Addisonian crisis

Emergency Medicine

Clinicals - History

Fact Explanation
A known patient with adrenal insufficiency. Adrenal insufficiency is a rare but life-threatening condition where adrenal cortex is dysfunctional either primarily (mostly due to autoimmune conditions) or secondarily (mostly due to hypothalamo-pituitary axis suppression). The patients might present with their previous diagnosis. A known patient with adrenal insufficiency.
Adrenal insufficiency is a rare but life-threatening condition where adrenal cortex is dysfunctional either primarily (mostly due to autoimmune conditions) or secondarily (mostly due to hypothalamo-pituitary axis suppression). The patients might present with their previous diagnosis.
Sudden syncope Normal cardiovascular reactivity which is maintained by catecholamines, requires glucocorticoids for maintenance of vascular tone and cardiac contractility. In adrenal insufficiency, especially in acute setting, the rapid loss of vasomotor response causes cardiovascular collapse and fainting. There can be associated cardiogenic shock also. Shock can preogress to coma and death if left untreated. The proposed pathophysiological mechanisma are hypovolemic shock due to decreased preload, depressed myocardial contractility, and increased systemic vascular resistance. Sudden syncope
Normal cardiovascular reactivity which is maintained by catecholamines, requires glucocorticoids for maintenance of vascular tone and cardiac contractility. In adrenal insufficiency, especially in acute setting, the rapid loss of vasomotor response causes cardiovascular collapse and fainting. There can be associated cardiogenic shock also. Shock can preogress to coma and death if left untreated. The proposed pathophysiological mechanisma are hypovolemic shock due to decreased preload, depressed myocardial contractility, and increased systemic vascular resistance.
Sudden weakness and fatigue, especially when standing up. Due to postural hypotension caused by loss of vasomotor tone. Sudden weakness and fatigue, especially when standing up.
Due to postural hypotension caused by loss of vasomotor tone.
Acute abdominal pain. Abdominal pain has been reported quite often in acute adrenal insufficiency. The pain itself could have been the trigger factor in decompensating well-controlled disease. Acute abdominal pain.
Abdominal pain has been reported quite often in acute adrenal insufficiency. The pain itself could have been the trigger factor in decompensating well-controlled disease.
Fever Hormonal hyperthermia has been reported in adrenal insufficiency. Fever
Hormonal hyperthermia has been reported in adrenal insufficiency.
A history of stressful condition There have been various precipitating factors associated with adrenal crisis identified. Especially the critically ill have been associated with very low corticosteroid levels and high mortality rates. Normally in critical illness, adrenal responsiveness to exogenous corticotropin is normally maintained. And during such critical periods the steroid binding globulins are reduced, in turn free corticosteroids are increased. They are important mechanisms in recovery. Even though it is so, during severe illnesses, the hypothalo-pituitary axis can be suppressed and there can be acute reduction of glucocorticosteroids, or an insidious loss during the course of illness. The known predisposing factors are surgeries, trauma, infections, sepsis, and hemorrhage. The well-known infections to precipitate a crisis an hypoadrenalism are dental infections, mycobacterium infections (tuberculosis), Human Immunodeficiency VIrus (HIV) and fungi. A history of stressful condition
There have been various precipitating factors associated with adrenal crisis identified. Especially the critically ill have been associated with very low corticosteroid levels and high mortality rates. Normally in critical illness, adrenal responsiveness to exogenous corticotropin is normally maintained. And during such critical periods the steroid binding globulins are reduced, in turn free corticosteroids are increased. They are important mechanisms in recovery. Even though it is so, during severe illnesses, the hypothalo-pituitary axis can be suppressed and there can be acute reduction of glucocorticosteroids, or an insidious loss during the course of illness. The known predisposing factors are surgeries, trauma, infections, sepsis, and hemorrhage. The well-known infections to precipitate a crisis an hypoadrenalism are dental infections, mycobacterium infections (tuberculosis), Human Immunodeficiency VIrus (HIV) and fungi.
A history of non-adherence to treatments Abrupt withdrawal of steroids causes adrenal crisis in patients who have been on long-term steroid therapy because the exogenous glucocorticoids suppress the adrenal axis and acutely there is a steroid deficiency. The risk of developing adrenal insufficiency after steroid withdrawal is dose-dependent. A history of non-adherence to treatments
Abrupt withdrawal of steroids causes adrenal crisis in patients who have been on long-term steroid therapy because the exogenous glucocorticoids suppress the adrenal axis and acutely there is a steroid deficiency. The risk of developing adrenal insufficiency after steroid withdrawal is dose-dependent.

