Adrenal Crisis in Emergency MedicineInthe clinical introduction of cortisone, a purified glucocorticoid preparation, revolutionized medical care of patients with a host of diseases and provided life-sustaining physiologic replacement in patients with acute or testosterone enanthate for sale uk adrenal steroid and adrenal insufficiency AI. Steroid and adrenal insufficiency recommendations about supplementation during major and minor illnesses or invasive procedures, rationale, and dosing schedules have changed. Corticosteroid Supplementation for Adrenal Insufficiency. Coursin, MD ; Kenneth E. First Page Preview View Large. Sign in to access your subscriptions Sign in to your personal account.
Everything You Need to Know about Steroids and Adrenal Insufficiency
Oct 10, Author: Although it is thought by experts that more than 50 steroids are produced within the adrenal cortex, [ 1 ] cortisol and aldosterone are by far the most abundant and physiologically active. Regulation of the adrenal cortex is illustrated in the image below. In primary adrenocortical insufficiency, glucocorticoid and mineralocorticoid properties are lost; however, in secondary adrenocortical insufficiency ie, secondary to disease or suppression of the hypothalamic-pituitary axis , mineralocorticoid function is preserved.
Although suppression of the hypothalamic-pituitary axis from chronic exogenous steroid use is the most common cause of secondary adrenal insufficiency, the possibility of hypopituitarism due to hypothalamic-pituitary disease must be considered. With acute hypopituitarism , other hormone deficiencies must be identified and treated in addition to treating adrenal insufficiency with corticosteroids. For instance, if a patient with panhypopituitarism due to Sheehan syndrome postpartum pituitary infarction is only treated for adrenal crisis, severe cardiovascular compromise from the untreated associated hypothyroidism likely occurs.
Death can result if the hypothyroid state is not diagnosed. Every emergency physician should be familiar with adrenocortical insufficiency, which is a potentially life-threatening entity. The initial diagnosis and decision to treat are presumptive and are based on history, physical examination, and, occasionally, laboratory findings.
Delay in treatment while attempting to confirm this diagnosis can result in poor patient outcomes. Sympathetic stimulation results in secretion. The adrenal cortex produces cortisol, aldosterone, and androgens. Cortisol is produced from 2 hydroxylations of 17alpha-hydroxyprogesterone. Glucocorticoids are nonspecific cardiac stimulants that activate release of vasoactive substances. In the absence of corticosteroids, stress results in hypotension, shock, and death.
Glucocorticoids act as follows to:. The renin-angiotensin system stimulates aldosterone release. Increased potassium stimulates aldosterone production, and decreased potassium inhibits production. Chronic adrenocorticotropic hormone ACTH deficiency may inhibit production. The primary targets are the kidneys; where it stimulates reabsorption of sodium and secretion of potassium and hydrogen ions. The effects on hydrogen probably can occur independently. Persistent aldosterone excess results in atrial natriuretic factor release and renal hemodynamic changes for compensation.
Congestive heart failure CHF and cirrhosis with ascites are exceptions that cause progressive sodium retention. Excess aldosterone results in sodium retention, hypokalemia , and alkalosis. Aldosterone deficiency results in sodium loss, hyperkalemia, and acidosis. Hyperkalemia stimulates aldosterone release to improve potassium excretion. Aldosterone is the first-line defense against hyperkalemia. Primary adrenal insufficiency, which can be acute or chronic, may be caused by the anatomic destruction of the gland.
This destruction can have various causes, including tuberculosis or fungal infection, other diseases infiltrating the adrenal glands, and hemorrhage. However, the most frequent cause is idiopathic atrophy, which is probably autoimmune in origin. Primary adrenal insufficiency also may be caused by metabolic failure eg, insufficient hormone production.
This failure may be a result of congenital adrenal hyperplasia CAH , enzyme inhibitors eg, metyrapone , or cytotoxic agents eg, mitotane. Primary adrenocortical insufficiency is rare and occurs at any age. The male-to-female ratio is 1: A retrospective study by Rushworth et al indicated that in pediatric patients with CAH, adrenal crises occur mostly in younger children.
