An endocrinologic emergency with a high mortality rate secondary to physiologic derangements from an acute deficiency of the adrenal hormone cortisol

UNSTABLE

Signs and Symptoms

• Hypotension ↓(<90/60), ↑ Tachycardia (>150) → in shock
• Abdominal Pain
• Severe Confusion, loss of LOC, Coma (GCS ≤ 8)
• Severe Muscle Weakness and Lethargic (GCS 13–15)
• !Hypovolemia ↓
• Hypoglycemia ↓( ≤ 4)
• N/V - Nausea/vomitting
• Perspiration/Diaphoresis on face and palm

Note:

• In !Addisonian crisis, administration of Hydrocortisone can cause elevation of measured @cortisol

  • can measure baseline hormone before administrate Hydrocortisone

  • can give Dexamethasone, which will not be measured as cortisol

    <aside> 💡 Does not have a secondary mineralocorticoid action as IV high dose Hydrocortisone

    </aside>

Management: Addisonian crisis

1. Stablize the !Hypovolemia ↓

   • IV Fluid Resuscitation
   • IV hypotonic (Dextrose/D5W)

2. Measure baseline hormone (AM Cortisol level , Renin, Aldosterone )

3. Administrate IV Hydrocortisone

   • IV, high dose → both glucocorticoid and mineralocorticoid effect
     • Start at 100 mg
     • Proceed with 80 mg Q8H
   • Cortisol inhibits ADH, thus administration of cortisol will also help reverse the !Hypovolemia ↓

   <aside> 💡 Note: rapid reversal of Hyponatremia ↓ [Na] (<135) can cause Central Poutine demyelination (brain shrinking) → Administrate DDAVP (ADH Agonist (-”pressin”)) to slow down the reversal, or take > 48 hr

   </aside>

4. ACTH Stimulation test

5. Abdominal CT → Investigation of etiology

   1. Or other specific tests mentioned in etiology section

6. Transition to daily maintenance medication once stabilized