Clinicals - Examination

Fact Explanation
Characteristic hyperpigmentation of the skin The charcteristic pigmentation pattern in Addisonsdisease is generalized hyperpigmentation which is classically described as “bronzing”. It is more prominent on sun-exposed areas and over pressure points, such as the elbows and knees, vermilion border, recent scars, genital skin, and oral mucosa. These are caused by increased levels of beta-lipotropin or Adrenocorticotropic hormone, each of which can stimulate melanocyte production. Intra-oral pigmentations occur earlier than skin, and it happens over a time period of months to years. In some autoimmune adrenalitis syndromes patients may have vitiligo as a part of the syndrome. Characteristic hyperpigmentation of the skin
The charcteristic pigmentation pattern in Addisonsdisease is generalized hyperpigmentation which is classically described as “bronzing”. It is more prominent on sun-exposed areas and over pressure points, such as the elbows and knees, vermilion border, recent scars, genital skin, and oral mucosa. These are caused by increased levels of beta-lipotropin or Adrenocorticotropic hormone, each of which can stimulate melanocyte production. Intra-oral pigmentations occur earlier than skin, and it happens over a time period of months to years. In some autoimmune adrenalitis syndromes patients may have vitiligo as a part of the syndrome.
Low blood pressure Due to loss of vasomotor tone, hypovolemia and shock. The hypotension is usually refractory to fluid therapy of vasopressors. Orthostatic hypotension is also an observation. Low blood pressure
Due to loss of vasomotor tone, hypovolemia and shock. The hypotension is usually refractory to fluid therapy of vasopressors. Orthostatic hypotension is also an observation.

Investigations - Diagnosis

Fact Explanation
Complete blood count To investigate whether there is an underlying inflammation or infection. Lymphocytopenia also has been associated with Addisons disease and chronic steroid therapy. Complete blood count
To investigate whether there is an underlying inflammation or infection. Lymphocytopenia also has been associated with Addisons disease and chronic steroid therapy.
Blood glucose level blood sugar at the admission. To exclude hypoglycemia. Blood glucose level
blood sugar at the admission. To exclude hypoglycemia.
Electrolyte levels In hypoadrenalism usually there is hyponatremia and hyperkalemia. Electrolyte levels
In hypoadrenalism usually there is hyponatremia and hyperkalemia.
Serum calcium There can be elevated serum calcium since volume depletion causes reduced glomerular filtration rate and excretion of calcium. Serum calcium
There can be elevated serum calcium since volume depletion causes reduced glomerular filtration rate and excretion of calcium.
Serum thyroxine level It's important to exclude hypothyroidism since it can mask hypoadrenalism. Serum thyroxine level
It's important to exclude hypothyroidism since it can mask hypoadrenalism.
Serum cortisol level Emergency serum cortisol level should be measured on arrival despite of diurnal variation of the hormone. In Addisons disease serum free cortisol level is low. The newer tendency is to measure salivary cortisol level as it's not an invasive method. Serum cortisol level
Emergency serum cortisol level should be measured on arrival despite of diurnal variation of the hormone. In Addisons disease serum free cortisol level is low. The newer tendency is to measure salivary cortisol level as it's not an invasive method.
Tetracosactide test This is a test done by administering low dose synthetic ACTH (Synacthen, tetracosactide) and measuring the cortisol response in 30, 60, 90, and 120 minutes. It's diagnostic of Addisons disease, but should be performed only after the acute management has been done. Tetracosactide test
This is a test done by administering low dose synthetic ACTH (Synacthen, tetracosactide) and measuring the cortisol response in 30, 60, 90, and 120 minutes. It's diagnostic of Addisons disease, but should be performed only after the acute management has been done.
Blood culture Blood cultures and maybe cultures from wounds etc should be assessed to exclude sepsis. Blood culture
Blood cultures and maybe cultures from wounds etc should be assessed to exclude sepsis.
ECG To identify the effects of electrolyte abnormalities on cardiac function, main concern being hyperkalemia. ECG
To identify the effects of electrolyte abnormalities on cardiac function, main concern being hyperkalemia.
Adrenal antibodies To diagnose autoimmune adrenalitis. Adrenal antibodies
To diagnose autoimmune adrenalitis.
Chest X-ray To exclude pulmonary tuberculosis. Chest X-ray
To exclude pulmonary tuberculosis.
Abdominal CT Usually to evaluate secondary causes of hypoadrenalism like calcifications, hemorrhages, or metastatic deposits. Abdominal CT
Usually to evaluate secondary causes of hypoadrenalism like calcifications, hemorrhages, or metastatic deposits.

