EM@3AM – Acute Adrenal Insufficiency

Author: Erica Simon, DO, MHA (@E_M_Simon, EM Chief Resident, SAUSHEC, USAF) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC, USAF)

Welcome to EM@3AM, an emdocs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.

A 57 year-old female with a previous medical history of rheumatoid arthritis (RA) (adalimumab and glucocorticoid therapy) presents to the ED for weakness and lethargy. The patient denies chest pain and shortness of breath. She denies a familial history of coronary artery disease, smoking, hypertension, hyperlipidemia, diabetes, and a personal/familial history of thyroid pathology. ROS is negative for recent hospitalization, recent illness, sick contacts, and foreign travel.

VS: HR 135, BP 81/62, RR 18, T103.1 Oral, SpO2 97% room air.

Physical exam: Toxic appearing obese female, GCS 15, A&O x3, no focal neurologic deficits, lungs CTAB, abdomen benign.

EKG: Sinus Tachycardia, normal axis, no acute ST-T wave changes.

Two peripheral IVs are obtained. Fluid resuscitation and broad-spectrum antibiotics are initiated. VBG reveals a lactate of 4.2.
UA: nitrite positive, leukocyte esterase positive, 3+ bacteria.

After 2L of NS, the patient’s HR is 131, her BP 80/63. Norepinephrine is initiated with minimal improvement in her MAP.

What do you suspect as a diagnosis? What’s the next step in your evaluation and treatment?

Answer: Acute Adrenal Insufficiency^1-3

• Precipitating Causes: Acute stress or illness in any patient who has been receiving glucocorticoid therapy or in those diagnosed with conditions associated with adrenal insufficiency (metastatic cancer, AIDS, tuberculosis).¹
  • May also be a manifestation of previously undiagnosed chronic adrenal insufficiency.

• Presentation: Consider in individuals with unexplained fever, abdominal pain, and orthostatic hypotension, or in patients experiencing shock refractory to vasopressors. ¹

• Evaluation:²
  • Utilize the H&P to direct evaluation and treatment (rule out underlying etiologies: infection, myocardial infarction, etc.)
    • Accucheck: evaluate for hypoglycemia
    • CBC: normochromic, normocytic anemia; relative lymphocytosis common
    • VBG: frequently mild metabolic acidosis
    • CMP: pre-renal azotemia
      • Primary adrenal insufficiency: look for hyponatremia and hyperkalemia
      • Secondary adrenal insufficiency: look for hyponatremia 

• Treatment:
  • 50-100mg hydrocortisone IV or IM every 6 hours¹
  • D5NS PRN

• Pearls:
  • If adrenal insufficiency is suspected, initiate glucocorticoid therapy as soon as possible. Improvement following steroid administration suggests the diagnosis.¹
  • A random serum cortisol level is of little utility:³
    • Cortisol is released in a pulsatile fashion demonstrating diurnal variation.
    • The administration of etomidate has been shown to decrease cortisol production.
    • Hypoalbuminemia (common in the critically ill) lowers cortisol-binding globulin (CBG) resulting in a decreased total cortisol measurement.
  • Corticosyn/Synacthen (Synthetic ACTH) Stimulation Testing is the standard screening test for diagnosis and should be considered upon specialty consultation.
    • Hydrocortisone therapy should be continued until stimulation testing is performed.¹

References:

1. Barthel A, Willenberg H, Gruber M, Bornstein S. In: Endocrinology: Adult and Pediatric. 7^th ed. Philadelphia, Saunders Elsevier. 2016; 1763-1774.e.4.
2. El Fassi D, Nielsen G. Hyperkalemia: A clue to the diagnosis of adrenal insufficiency. Circulation. 2013; 128: 2620-2621.
3. Hamrahian A, Oseni T, Arafah B. Measurements of serum free cortisol in critically ill patients. N Engl J Med. 2004; 350: 1629-1638.

For Additional Reading:

Adrenal Crisis in the ED:

Adrenal Crisis in the ED