In this post I link to the podcast and show notes of Emergency Medicine Cases‘ EM Quick Hits 17 Adrenal Crisis, Strep Throat, Posterior MI, DKA Just the Facts, Ovarian Torsion Imaging, HINTS Exam, Canadian CT Head Rule, April 2020.
Dr. Swaminathan’s lecture is an excellent review of the routine evaluation and treatment of probable septic shock and also of vasopressor resistant hypotension and of the recognition and management of adrenal insufficiency. [Note to myself: Dr. Swaminathan’s lecture is worth reviewing over and over.]
Note and reminder to myself: I made a transcript his remarks but can’t guarantee that I’ve not made any errors and also I don’t have permission to publish it. Therefore, I’m not publishing it. Rather it is in a private post “Transcript of Adrenal Crisis in the ED From EMC” only available to me.
Here are the show notes:
Adrenal crisis recognition and ED management
- Adrenal crisis results from an acute deficiency of adrenocortical hormones which carries a significant mortality rate if not recognized early and managed aggressively
- The hallmark is severe hypotension/vasodilatory shock refractory to IV fluids and vasopressors
- Other diagnoses to consider in patients with fluid and vasopressor refractory shock include B-blocker overdose, calcium channel blocker overdose, anaphylaxis, hypocalcemia, cardiogenic shock, occult bleeding, severe hypothyroidism
- 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
- Adapt a cognitive forcing strategy to think of adrenal crisis in patients suspected of septic shock who are not responding to treatment as expected, as shock and fever may be the only signs, especially in those with pre-exististing adrenal insufficiency (e.g. Addison’s) and in those with a history of steroid medications use
- Lab clues include hypoglycemia, hyponatremia, hyperkalemia, non-anion gap metabolic acidosis, low bicarbonate, elevated BUN/creatinine, however these are neither sensitive nor specific
- Hydrocortisone 100mg IV bolus, then 25 mg IV hydrocortisone IV q6hr is the preferred initial treatment for most patients
- Dexamethasone 4-6 mg IV may be considered for those with pre-existing adrenal insufficiency as dexamethasone does not interfere with measurement of cortisol levels
- Treat the underlying trigger whenever possible
- Consider “stress-dose steroids” in any patient on chronic steroids or with chronic adrenal insufficiency to prevent adrenal crisis