ADRENAL CRISIS

RISK FACTORS

Congenital Adrenal hyperplasia
Hypopituitarism on replacement therapy
Prolonged steroid therapy or sudden withdrawal of treatment
Dehydration
Infection/ physical stress
Injury to the adrenal or pituitary gland
Surgery/ Trauma

SYMPTOMS

Abdominal pain
Altered consciousness
Dehydration/ Fatigue
Fever/ Headache
Low blood pressure
Nausea/ vomiting
Tachycardia/ Tachypnea

FEATURES

a) Mineralocorticoid deficiency

Dehydration
Hyperkalaemia
Hyponatraemia
Pre renal failure

b) Glucocorticoid deficiency

Hypoglycaemia ·
Weakness
Vomiting ·
Hypotension

MANAGEMENT

Hourly-

Blood pressure/ Heart rate
Respiratory rate.
Blood sugars.
Neurological observations
Input and output chart.

Investigations

Urea and electrolytes
Cortisol levels
Blood sugar
Cortisol and 17 hydroxyprogesterone
ACTH stimulation test

Treatment

In stable patients-

Oral fluids
Oral fludrocortisone

In persistent vomiting, manage as below-

a) CIRCULATION

In mild dehydration:

Give Maintenance fluids x 1.5 over 24 hrs
In moderate dehydration:

0.9% Saline 10 ml/kg bolus
Maintenance plus deficit over 24 hrs.

In Shock/Severe dehydration:

0.9% Saline 20 ml/kg bolus.
Maintenance plus deficit over 24 hrs.

b) IV Hydrocortisone ·

Neonates – 25 mg 1st dose.
10mg QDS · in children <1year
25mg QDS · in children 1-3 years
50mg QDS · in children 4-12 years
75 mg QDS · in children 12+ years

c) Treat Hypoglycaemia as below-

Bolus 5 mls/kg 10% glucose

KEY POINTS

Give double oral maintenance steroids during periods of stress
IM/IV hydrocortisone if vomiting/diarrhoea