1. By- Prem Mohan Jha
Jr3 (medicine)

2.  Life-threatening emergency
 Triggered by anything that increases the person’s
normal stress level
 The body is unable to release sufficient cortisol to
respond appropriately
 May lead to shock & vascular collapse
 Typically resistant to catecholamine and IVF
resuscitation

3. The Adrenal Gland
releases… Androgens (sex
hormones)
Mineralocorticoids
Glucocorticoids
Glucocortoicoids
(most potent is cortisol)
Action: anti-inflammatory,
growth suppressing,
affects sleep patterns &
awareness, stress response
Mineralcorticoids
(Aldosterone)
Action: Manages
sodium/potassium balance
Internet.

4. Kronenberg - Williams Textbook of Endocrinology 11th ed

5.  Dehydration, hypotension, or shock out of proportion to
severity of current illness
 Nausea and vomiting with a history of weight lost and
anorexia
 Abdominal pain, so-called acute abdomen
 Unexplained hypoglycemia
 Unexplained fever
 Hyponatremia, hyperkalemia, azotemia, hypercalcemia, or
eosinophilia
 Hyperpigmentation or vitiligo
 Other autoimmune endocrine deficiencies, such as
hypothyroidism or gonadal failure
Kronenberg - Williams Textbook of Endocrinology 11th ed

6.  Abrupt adrenal failure usually from
 Bilateral adrenal infarction
 Bilateral adrenal Hemorrhage
 Primary Adrenal Insufficiency
 Serious infection
 Acute stress in previously undiagnosed cases
 No extra glucocorticoid therapy during infection
 Secondary adrenocortical insufficiency -Abrupt withdrawal
from glucocorticoids
 Catastrophic HPA axis failure
 Head trauma
 Hemorrhage of pituitary adenoma
 Post-partum herniation (Sheehan syndrome)
Kronenberg - Williams Textbook of Endocrinology 11th ed

7. Immediate Laboratory Work up
 Electrolytes, glucose
 Baseline Cortisol and ACTH
 Send immediately (before steroid administration)
 Send in early morning sample if pt is stable with
suspected chronic adrenal insufficiency
 Can measure urinary 17-OHCS
 Renin(+/- aldosterone- less sensitive)Random Cortisol
Kronenberg - Williams Textbook of Endocrinology 11th ed

8.  Cosyntropin(synthetic ACTH) stimulation test is (used in
all patients in whom adrenal insufficiency is being
considered
 Cortisol levels measured at 0 and 30 minutes following
cosyntropin administration
 Normal response is defined by a peak plasma cortisol of
> 20mcg/dl.
 Primary adrenal insufficiency has a low or no rise in
cortisol following ACTH stimulation
 Secondary or Tertiary causes due to deficient
endogenous ACTH have an increase in cortisol
(sub sub-normal) following ACTH stimulation.
Kronenberg - Williams Textbook of Endocrinology 11th ed

9.  Imaging:
 Abdominal CT to evaluate for adrenal findings (ie. Infection,
calcification, hemorrhage)
 Head CT or MRI if secondary AI is diagnosed
 Other Labs:
 Anti-adrenal antibodies
 VLCFA (very long chain fatty acids)(acids)
 Especially in young males with negative antibodies
 Evaluate for other autoimmune disorders as indicated
 PPD if TB is suspected
 Metyrapone test: : ↓↓cortisol synthesis, should see a
resultant ↑↑in ACTH. Used to diagnosis partial ACTH
Kronenberg - Williams Textbook of Endocrinology 11th ed

10.  EMERGENCY MEASURES
1) Establish intravenous access with a large-gauge needle
2) Draw blood for stat serum electrolytes and glucose and
routine measurement of plasma cortisol and ACTH. Do not
wait for laboratory results.
3) Infuse 2 to 3 L of 0.9% saline solution or 5% dextrose in
0.9% saline solution as quickly as possible. Monitor for
signs of fluid overload by measuring central or peripheral
venous pressure and listening for pulmonary rales. Reduce
infusion rate if indicated.
4) Inject intravenous hydrocortisone (100 mg immediately and
every 6 hr)
5) Use supportive measures as needed.
Kronenberg - Williams Textbook of Endocrinology 11th ed

11.  Continue iv 0.9% saline solution at a slower rate for next 24
to 48 hr
 Search for and treat possible infectious precipitating causes
of the adrenal crisis
 Perform a short ACTH stimulation test to confirm the
diagnosis of adrenal insufficiency, if he is not a known case .
 Determine the type of adrenal insufficiency and its cause if
not already known.
 Taper glucocorticoids to maintenance dosage over 1 to 3
days, if precipitating or complicating illness permits.
 Begin mineralocorticoid replacement with fludrocortisone
(0.1 mg by mouth daily) when saline infusion is stopped.
Kronenberg - Williams Textbook of Endocrinology 11th ed

12.  Glucocorticoid replacement
 Dexamethasone or prednisone (longer-acting or once daily
acting) daily
 Alternative therapy with hydrocortisone BID -TID
 Mineralocorticoid replacement
 Fludrocortisone
 Liberal salt intake
 Patient Education
 Recognition and treatment of minor and major stress/ illness
 Instructions to triple the dose of steroid in the event of an
intercurrent illness, accident or mental stress
 Emergency precautions
 Medic-alert bracelet, pre alert pre--filled dexamethasone
syringes
Kronenberg - Williams Textbook of Endocrinology 11th ed

13.  Tuberculosis is known to affect adrenal glands
directly.
 Adrenal destruction by tuberculosis may lead to overt
or subclinical adrenal insufficiency
 In India it is the most common cause of Addison’s
disease .
 CT abdomen shows typically shrunken and calcified
adrenals in chronic stage and enlarged in the active
stage. Confirmed by FNAC
 ATT increase the degratdation of corticosteroids, may
precipitate the adrenal crisis & has been reported with
rifampicin therapy
INT. J. DIAB. DEV. COUNTRIES (1999), VOL. 19

14.  “Unexplained hyponatremia and hyperkalemia in
the setting of hypotension unresponsive to
catecholamine and fluid administration… should
receive 100mg hydrocortisone intravenously.”
 Prevention through careful titration of steroids
 Patient, family, friends aware of signs/symptoms of
crisis
Thank You