Download Recognition and management of acute adrenal crises [RR 2016].

RECOGNITION AND MANAGEMENT
OF ACUTE ADRENAL CRISES
Dr Rohit Rajagopal
Staff Specialist Endocrinologist
August 2016
OUTLINE
• Basic Physiology and Terminology
• Clinical Presentation
• Management
OUTLINE
• Basic Physiology and Terminology
• Clinical Presentation
• Management
HYPOTHALAMIC-PITUITARY-ADRENAL AXIS
Tertiary Adrenal Failure
Secondary Adrenal Failure
Hypothalamic/Pituitary mass
Pituitary apoplexy
Irradiation
Trauma
Long-term steroid use
Primary Adrenal Failure
Autoimmune adrenalitis (Addison’s disease)
TB, HIV, Cryptococcus
Bilateral adrenal haemorrhage/infarct
Congenital
Drugs – eg ketoconazole
OTHER PITUITARY HORMONES
• LH, FSH – sex hormones, reproductive function
• GH – linear growth, metabolic effects, body composition
• Prolactin – lactation
• TSH – thyroid hormones
• ADH – regulation of osmolality and water balance
OTHER ADRENAL HORMONES
• Aldosterone
• Regulation of salt and water balance and hence volume and
BP by acting on the renal distal tubule to facilitate K
excretion and Na/H2O reabsorbtion
• Main stimulus is serum K level and the Renin-Angiotensin
system (not ACTH)
• Sex steroids
OUTLINE
• Basic Physiology and Terminology
• Clinical Presentation
• Management
ADRENAL CRISES
• A life-threatening emergency related to acute
adrenal insufficiency (usually primary) although
may also occur with secondary/tertiary especially
if acute or following sudden withdrawal of longterm steroid therapy
• Majority of manifestations are due to aldosterone
deficiency although cortisol is also important for
BP maintenance
ADRENAL CRISES
• Incidence: 5-10 cases per 100 patient years annually
and a recent Australian study suggests an increasing
trend
• 1 in 200 patients die from an adrenal crisis
• Early recognition of the clinical features and prompt
institution of treatment is vital!
ADRENAL CRISES – CLINICAL FEATURES
• Predominant manifestation is shock usually out of
proportion to the severity of the presenting illness
• Other symptoms include:
• Nausea, vomiting and anorexia
• Abdominal pain – may mimic an “acute abdomen”
• Unexplained fever
• Lethargy, fatigue, weakness, confusion, coma
• May have a background history of long-standing lethargy,
anorexia, weight loss and fatigue
• May carry a “Sick day plan” or MedicAlert tag
ADRENAL CRISES – CLINICAL
FEATURES
• Other symptoms/signs may also be present that may
point to an aetiology of the underlying disease or
precipitant:
• Increased pigmentation – suggests chronic ACTH excess
• Vitiligo and other autoimmune diseases
• Headaches and visual field disturbances
• Source of infection or history of missed steroid doses
ADRENAL CRISES - LABORATORY
FEATURES
• Hyponatraemia
• Hyperkalaemia (usually primary)
• Hypoglycaemia (ACTH deficiency)
• Increased urea
• Anaemia, eosinophilia
• Increased ESR
• Mild hypercalcaemia
• High TSH
ADRENAL CRISES – OTHER
INVESTIGATIONS
• Should be directed at possible precipitant:
• Blood and urine cultures, CXR, ECG etc
• IF FEBRILE, PATIENT HAS AN INFECTION TILL
PROVEN OTHERWISE
• Collect blood for ACTH, Cortisol, Aldosterone
and Renin
BUT DO NOT WAIT FOR RESULTS PRIOR TO
INITIATING TREATMENT!
• 51 yo female with 7 yr history of known Addison’s disease
• On Hydrocortisone 20 mg mane, 10 mg nocte and Fludrocortisone 0.1 mg bd
• Had a MedicAlert bracelet and aware of sick day management
• Developed viral gastroenteritis with a 24 hour history of vomiting
and diarrhoea
• Tripled usual hydrocortisone but unable to keep pills down
• Called ambulance as directed
• Found to have BP of 80/60 at scene; given 1L Hartmann’s and transferred to ED
Gargya, IMJ - 2016
• On arrival, BP was 101/62. Labelled as ‘normotensive’ and triaged to
be reviewed in 60 min
• IV fluids and steroids not given although requested by family
• 3 hours later, patient had a cardiorespiratory arrest and found to
have a pH of 7.06
• Resuscitated, intubated and transferred to ICU
• Treating endocrinologist informed 5 hours later
• Total LOS 16 days and admission complicated by stress-induced
cardiomyopathy and a broken tooth
Gargya, IMJ - 2016
Gargya, IMJ - 2016
OUTLINE
• Basic Physiology and Terminology
• Clinical Presentation
• Management
ADRENAL CRISES – ACUTE
MANAGEMENT
• Establish IV access – preferably 2 large bore
cannulas (collect bloods as per previously)
• IV Fluids:
• 1-3 litres of N/Saline as quickly as possible
• 5% dextrose via second line if hypoglycaemic
• Regular monitoring of haemodynamic status including
urine output and electrolytes/glucose to prevent fluid
overload
• Glucocorticoid replacement:
• 100 mg iv hydrocortisone bolus followed by 50 mg q 8
hourly
ADRENAL CRISES – SUBACUTE
MANAGEMENT
• Contact Endocrinology service
• Ongoing IV N/Saline for next 24-48 hours
• Search for and treat possible precipitant eg
infection
• Taper IV steroids over next 24-48 hours and
commence oral replacement
• Oral fludrocortisone if required once IV fluids
ceased
ADRENAL CRISES – LONG-TERM
MANAGEMENT
• If no previous diagnosis, establish cause of adrenal
insufficiency
• A low cortisol (<100 nmol/L) with an elevated ACTH is diagnostic of
primary adrenal failure
• Borderline cortisol levels or inappropriately normal ACTH levels
may require further dynamic testing
• Lifelong hormone replacement
• Hydrocortisone 18-30 mg daily in divided doses or Prednisolone
4.5-7.5 mg daily
• Fludrocortisone or other pituitary hormone replacement as
indicated
• Sick day plans, script for IM Solu-Cortef and instructions on
how to use, MedicAlert tags, Addison’s society
SICK DAY PLANS
Gargya, IMJ - 2016
WHAT DO AMBULANCES CARRY?
Gargya, IMJ - 2016
ANY QUESTIONS?