Investigations - Management

Fact Explanation
Cortisol level Checking serum cortisol levels fequently and re-adjusting the dose of hydrocortisone/ fludrocortisone level until it replaces the natural level. It can be tested in serum or saliva. Individual adjustment of glucocorticoids to approach normal cortisol concentrations during the day can reduce overreplacement, especially in the evening. This can lead to a reduction of sleep disturbances and fatigue in patients with Addison's disease. Cortisol level
Checking serum cortisol levels fequently and re-adjusting the dose of hydrocortisone/ fludrocortisone level until it replaces the natural level. It can be tested in serum or saliva. Individual adjustment of glucocorticoids to approach normal cortisol concentrations during the day can reduce overreplacement, especially in the evening. This can lead to a reduction of sleep disturbances and fatigue in patients with Addison's disease.
Serum electrolytes Since symptomatic adrenal insufficiency causes hyponatremia and hyperkalemia it's important to asses whether the patient has been treated with adequate mineralocorticoids by checking serum sodium and potassium frequently. Serum electrolytes
Since symptomatic adrenal insufficiency causes hyponatremia and hyperkalemia it's important to asses whether the patient has been treated with adequate mineralocorticoids by checking serum sodium and potassium frequently.
Blood glucose level Over-treatment with glucocorticoids can cause hyperglycemia and adrenal insufficiency or under-treatment can cause hypoglycemia. The autoimmune causes of Addisons can cause type I diabetes mellitus. Blood glucose level
Over-treatment with glucocorticoids can cause hyperglycemia and adrenal insufficiency or under-treatment can cause hypoglycemia. The autoimmune causes of Addisons can cause type I diabetes mellitus.

Management - Supportive

Fact Explanation
Securing the airway, breathing and circulation. In the patients who present with acute weakness, syncope or patients with cardiovascular demise, ABC approach should be taken. Securing the airway, breathing and circulation.
In the patients who present with acute weakness, syncope or patients with cardiovascular demise, ABC approach should be taken.
Patient education Educating the patients and his/her family regarding the illness and it's precipitating factors together with the importance of adherence to treatments can improve the quality of life. Patient education
Educating the patients and his/her family regarding the illness and it's precipitating factors together with the importance of adherence to treatments can improve the quality of life.
Avoidance of precipitating factors The risk factors for developing a crisis in chronic Addisons disease patients should be identified and taught to avoid. i. e. acute drug withdrawal, untreated infections, surgery etc. Avoidance of precipitating factors
The risk factors for developing a crisis in chronic Addisons disease patients should be identified and taught to avoid. i. e. acute drug withdrawal, untreated infections, surgery etc.
Assess cardiovascular status and electrolytes frequently. Once the patient is euadrenal, follow-up examinations and investigations to maintain the desirable blood pressure and electrolytes, with frequent (preferably once a month) overall assessment should be done. Assess cardiovascular status and electrolytes frequently.
Once the patient is euadrenal, follow-up examinations and investigations to maintain the desirable blood pressure and electrolytes, with frequent (preferably once a month) overall assessment should be done.

Management - Specific

Fact Explanation
Correct fluid status. Prompt and aggressive fluid resuscitation is an important initial step because the patients may be severely dehydrated with low blood pressure. Correct fluid status.
Prompt and aggressive fluid resuscitation is an important initial step because the patients may be severely dehydrated with low blood pressure.
Correct hypoglycemia. Adrenal crisis can be associated with hypoglycemia which can in turn make electrolyte abnormalities even worse, so it's important to correct the blood glucose status. Correct hypoglycemia.
Adrenal crisis can be associated with hypoglycemia which can in turn make electrolyte abnormalities even worse, so it's important to correct the blood glucose status.
Correct electrolyte status. Hyponatremia and hyperkalemia are well recognized electrolyte abnormalities in Addisons disease. Hypercalcemia is also a complication in severe dehydration. All the electrolytes should be corrected but special attention should be given to the potassium status since small changes affect the cardiac and neurological status. Correct electrolyte status.
Hyponatremia and hyperkalemia are well recognized electrolyte abnormalities in Addisons disease. Hypercalcemia is also a complication in severe dehydration. All the electrolytes should be corrected but special attention should be given to the potassium status since small changes affect the cardiac and neurological status.
Steroid replacement. Steroid replacement is life-saving in adrenal crisis. At the presentation, a bolus of intravenous hydrocortisone with maintenace steroid as oral hydrocortisone 15-25 mg/day in divided doses (dose monitoring based on the clinical judgement) Fludrocortisone 0.05-0.2 mg/day is given for substitution in mineralocorticoid deficiency aiming at normotension, normokalaemia and a plasma renin activity in the upper normal range. Continuos monitoring is essential. Steroid replacement.
Steroid replacement is life-saving in adrenal crisis. At the presentation, a bolus of intravenous hydrocortisone with maintenace steroid as oral hydrocortisone 15-25 mg/day in divided doses (dose monitoring based on the clinical judgement) Fludrocortisone 0.05-0.2 mg/day is given for substitution in mineralocorticoid deficiency aiming at normotension, normokalaemia and a plasma renin activity in the upper normal range. Continuos monitoring is essential.

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