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Acute adrenal insufficiency /certified fixed orthodontic courses by Indian dental academy
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Acute adrenal insufficiency /certified fixed orthodontic courses by Indian dental academy



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Acute adrenal insufficiency /certified fixed orthodontic courses by Indian dental academy Presentation Transcript

  • 1. Acute Adrenal Insufficiency INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  • 2. Introduction Cortisol – is secreted by Adrenal Cortex - Functions • Helps body to adapt to stress • Extremely vital for survival - Hyper secretion CUSHINGS SYNDROME » Buffalo hump » Increased B.P. » Eosino & Lymphopenia » Not an acute life threatening condition - Hypo secretion Adreno Cortical insufficiency life threatening condition www.indiandentalacademy.com
  • 3. Adreno Cortical Insufficiency - Secondary - Primary the defect is with the gland itself - C/a Addisons Disease the gland parenchyma is fully functional but suppressed by certain exogenous factors -1st recognised by Addison in 1844 Normal daily secretion of Cortisol is 20mg/ day Acute Adreno Cortical Insufficiency is a Medical Emergency www.indiandentalacademy.com
  • 4. Why is it a Medical Emergency 1. Glucocorticoid insufficiency 2. Peripheral vascular collapse (shock) 3. Ventricular asystole • Clinical manifestations DO NOT develop until at least 90% of the Adrenal Cortex is destroyed. Thus diagnosis is usually late. • Condition is dangerous because patient is able to maintain a basal level of cortisol, but in stressful situations adequate cortisol is NOT produced and thus acute Adreno Cortical Insufficiency develop. www.indiandentalacademy.com
  • 5. Cortisol Regulation • • Mainly by two methods 1. ACTH levels influenced by blood cortisol levels 2. ACTH – Diurnal variation - start rising by 2 AM in people who sleep at night & becomes maximum in the morning. Only under stressful situations 3. Stress Hypothalamus CRF ACTH www.indiandentalacademy.com
  • 6. Stress Higher centers of brain op ath P ys h gy olo i Hypothalamus CRF Anterior Pitutary stimulated Increase in ACTH Adrenal Cortex stimulated Cannot produce Cortisol www.indiandentalacademy.com Endogenous Cortisol decrease
  • 7. Pre Disposing Factors 1. Sudden withdrawal of steroid hormones in a patient who suffers from Addisons disease. 2. Sudden withdrawal of steroid hormones in a patient with normal ardenals. 3. After Stress • Physiologic – infection, trauma, surgery • Psychologic 1. After B/L Adrenalectomy 2. After sudden destruction of pituitary gland 3. Direct injury to Adrenals – trauma, hemorrhage, infection www.indiandentalacademy.com
  • 8. Sudden withdrawal of steroid hormones in a patient with normal ardenals…. • Acute Adrenal Insufficiency is produced because exogenous corticosteroids produce dysuse atrophy of the adrenal cortex. • This is Secondary Adreno Cortical Insufficiency www.indiandentalacademy.com
  • 9. Return to Normal Functioning depends upon … 1. WHICH corticosteroid was given - 20 mg Hydocortisone = 5 mg Prednisolone = 0.75 dexamethasone - Patients with Addisons disease require 15- 25 mg of hydrocortisone in 2 divided doses i.e. 2/3 in morning & 1/3 in evening - But patients suffering from diseases such as arthritis receive 10 mg Prednisolone equivalent to 50 mg of Hydrocortisone 1. DOSE of exogenous corticosteroid administered www.indiandentalacademy.com ……
  • 10. 3. DURATION of treatment – any patient receiving glucocorticoids for 2 weeks or more 4. How FREQUENTLY glucocorticoids were given 5. ROUTE of administration - topical & intra articular injections do NOT suppress adrenal cortex - rest all route suppress adrenals www.indiandentalacademy.com
  • 11. Always ask the patient … • • Any corticosteroids taken within last 2 years h/o 1. Allergy Because in these conditions 2. Asthma usually corticosteroids are given 3. Arthritis 4. Rheumatism www.indiandentalacademy.com
  • 12. Rule of “Two” • Adreno Cortical Insufficiency may be suspected in a patient who has received glucocorticoids 1. In a dose of 20 mg or more of cortisone or its equivalent. 2. Oral or parenteral steroids for 2 weeks or more 3. Above two within 2 yrs of dental treatment www.indiandentalacademy.com
  • 13. Clinical Features • Males = Females • Lethargy, fatigue, weakness • Hyperkalemia » skeletal muscle paralysis • Decrease in blood pressure • Mucocutaneous hyperpigmentation • Orthostatic hypotension • Anorexia • Hypoglycemia • In dental set up » Progressive mental confusion » pain in abdomen, lower back, legs www.indiandentalacademy.com
  • 14. Criteria for Determination of Adreno Cortical Insufficiency • h/o current or recent long term steroid therapy • Mental confusion • Nausea & vomiting • Abdominal pain • Hypotension www.indiandentalacademy.com
  • 15. Diagnosis 1. ACTH Stimulation Test • 0.25 mg Cosyntropin ( synthetic ACTH ) administered at time 0. • Blood samples withdrawn at time 0, 1, 6-8 hrs • Normal Adrenal Cortex response is 3 times increase in cortisol levels compared to basal levels 1. Blood electrolytes testing 2. BSL www.indiandentalacademy.com
  • 16. Management Overview • Though all corticosteroids may be deficient, administration of cortisol can treat most of the pathophysiologic effects of Addisons disease. • Patients with Addisons disease require life long administration of glucocorticoids. • Identify & prevent acute precipitation. www.indiandentalacademy.com
  • 17. Definitive Management In a CONCIOUS patient 1. Terminate the on going procedure 2. Position – supine with leg slightly elevated 3. ABC assess 4. Monitor vital signs  You will see tachycardia and hypotension 5. Call physician 6. O2 - 5 – 10 Lts/ min 7. Adm. Glucocorticoid (only if the patient is a known sufferer of insufficiency)  Give 100 mg hydrocortisone I.V. over 30 sec  Or 100 mg hydrocortisone I.M. www.indiandentalacademy.com
  • 18. Treat other Problems • Hypovolemia » by 1Lt. of NS infused with in 1 hr. • Patient may require upto 3 Lt. of fluids – to be given over 8 hours • Hypoglycemia » by 5% Dextrose www.indiandentalacademy.com
  • 19. In an Unconscious Ptaient 1. 2. 3. 4. 5. 6. 7. Shake & Shout Position – supine with leg slightly elevated ABC assess O2 - 5 – 10 Lts/ min Aromatic spirits – NH3 Call physician Monitor vital signs  You will see tachycardia and hypotension 8. Administer glucocorticoids  100 mg glucocorticoid I.M./ I.V.  Best if I.V. over 30 sec  Also start I.V. infusion 100 mg hydrocortisone administered over 2 hrs. 9. Shift to hospital www.indiandentalacademy.com
  • 20. Prevention • Stress Reduction Protocol • If patient is taking steroids then increase the dose by 2 or 4 times on the day of dental treatment. www.indiandentalacademy.com
  • 21. www.indiandentalacademy.com Leader in continuing dental education ……… Thank you www.indiandentalacademy.com