Acute Adrenal Insufficiency

INDIAN
DENTAL
ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

www....
Introduction
Cortisol – is secreted by Adrenal Cortex
- Functions
• Helps body to adapt to stress
• Extremely vital for su...
Adreno Cortical Insufficiency
- Secondary

- Primary
the defect is with
the gland itself
- C/a Addisons Disease

the gland...
Why is it a Medical Emergency
1. Glucocorticoid insufficiency
2. Peripheral vascular collapse (shock)
3. Ventricular asyst...
Cortisol Regulation
•

•

Mainly by two methods
1. ACTH levels influenced by blood cortisol levels
2. ACTH – Diurnal varia...
Stress
Higher centers of brain

op
ath
P

ys
h

gy
olo
i

Hypothalamus
CRF

Anterior Pitutary stimulated
Increase in ACTH
...
Pre Disposing Factors
1. Sudden withdrawal of steroid hormones in a patient who
suffers from Addisons disease.
2. Sudden w...
Sudden withdrawal of steroid hormones
in a patient with normal ardenals….
• Acute Adrenal Insufficiency is produced becaus...
Return to Normal Functioning depends
upon …
1. WHICH corticosteroid was given
-

20 mg Hydocortisone = 5 mg Prednisolone
=...
3. DURATION of treatment – any patient receiving
glucocorticoids for 2 weeks or more
4. How FREQUENTLY glucocorticoids wer...
Always ask the patient …
•
•

Any corticosteroids taken within last 2 years
h/o
1. Allergy
Because in these conditions
2. ...
Rule of “Two”
•

Adreno Cortical Insufficiency may be suspected in a
patient who has received glucocorticoids
1. In a dose...
Clinical Features
• Males = Females
• Lethargy, fatigue, weakness
• Hyperkalemia
» skeletal muscle paralysis
• Decrease in...
Criteria for Determination of
Adreno Cortical Insufficiency
• h/o current or recent long term steroid therapy
• Mental con...
Diagnosis
1. ACTH Stimulation Test
•

0.25 mg Cosyntropin ( synthetic ACTH )
administered at time 0.

•

Blood samples wit...
Management Overview
• Though all corticosteroids may be deficient,
administration of cortisol can treat most of the
pathop...
Definitive Management
In a CONCIOUS patient
1. Terminate the on going procedure
2. Position – supine with leg slightly ele...
Treat other Problems
• Hypovolemia
» by 1Lt. of NS infused with in 1 hr.
• Patient may require upto 3 Lt. of fluids – to b...
In an Unconscious Ptaient
1.
2.
3.
4.
5.
6.
7.

Shake & Shout
Position – supine with leg slightly elevated
ABC assess
O2 -...
Prevention
• Stress Reduction Protocol
• If patient is taking steroids then increase the dose by 2
or 4 times on the day o...
www.indiandentalacademy.com
Leader in continuing dental education

……… Thank you
www.indiandentalacademy.com
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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

  1. 1. Acute Adrenal Insufficiency INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 21. www.indiandentalacademy.com Leader in continuing dental education ……… Thank you www.indiandentalacademy.com

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