia 
Skin hyperpigmentation - in only primary 
Low blood pressure -
pronounced in primary 

shock (HR; vasoconstriction; pos- tural hypotension; oliguria; weak; confused; comatose)

fatigue , vomiting , diarrhea , weight loss
orthostatic hypotension

hypoaldosternosim :
Salt craving - in only primary 
Hyponatrameia 
Hyperkalemia - in primary only 
Myalgia and joint pain

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secondary - decrease in ACTH
= only hypogonadism and hypocortisolilsm
mineral corticoids not affected

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tertiary decrease in CRH - leading to deficiency in ACTH = same manifestations as secondary

Question 5

diagnose adrenal insufficiency

Answer 5

morning serum cortisol measured = they are low

Plasma acth measured

If high = primary adrenal
if low - secondary

if primary screen for :

21 hydroxylase antibodies = positive = autoimmune Addison disease

HYPONATREMIA
HYPERKALEMIA
HYPOGLYCEMIA
metabolic acidosis

confirmatory test

ACTH stimulation test / syncathen test
ACTH ANALGOUE

there should be a rise of cortisol in 30 minutes if not :

CT adrenals - infective or infiltrative hemorrhages

Serum of very long chain fatty acids = adrenoleukodystrophy

————-
If ACTH is low or normal

Secondary adrenal insufficiency

MRI of pituatory

Also test for other Anterior pituitary hormones

Question 6

management of primary adrenal insufficiency?

Answer 6

Monitor salt craving , postural hypotension

call for help

A-E

Bloods for cortisol and ACTH (this needs to go straight to laboratory, call ahead!),
U&ES—can have K+ (check ECG and give calcium gluconate if needed, see p301) and
Na+ (salt depletion, should resolve with rehydration and steroids)

Monitor blood glucose: the danger is hypoglycaemia.

Glucocorticoid regime
Hydrocortisone - emergency 100mg/ 8hr iv

Glucose IV may be needed if hypoglycaemic

Change to oral steroids after 72h if patient’s condition good.

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Monitor BMI , postural BP

Mineral corticoid
To maintain sodium fluid balance
Fludrocortisone

decreased libido by DHEA

Question 7

What is causes adrenal crisis ?

Answer 7

Gastroenteritis and fever , stress

Trauma and surgery

sudden discontinuation of glucocorticoid dose

Question 8

adrenal crisis diagnosis ?

Answer 8

Vomiting
Abdominal pain 
Hypotension 
Hypovolemic shock 
Hyperkalemia 
Hyponatremua 
Hypoglycaemia 
Muscle cramps 
Pre renal failure

Question 9

prevent adrenal crisis ?

Answer 9

Patient education - tell patient to increase dose during fever or infection
And self parenetral administration of emergency glucocorticoids

All patients equipped with steroid emergency card and medical alert identification card