Secondary adrenal insufficiency may be caused by hypopituitarism due to hypothalamic-pituitary disease or may result from suppression of the hypothalamic-pituitary axis by exogenous steroids or endogenous steroids ie, tumor.
Secondary adrenocortical insufficiency is relatively common. Extensive therapeutic use of steroids has greatly contributed to increased incidence. Adrenal crisis may result from an acute exacerbation of chronic insufficiency, [ 3 ] usually caused by sepsis or surgical stress. Acute adrenal insufficiency also can be caused by adrenal hemorrhage eg, usually septicemia-induced Waterhouse-Friderichsen syndrome [fulminant meningococcemia] and anticoagulation complications.
Steroid withdrawal is the most common cause of acute adrenocortical insufficiency and almost exclusively causes a glucocorticoid deficiency. Primary adrenocortical insufficiency is an uncommon disorder with an incidence in Western populations near 50 cases per 1,, persons.
With the advent of widespread corticosteroid use, however, secondary adrenocortical insufficiency due to steroid withdrawal is much more common. Approximately 6,, persons in the United States are considered to have undiagnosed adrenal insufficiency, which is clinically significant only during times of physiologic stress.
Glandular infiltration by tuberculosis is the second most frequent etiology. In patients with primary adrenocortical insufficiency due to idiopathic autoimmune lymphocytic infiltration, the presence of other associated endocrine disorders must be entertained. Consider polyglandular autoimmune disorders PGAs such as Schmidt syndrome. Schmidt syndrome PGA type II includes adrenal insufficiency, autoimmune thyroid disease, and, occasionally, insulin-dependent diabetes mellitus.
Adrenal insufficiency usually occurs in these patients when they are older than 20 years. PGA type I includes hypoparathyroidism and mucocutaneous candidiasis in conjunction with adrenal insufficiency. In a study from the Netherlands, Smans et al found evidence that in primary and secondary adrenal insufficiency, the incidence rate of adrenal crisis per person-years is 5.
Acute adrenocortical insufficiency is a difficult diagnosis to make. The disorder rarely occurs without concomitant injury or illness. Many of the presenting signs and symptoms are nonspecific. For instance, a postoperative fever may presumptively be treated as infection or systemic inflammatory response syndrome when it may be a subtle indicator of adrenal insufficiency.
Left untreated, a patient with acute adrenal insufficiency has a dismal prognosis for survival. Therefore, treatment upon clinical suspicion is mandatory. Any delay in management while waiting for diagnostic confirmation cannot be justified.
A Japanese study, by Ono et al, indicated that among patients with adrenal crisis, the risk of death is relatively high in those who are older and have impaired consciousness and diabetes mellitus. In the study, of patients with adrenal crisis and concomitant primary or secondary adrenal insufficiency at hospital admission, 2.
Although primary adrenocortical insufficiency affects men and women equally, women are affected times more often by the idiopathic autoimmune form of adrenal insufficiency. In idiopathic autoimmune adrenal insufficiency, the diagnosis is most often discovered in the third to fifth decades of life; however, it is particularly important to recognize that adrenocortical insufficiency is not limited to any specific age group.
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Med Sci Sports Exerc. Lelubre C, Lheureux PE. Epigastric pain as presentation of an addisonian crisis in a patient with Schmidt syndrome. Am J Emerg Med. Timelines in the management of adrenal crisis - targets, limits and reality. American College of Emergency Physicians Disclosure: Received salary from Medscape for employment. Sign Up It's Free! If you log out, you will be required to enter your username and password the next time you visit.
Share Email Print Feedback Close. Adrenal Crisis in Emergency Medicine. Sections Adrenal Crisis in Emergency Medicine. Background Adrenal crisis and severe acute adrenocortical insufficiency are often elusive diagnoses that may result in severe morbidity and mortality when undiagnosed or ineffectively treated. Regulation of the adrenal cortex. Exhibit anti-inflammatory effects, including the following: Maintenance of normal vascular response to vasoconstrictors Opposition to increases in capillary permeability Inhibition of interleukin-2 IL-2 production by macrophages Stimulation of polymorphonuclear neutrophil PMN leukocytosis Reduction of adherence of macrophages to endothelium Depletion of circulating eosinophils and lymphocytes Reduction of circulating lymphocytes primarily T cells.