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Adrenal Crisis

What is Adrenal Crisis?

Adrenal crisis, synonymous to Addisonian crisis, is a fatal condition and complication of a chronic adrenal disease (Addison disease). The condition arises when there is no enough production of cortisol by the adrenal glands. This deficiency can result to such life-threatening state for it plays a big role in regulating our blood sugar level, controlling our immune responses and responses to stress. This medical condition is also referred as acute adrenal failure, which is likely a complication from untreated and under-managed Addison disease.

Series of tests are placed in order to attain final diagnosis of adrenal crisis. The following tests shall assist in finding the cause of the patient’s state:

  • Blood analysis. Patients suffering from adrenal crisis are expected to suffer from hyponatremia. This is a common result though not a complete identifier that one is suffering from adrenal crisis. Increased potassium levels, metabolic acidosis and hypoglycemia are reported.
  • Serum cortisol. Expected result would be a cortisol level less than 20mcg/dL.
  • ACTH test. This is considered the determining diagnosis. The procedure shall include taking the initial baseline serum cortisol of the client. Administration of ACTH 250 mcg via IV push is done then about 30 to 60 minutes after, serum ACTH shall be checked. If there is a significant increase of less than 9mcg/dL, adrenal insufficiency is likely the diagnosis.
  • CBC. Anemia and presence of infection shall be noted in the result.
  • Chest X-ray. This may be necessary to identify presence of tuberculosis which is a probable cause of the crisis. This can also identify presence of lymphoma and other malignant diseases.
  • Abdominal CT scan. This can visualize presence of hemorrhage in the abdominal area which may have affected the adrenal glands. When adrenal bleeding is suspected, there shall be bilateral enlargement of the adrenal glands and they appear hyper dense in the scan result.
  • ECG test. In an ECG result, a person suffering from adrenal crisis will have deep inverted T waves. Prolonged QT interval would indicate ventricular arrhythmias.

Adrenal Crisis

Picture : Functions of adrenal gland

Image source : ADAM Inc

Symptoms and Signs

Adrenal crisis needs emergent care when identified. The following are the said manifestations of the condition:

  • Extreme weakness accompanied by confusion
  • Changes in motor activity
  • Loss of consciousness or may also lead to coma
  • Acute postural hypotension
  • Abdominal discomfort/ pain which may cause loss of appetite, anorexia and nausea and vomiting
  • High fever secondary to underlying infection
  • Darkening of the skin or skin rashes
  • Dehydration
  • Rapid heart rate and respiratory rate
  • Death is a possibility when left untreated

Adrenal Crisis Causes

This crisis is an acute and emergent medical condition that is basically experienced by most patients with Addison disease. There are a number of triggering factors for adrenal crisis because the human body tends to demand what is required but is in the end not met because of an underlying chronic disease. The major precipitating factor for an adrenal crisis is stress and illness. Other conditions such as infection, dehydration, surgery, trauma, pregnancy, burns and abrupt cessation in Addison disease treatment can result to an adrenal crisis.

There are cases where patients who are undergoing long-term steroid treatment suffer from adrenal crisis. When steroid treatment is stopped, possible steroid withdrawal occurs. This is included as a cause when the treatment may have affected the normal functioning of the cortisol release by suppression.

Conditions such as tuberculosis, HIV-AIDS and congenital adrenal hypoplasia have been linked to cause adrenal crisis.

Adrenal Crisis Pathophysiology

Adrenal crisis arises when sufficient production of cortisol is not met. It is known that cortisol production is regulated by the pituitary gland. A healthy person shall have a sufficient amount of this glucocorticoid because the pituitary gland releases ACTH (adrenocorticotropic hormone), which is responsible in triggering the release of cortisol from the adrenal glands. The human body has two adrenal glands, located on top of each kidney. The glands are divided into two portions; the adrenal cortex, located outside and the medulla, the inner section of the adrenal gland.

The adrenal cortex is basically the easiest target for damage/trauma while the adrenal medulla is usually affected when tumors arise. The adrenal cortex produces essential hormones of the body that regulate the body’s blood sugar, immune responses and stress response. When there is damage to the adrenal gland, the primary result would be insufficiency.

When the regulatory gland of the brain, pituitary gland, is injured it would result to the cessation of hormone ACTH release. When a patient is under treatment for Addison disease and is not properly managed, then they tend to suffer from this life-threatening crisis.

Treatment

Before continue reading, it is a strict reminder not to do self medication or self treatment. Always seek help from your doctor in order not to complicate the situation.

Adrenal crisis is an emergency case in the triage of treatment. The following are the interventions for adrenal crisis:

  • Start resuscitation without delay. There should be immediate care rendered to the patient. When adrenal crisis is suspected, especially to those high risk patients, the need for confirmation is unnecessary.
  • Provide glucocorticoids via intravenous route (if line is started) or intramuscularly. Dexamethasone is the drug of choice for an adrenal crisis.
  • It is necessary to provide airway (oxygenation).
  • Provide client fluid replacement to correct hypotension, dehydration and fluid and electrolyte imbalance.
  • Hypotension should be properly treated with vasopressors (dopamine).
  • When infection may be the triggering condition for adrenal crisis, treating it with antibiotics is done.
  • Proper monitoring is done to patients to see progress from the treatment provided. Blood analysis and urinalysis are done in a regular basis to check cortisol levels.

Prevention is quite necessary with adrenal crisis, as this is can be fatal to the patient. The following measures can prevent a future episode of adrenal crisis:

  1. Proper taking of glucocorticoid maintenance. Consulting the doctor for proper dosage of the maintenance drug is a must.
  2. Avoid too much stress.
  3. Eat healthy and maintain the ideal lifestyle for optimum health.
  4. Avoid acquiring infections by keeping away from people with infectious diseases.
  5. When infection is suspected, seeking medical advice is a must to avoid worsening of one’s state and to avoid occurrence of adrenal crisis.

References

http://www.patient.co.uk/doctor/Addisonian-Crisis.htm

http://adrenalcrisis.org/

http://emedicine.medscape.com/article/116716-overview



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