Rosen & Barkin's 5-Minute Emergency Medicine Consult (35 page)

• Hypothalamus insufficiency
  
• Sepsis
  
• Infiltrative: Neoplasm, amyloid, sarcoid, and hemochromatosis
  
• Head trauma
  

DIAGNOSIS

• Symptoms:
  
  • Depression
    
  • Weakness, tiredness, fatigue
    
  • Anorexia
    
  • Abdominal pain (can mimic acute abdomen)
    
  • Nausea or vomiting
    
  • Salt craving
    
  • Postural dizziness
    
  • Muscle or joint pains
    
  • Dehydration (found in primary adrenal insufficiency only)
    
• Signs:
  
  • Fever or hypothermia
    
  • Mental status changes
    
  • Hypotension (<110 mm Hg systolic)
    
  • Tachycardia
    
  • Orthostatic BP changes or frank shock
    
  • Weight loss
    
  • Goiter
    
  • Hypogonadism
    
  • Hyperkalemia
    
  • Hypercalcemia
    
  • Sodium depletion
    
  • Azotemia
    
  • Eosinophilia
    
  • Hyperpigmentation (found in primary adrenal insufficiency only)
    
  • Vitiligo
    
• Addisonian crisis:
  
  • Hypotension and shock
    
  • Hyponatremia
    
  • Hyperkalemia
    
  • Hypoglycemia
    

• Lab confirmation of diagnosis not possible in emergency department
  
• Adrenal crisis: Life-threatening condition:
  
  • High degree of suspicion should prompt initiation of therapy before definitive diagnosis.
    
• Plasma cortisol level <20 μg/dL accompanied by shock suggests adrenal insufficiency.
  
• Stat electrolytes:
  
  • Potassium, sodium
    
• BUN, creatinine:
  
  • Elevated owing to dehydration
    
• Serum glucose levels may be low.
  

• CBC with differential:
  
  • Anemia
    
  • Eosinophilia
    
  • Lymphocytosis
    
• Arterial blood gases:
  
  • Hypoxemia
    
  • Acidosis
    
• Cosyntropin stimulation test:
  
  • Adrenal deficiency:
    
    • Random serum cortisol <20 μg/dL (while stressed)
      
    • ACTH stimulation unresponsive
      
  • Functional hypoadrenalism:
    
    • Random serum cortisol = 20 μg/dL (while stressed)
      
    • 60 min post ACTH stimulation <30 μg/dL or delta cortisol (60 min – baseline) = 9 μg/dL
      
• Normal anion gap metabolic acidosis due to aldosterone deficiency
  
• Search for underlying infection
  

CXR:

• Look for infection or edema
  

ECG:

• Evaluate for electrolyte disturbances
  

• Sepsis
  
• Shock (any cause)
  
• Acute abdominal emergency
  

TREATMENT

• Airway, breathing, and circulation management (ABCs)
  
• Cardiac monitor
  
• BP support for hypotension:
  
  • Normal saline (0.9%) IV fluids 500 mL–1 L (peds: 20 mL/kg) bolus
    
  • Avoid pressors (if possible):
    
    • May precipitate dysrhythmias
      
• Supplemental oxygen to meet metabolic needs
  
• Correct hyperthermia:
  
  • Initiate cooling measures.
    

• Glucocorticoid replacement:
  
  • IV hydrocortisone or dexamethasone immediately
    
  • Use IM route if no IV access
    
  • Dexamethasone will not interfere with results of cosyntropin stimulation tests.
    
• Volume expansion:
  
  • NS (0.9%) or D
    ₅
    NS at rate of 500–1,000 mL/hr for 1st 3–4 hr
    
  • Care should be taken to note patient’s age, volume, and cardiac and renal function.
    
• For hypoglycemia:
  
  • D
    ₅₀
    W
    
• Treat life-threatening dysrhythmias secondary to hyperkalemia with calcium, bicarbonate, and insulin/glucose.
  
• Identification and correction of underlying precipitant
  
• Should see BP improvement within 4–6 hr of therapy
  

• Dexamethasone: 6–10 mg (peds: 0.15 mg/kg per dose) q12h
  
• Dextrose: 50–100 mL D
  ₅₀
  (peds: 2 mL/kg of D
  ₁₀
  over 1 min) IV
  
• Hydrocortisone: 100 mg (peds: 1–2 mg/kg per dose) IV q6h
  
• Insulin (regular): 10 U by IV push (for hyperkalemia)
  
• Sodium bicarbonate: 1–2 mEq/kg IV (for hyperkalemia)
  

FOLLOW-UP

• All patients with acute adrenal insufficiency
  
• ICU admission for patients with unstable or potentially unstable cases
  

• Normal lab evaluation with treated adrenal insufficiency
  
• Should speak with endocrinologist before discharge with chronic patients
  

• Should have primary care physician follow-up within a few weeks depending on symptoms.
  
• May benefit from endocrinology referral.
  

• Acute adrenal insufficiency is a life-threatening emergency, and treatment should not be delayed in the ED while waiting for definite lab diagnosis.
  
• Cancer of any type can present with adrenal insufficiency; the most common being lung, melanoma, and breast.
  
• The benefit from steroids for relative adrenal insufficiency in septic shock is limited to the treatment of shock refractory to vasopressive (mortality benefit and clinical effect is questionable).
  
• The clinical consequence of a single dose of etomidate for rapid sequence intubation is controversial. Studies do show biochemical adrenal suppression which must be weighed against agents with other undesirable properties while performing a critical, life-saving procedure.
  

• Bouillon R. Acute adrenal insufficiency.
  Endocrinol Metab Clin N Am.
  2006;35:767–775.
  
• Kwon KT, Tsai VW. Metabolic emergencies.
  Emerg Med Clin N Am
  . 2007;25:1041–1060.
  
• Maxime V, Lesur O, Annane D. Adrenal insufficiency in septic shock.
  Clin Chest Med.
  2009;30:17–27.
  
• Taub YR, Wolford RW. Adrenal insufficiency and other adrenal oncologic emergencies.
  Emerg Med Clin N Am.
  2009;27:271–282.
  
• Tuuri R, Zimmerman D. Adrenal insufficiency in the pediatric emergency department.
  Clin Pediatr Emerg Med.
  2009;10:260--271.
  
• Williams RH, Melmed, S, eds.
  Williams Textbook of Endocrinology
  12th ed. Philadelphia, PA: Elsevier/Saunders, 2011.
  

See Also (Topic, Algorithm, Electronic Media Element)

Cushing Syndrome

CODES

• 255.41 Glucocorticoid deficiency
  
• 255.5 Other adrenal hypofunction
  

BASICS