Adrenal Crisis Nicole Wilde UNC Morning Report 5/18/10

Adrenal Crisis: Acute Adrenal Insufficiency Primary Adrenal Insufficiency Primary Adrenal Insufficiency –Serious infection –Acute stress in previously undiagnosed cases –No extra glucocorticoid therapy during infection –Abrupt withdrawal from glucocorticoids Bilateral adrenal infarction Bilateral adrenal infarction Bilateral adrenal Hemorrhage Bilateral adrenal Hemorrhage

Signs/Symptoms Shock Shock Anorexia Anorexia Nausea/Vomiting Nausea/Vomiting Abdominal Pain Abdominal Pain Weakness/Fatigue Weakness/Fatigue Fever Fever Confusion/Coma Confusion/Coma

Bilateral Adrenal Hemorrhage or Infarction Before CT was diagnosed on autopsy Before CT was diagnosed on autopsy Look for hyperkalemia, hyponatremia, and occult hemorrhage Look for hyperkalemia, hyponatremia, and occult hemorrhage Risk Factors Risk Factors –Anticoagulant therapy –Coagulopathy –Post operative State –Meningococcemia or Pseudmonas (sepsis)

Pituitary Apoplexy Adrenal crisis is rare with pituitary or hypothalamic adrenal insufficiency Adrenal crisis is rare with pituitary or hypothalamic adrenal insufficiency –Hypovolemia rare due to normal Renin- agiotensin-aldosterone system Crisis can occur with Pituitary infarct Crisis can occur with Pituitary infarct –Acute cortisol deficiency

Chronic 1° Adrenal Insufficiency Glucocorticoid, mineralocorticoid, and androgen deficiency (women) Glucocorticoid, mineralocorticoid, and androgen deficiency (women) Dehydration Dehydration Hyperpigmentation Hyperpigmentation Hyperkalemia Hyperkalemia Secondary and Tertiary adrenal insufficiency have normal mineralocorticoid function Secondary and Tertiary adrenal insufficiency have normal mineralocorticoid function

Diagnosis Random Cortisol Random Cortisol Acute ACTH Stimulation Test Acute ACTH Stimulation Test Determine cause: CT abdomen, MRI Head, Rule out sepsis, look for autoimmune disease, etc. Determine cause: CT abdomen, MRI Head, Rule out sepsis, look for autoimmune disease, etc.

Treatment Treat Hypotension Treat Hypotension Reversal of Electrolyte Abnormalities Reversal of Electrolyte Abnormalities IVF IVF Dexamethasone if measuring cortisol Dexamethasone if measuring cortisol Hydrocortisone for no biochemical tests Hydrocortisone for no biochemical tests Fludocortisone Fludocortisone

The End