Sudden penetrating pain in the legs, lower back or abdomen Severe vomiting and diarrhea, resulting in dehydration Low blood pressure, Unexplained shock, usually refractory to fluid and pressor resuscitation Syncope (loss of consciousness) Hypoglycemia Confusion, psychosis, slurred speech Severe lethargy Hypercalcemia Convulsions Fever Rapid withdrawal of long-term steroid therapy Hyperthermia or hypothermia
Meningococcemia & Organisms associated with adrenal crisis e.g Haemophilus influenzae, Staphylococcus aureus,Streptococcus pneumonia, fungi Severe physiologic stress Azotemia Anticoagulants, hemorrhagic diathesis Adrenocorticotropin therapy, known primary or secondary adrenocortical insufficiency AIDS Invasive or infiltrative disorders Tuberculosis Prior steroid use Topical steroids : large surface, long periods of use Inhaled steroids : > 8 mg/dl for long time, Fluticasone even at lower dose
Serum cortisol: <20 mcg/dL in severe stress or after ACTH stimulation is indicative of adrenal insufficiency ACTH test : diagnostic Serum chemistry, ↓Na, ↑K, metabolic acidosis, Hypoglycemia CBC: Anemia, lymphocytosis, and eosinophilia (highly suggestive) Cultures, Infection is a common cause of acute adrenal crisis.
Chest radiography: Assess for tuberculosis, histoplasmosis, malignant disease, sarcoid, and lymphoma. Abdominal CT scanning: Visualize adrenal glands for hemorrhage, atrophy, infiltrative disorders, and metastatic disease. Electrocardiography
Primary adrenocortical failure : evidence of infection, infiltrative disease. Secondary adrenocortical insufficiency: atrophy of the adrenals or no histologic evidence at all, especially if due to exogenous steroid ingestion. Appearance of bilateral adrenal hemorrhage may be striking, as if bags of blood are replacing the glands.
During an addisonian crisis, low blood pressure, low blood glucose, and high levels of potassium can occur. Specific addisonian crisis treatment for these symptoms involves intravenous (IV) injections of: Hydrocortisone Saline Dextrose These addisonian crisis treatments usually bring rapid improvement. When the patient can take fluids and medications by mouth, the amount of hydrocortisone is decreased until a maintenance dose is achieved. If aldosterone is deficient, maintenance therapy also includes oral doses of fludrocortisone acetate.
Dexamethasone : Used as empiric treatment of shock in suspected adrenal crisis or insufficiency until serum cortisol levels are drawn. Hydrocortisone :DOC because of mineralocorticoid activity and glucocorticoid effects Fludrocortisone (Florinef) : mineralocorticoids, . Produces marked sodium retention and increased urinary potassium excretion. Methylprednisolone : 3rd Line, of lack of mineralocorticoid activity, in patients with fluid overload, edema, or hypokalemia
Endocrinologist Infectious disease specialist Critical care physician Surgeon Corticosteroids & IV fluids are the mainstays of treatment. Other medications, such as pressors (eg, dopamine, norepinephrine) or antibiotics, are administered as clinically indicated.