Adrenal Disease in the ED

2.  26 year old Male
 PC: 2 day history
 Fever, Nausea, Vomiting and Diarrhoea
 Postural syncopal episode
 No Past medical history/medications
 Low energy Levels
 Clinical – Looks ill, distressed
 T 37.8
 PR 120
 BP 65/40
 RR 26
 Chest: Clear
 Abdomen: SNT

3. ABG
pH 7.32
pCO2 45
pO2 50
HCO3- 17.1
BE -6.9
Na+ 121
K+ 6.1
Cl- 92
BSL 3.0
Creat. 110
Urine Dipstick: Clear
ECG: NSR, Sinus Tachy.
CXR: Clear

7. DON’T MIND ME…
I’M JUST STRESSED!
An overview of Adrenal Insufficency in the Emergency
Department
Dr Kyle Kophamel
1st May 2014
SCGH - CME

8. Aims
 Define Adrenal Insufficiency/Crisis
 Outline Approach specific to Emergency
Setting
 Highlight Adrenal Insufficiency as a diagnostic
Consideration

10. Function
 Glucocorticoids
 Cortisol
 “facilitates stress response”
 Increase Glucose
 Fat, Protein, Carbohydrate Metabolism
 Immunosuppression
 Vascular tone + Cardiac Contractility
 Mineralocorticoids
 Aldosterone
 Reabsorption of Na+ and Water
 Excretion K+

11. Adrenal Failure
 Basal Failure results in Adrenal Insufficiency
 Insidious wasting disease
 Stress failure results in Adrenal Crisis
 Life Threatening

12. Adrenal Insufficiency
 Primary
 Failure of Adrenal glands
 Most common:
 Autoimmune Adrenalitis - Addison’s (70-80%)
 Infectious TB
 Results in  Cortisol AND  Aldosterone
 Secondary
 Failure of HPA axis
 Exogenous glucocorticoid administration
 Results in  Cortisol

13. Adrenal Insufficiency
1 in 500

14. Chronic Insufficiency
 Hyponatremia
 Hypernatremia
 Only in 2 Failure
 Hyperkalemia
 Only 1 Failure
 Nonspecific
 Fatigue, Anorexia
 Neurologicial
 Headaches, Visual
changes
 Gastrointestinal
 Pain, N+V, Diarrhoea
 Orthostatic Hypotension
 Hypoglycemia
 Hyperpigmentation

15. Adrenal Crisis
  Supply  Demand

16. Adrenal Crisis
 STRESS
 Normal Response
 Increases glucocorticoid and mineralocorticoid levels 5-10
fold
 Adrenal Insufficient individuals
 High risk for Adrenal Crisis
 Stressors
 AMI, Febrile Illness, Trauma, Surgery, V+D.

17. Adrenal Crisis
Clinical Presentation
 Profound Shock
 Resistant to IVF resuscitation and
Vasopressors
 Electrolyte Disturbance
 Pallor/Dizziness/Headache/
 Altered Mental state
 Lethargy/Weakness
 Abdominal Pain
 N+V
 Hypoglycemia

18. Adrenal Crisis
Management
 Attend ABC’s
 IV Fluid Resuscitation
 Normal Saline – Resus and correct Na+
 Dextrose – correct BSL
 Treat Hyperkalemia
 IV Hydrocortisone 100-150mg
 OR Dexamethasone 4mg IV
 Vasopressors
 Norepinephrine
 Investigate and Treat underlying stress

19. Adrenal Crisis
Investigation
 Vitals
 Blood Gas
 WCC, Urea, Creatinine, Calcium, Serum Cortisol
 ECG
 CXR, MSU, Blood Cultures
 CT Abdomen
 CT Head
 Short Synacthen Test

20. Considering the Diagnosis
 Unexplained Hypotension
 Especially in high risk populations
 Characteristic Electrolyte abnormalities
 Primary vs Secondary

21. Disposition
 Critically Ill
 ICU/HDU
 Patients with Chronic Adrenal Insufficiency with Acute
Illness or Injury
 Patients with Past Corticosteroid Treatment

22. References
 Arlt W. The approach to the adult with newly diagnosed adrenal
insufficiency. J Clin Endocrinol Metab. 2009 Apr;94(4):1059-67.
PMID: 19349469.
 Arlt W, Allolio B. Adrenal insufficiency. Lancet. 2003 May
31;361(9372):1881-93. PMID: 12788587
 Tintinalli's Emergency Medicine: A Comprehensive Study Guide,
7e. Judith E. Tintinalli
 Adrenal Crisis in Emergency Medicine Workup Author: Kevin M
Klauer, DO, FACEP; Chief Editor: Erik D Schraga, MD
http://emedicine.medscape.com/article/765753-overview
 http://lifeinthefastlane.com/education/ccc/adrenal-insufficency/