Acute Adrenal Crisis; Steroids or Fluids First?

[tyagee]

A 6-year-old girl presents to the Emergency Room with profound weakness, headache, high fever, and shaking chills for the past 12 hours. According to the child’s mother, the girl has been complaining of intermittent fatigue, weakness, decreased appetite, nausea, abdominal pain, and diarrhea for the past few weeks, but her symptoms suddenly worsened last night. Now she seems confused and disoriented and is difficult to arouse from sleep. On exam, she is pale, diaphoretic, and tachypneic, with a temperature of 40°C (104.5°F), BP of 60/36, and a pulse of 140. The physician notices some hyperpigmentation over her knuckles, elbows, knees, and mucous membranes (see figure) but the rest of her exam is normal. Laboratory testing reveals serum sodium of 127 mmol/L, plasma adrenocorticotropic hormone (ACTH) 224 pmol/L, and plasma cortisol of 62 nmol/L. 17-Hydroxyprogesterone and deoxycortisol levels are within normal limits. What is the most appropriate next step in this patient’s treatment?

A. Fludrocortisone
B. Growth hormone
C. Hydrocortisone
D. Infusion of isotonic NaCl
E. Levothyroxine

[firstaid150]

C. Hydrocortisone- more imp to adm in crisis

[anomali]

how much fluids u pump in, it will be futile if u do not administer steroids for cardiovascular support(vascular tone) so hydrocortisone first

[step_enhancer]

Answer C Hydrocortisone .Cortisol not on board ,patient will have circulatory collapse .No iv fluids can help till steroids are infused.

[tyagee]

ans given is IV fluids. thats why i asked. i accept answer given is wrong and in test, i would pick steroids.

[Novobiocin]

Originally Posted by tyagee

A 6-year-old girl presents to the Emergency Room with profound weakness, headache, high fever, and shaking chills for the past 12 hours. According to the child’s mother, the girl has been complaining of intermittent fatigue, weakness, decreased appetite, nausea, abdominal pain, and diarrhea for the past few weeks, but her symptoms suddenly worsened last night. Now she seems confused and disoriented and is difficult to arouse from sleep. On exam, she is pale, diaphoretic, and tachypneic, with a temperature of 40°C (104.5°F), BP of 60/36, and a pulse of 140. The physician notices some hyperpigmentation over her knuckles, elbows, knees, and mucous membranes (see figure) but the rest of her exam is normal. Laboratory testing reveals serum sodium of 127 mmol/L, plasma adrenocorticotropic hormone (ACTH) 224 pmol/L, and plasma cortisol of 62 nmol/L. 17-Hydroxyprogesterone and deoxycortisol levels are within normal limits. What is the most appropriate next step in this patient’s treatment?

A. Fludrocortisone
B. Growth hormone
C. Hydrocortisone
D. Infusion of isotonic NaCl
E. Levothyroxine

D. Infusion of isotonic NaCl

Answer given is correct. Never forget your ABC's.
This patient is hyponatremic and hypotensive (confusion & disorientation).
The next step in management is resuscitation which in this case means isotonic fluids. Steroids takes time since their mechanism of action is via nuclear receptors.

Glucocorticoids bind to the cytosolic glucocorticoid receptor (GR). This type of receptor is activated by ligand binding. After a hormone binds to the corresponding receptor, the newly formed receptor-ligand complex translocates itself into the cell nucleus, where it binds to glucocorticoid response elements (GRE) in the promoter region of the target genes resulting in the regulation of gene expression. This process is commonly referred to as transactivation.[8]

Adrenal crisis

• Adrenal crisis
  • Intravenous fluids[4]
  • Intravenous steroid (Solu-Cortef/injectable hydrocortisone) later hydrocortisone, prednisone or methylpredisolone tablets[4]
  • Rest

Adrenal Crisis in Emergency Medicine Treatment & Management

• Maintain airway, breathing, and circulation in patients with adrenal crisis.
• Use coma protocol (ie, glucose, thiamine, naloxone).
• Use aggressive volume replacement therapy (dextrose 5% in normal saline solution [D5NS]).
• Correct electrolyte abnormalities as follows:
  • Hypoglycemia (67%)
  • Hyponatremia (88%)
  • Hyperkalemia (64%)
  • Hypercalcemia (6-33%)
• Use dextrose 50% as needed for hypoglycemia.
• Administer hydrocortisone 100 mg intravenously (IV) every 6 hours. During adrenocorticotropic hormone (ACTH) stimulation testing, dexamethasone (4 mg IV) can be used instead of hydrocortisone to avoid interference with testing of cortisol levels.
• Administer fludrocortisone acetate (mineralocorticoid) 0.1 mg every day.
• Always treat the underlying problem that precipitated the crisis.