Adrenal Crisis
Adrenal crisis is a bit like DKA. It can either be caused by chronic adrenal insufficiency plus a trigger, or it can be caused by acute adrenal insufficiency alone - Josh Farkas
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Adrenal Crisis
Basically people in adrenal crisis can present with any chief complaint. They may have pains, infections, weakness, confusion, skin changes. The big kicker to this, is that they will look sick. Their pressures will be low and will stay low in spite of your iv fluid resuscitation. Normally cortisol has an additive effect with catecholamines to vasoconstrict… now, however without enough cortisol vasodilation will reign...
If this patient says- hey, I’ve got the Addison’s disease, or their chart says “hx of Adrenal crisis” and so you know that this is likely an Adrenal Crisis. Then you given them Hydrocortisone bolus (100mg IV) and get them up to the ICU.
If this is looking…
Resources
Adrenal Crisis Can Kill
Each year, typically 8% of people with Addison's disease experience adrenal crisis. This means they need extra steroid medication immediately, in the form of an emergency injection of intra-muscular hydrocortisone. This is a medical emergency and must be treated immediately.
Adrenal Crisis in the ED
Adrenal crisis is a life-threatening emergency that needs to be recognized and treated quickly in the ED to prevent subsequent morbidity and mortality. Approximately half of patients will have no past medical history of adrenal insufficiency. The hallmark of the disease is hypotension refractory to IV fluids and vasopressors. Treat empirically with hydrocortisone and treat any precipitating causes.
Adrenal Crisis: Early Recognition and Management Save Lives
If hydrocortisone is available, give 100 mg IV as a loading dose, followed by 50 mg IV hydrocortisone every 6 hours as a maintenance dose.
Adrenal Crisis: Still a Deadly Event in the 21st Century
Despite it being a treatable condition for almost 70 years, failure of adequate preventive measures or delayed treatment has often led to unnecessary deaths. Gastrointestinal illness is the most common precipitant for an adrenal crisis.
Clinical Unmet Needs in the Treatment of Adrenal Crisis: Importance of the Patient’s Perspective
Adrenal crisis is the most severe manifestation of adrenal insufficiency (AI), but AI can present with variable signs and symptoms of gradual severity. Despite current hormone replacement strategies, adrenal crisis is still one of the leading causes of mortality in AI patients.
CORE EM: Adrenal Crisis
Hallmark is hypotension refractory to IVF/pressors; < 50% of patients will have a formal diagnosis on presentation.
EM Quick Hits 17 Adrenal Crisis...
Diagnosis is challenging as symptoms are highly variable and non-specific, which may include nausea, vomiting, abdominal pain, weakness, confusion or fever, however a presumptive diagnosis can be made if the patient responds to IV steroid therapy within 1-2hrs.
Pediatric Emergency Management of Adrenal Insufficiency and Adrenal Crisis
Adrenal insufficiency (AI) is a rare diagnosis in childhood and adolescence; however, it can become a major cause of morbidity and mortality in pediatric patients, as 1 in 200 cases of adrenal crisis leads to death.
PEM Pearls: Hydrocortisone stress-dosing in adrenal insufficiency for children
Commonly, the recommended dose of hydrocortisone is 50 mg/m2. Measuring the m2 is a reflection of the Body Surface Area (BSA), which in the acute setting, such as the emergency department, it can be difficult to calculate.
Adrenal Crisis
If this patient says- hey, I’ve got the Addison’s disease, or their chart says “hx of Adrenal crisis” and so you know that this is likely an Adrenal Crisis. Then you given them Hydrocortisone bolus (100mg IV) and get them up to the ICU.
Life in the Fastlane
concurrent illness, surgery, failure to take medications...
WikEM
Hypotension (refractory to fluids/pressors)(90%).
StatPearls
Acute adrenal crisis can be the first presentation of unknown adrenal insufficiency and can occur in up to 50% of patients with known adrenal insufficiency.
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