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Addisonion crisis
1. Sudden penetrating pain in the legs, lower back or
abdomen
Severe vomiting and diarrhea, resulting in dehydration
Low blood pressure, Unexplained shock, usually refractory
to fluid and pressor resuscitation
Syncope (loss of consciousness)
Hypoglycemia
Confusion, psychosis, slurred speech
Severe lethargy
Hypercalcemia
Convulsions
Fever
Rapid withdrawal of long-term steroid therapy
Hyperthermia or hypothermia
2. Meningococcemia & Organisms associated with adrenal crisis e.g
Haemophilus influenzae, Staphylococcus aureus,Streptococcus
pneumonia, fungi
Severe physiologic stress
Azotemia
Anticoagulants, hemorrhagic diathesis
Adrenocorticotropin therapy, known primary or secondary
adrenocortical insufficiency
AIDS
Invasive or infiltrative disorders
Tuberculosis
Prior steroid use
Topical steroids : large surface, long periods of use
Inhaled steroids : > 8 mg/dl for long time, Fluticasone even at
lower dose
3. Serum cortisol: <20 mcg/dL in severe stress
or after ACTH stimulation is indicative of
adrenal insufficiency
ACTH test : diagnostic
Serum chemistry, ↓Na, ↑K, metabolic
acidosis, Hypoglycemia
CBC: Anemia, lymphocytosis, and
eosinophilia (highly suggestive)
Cultures, Infection is a common cause of
acute adrenal crisis.
4. Chest radiography: Assess for tuberculosis,
histoplasmosis, malignant disease, sarcoid,
and lymphoma.
Abdominal CT scanning: Visualize adrenal
glands for hemorrhage, atrophy, infiltrative
disorders, and metastatic disease.
Electrocardiography
5. Primary adrenocortical failure : evidence of
infection, infiltrative disease.
Secondary adrenocortical insufficiency:
atrophy of the adrenals or no histologic
evidence at all, especially if due to exogenous
steroid ingestion.
Appearance of bilateral adrenal hemorrhage
may be striking, as if bags of blood are
replacing the glands.
6. During an addisonian crisis, low blood pressure, low blood glucose,
and high levels of potassium can occur. Specific addisonian crisis
treatment for these symptoms involves intravenous (IV) injections
of:
Hydrocortisone
Saline
Dextrose
These addisonian crisis treatments usually bring rapid
improvement.
When the patient can take fluids and medications by mouth, the
amount of hydrocortisone is decreased until a maintenance dose
is achieved. If aldosterone is deficient, maintenance therapy also
includes oral doses of fludrocortisone acetate.
7. Dexamethasone : Used as empiric treatment of
shock in suspected adrenal crisis or insufficiency
until serum cortisol levels are drawn.
Hydrocortisone :DOC because of
mineralocorticoid activity and glucocorticoid
effects
Fludrocortisone (Florinef) : mineralocorticoids, .
Produces marked sodium retention and
increased urinary potassium excretion.
Methylprednisolone : 3rd Line, of lack of
mineralocorticoid activity, in patients with fluid
overload, edema, or hypokalemia
8. Endocrinologist
Infectious disease specialist
Critical care physician
Surgeon
Corticosteroids & IV fluids are the mainstays
of treatment. Other medications, such as
pressors (eg, dopamine, norepinephrine) or
antibiotics, are administered as clinically
indicated.