This document outlines acute adrenal insufficiency, also known as adrenal crisis. It may occur in patients with primary adrenal insufficiency during periods of stress due to insufficient cortisol levels. Common causes include rapid withdrawal from exogenous corticosteroids or massive adrenal hemorrhage. Clinical features mimic other conditions and include postural hypotension, abdominal pain, nausea/vomiting, decreased responsiveness, and muscle cramps. Biochemical derangements include hypoglycemia, hyponatremia, hyperkalemia, and hypercalcemia. Treatment involves correcting volume depletion with normal saline, replacing glucocorticoids with intravenous hydrocortisone, correcting other metabolic abnormalities, and treating any

1. (ACUTE ADRENAL INSUFFICIENCY)
DEEPAK KUMAR MISHRA
8th Semester MBBS

2. OUTLINE
• Functional anatomy and physiology of adrenal gland
• Adrenal Crisis
• Causes
• Clinical features
• Biochemical derangement
• Investigation
• Management

3. FUNCTIONAL ANATOMY AND PHYSIOLOGY

4. ADRENAL CRISIS
• Acute adrenal insufficiency
• Frequently in patients with primary adrenal insufficiency
• Due to insufficient level of crotisol

5. CAUSES
• Chronic adrenal insufficiency Pts During period of stress
• Pts on exogenous corticosteroid Rapid withdrawal
Failure to increase steroids
• Massive adrenal haemorrhage Newborn with birth trauma and hypoxia
Pts on anticoagulant therapy
Disseminated intravascular coagulation
Meningococcal Sepsis (Waterhouse -
Friderichsen syndrome)

6. CLINICAL FEATURES
• Postural hypotension progress to hypovolemic shock refractory to vasopressor
• Mimic acute abdomen Abdominal tenderness
Nausea & Vomiting
• Mimic neurologic disease Decreased responsiveness
Stupor & Coma
• Muscle cramps
• Unexplained fever

7. BIOCHEMICAL DERANGEMENT
• Hypoglycemia
• Hyponatremia
• Hyperkalemia
• Hypercalcemia

8. INVESTIGATION
• ACTH STIMULATION TEST
• Cosyntropin 0.25 mg IM or IV
• Collect blood sample at 0, 30 & 60 mins
• Normal = Cortisol level > 15-20 µg/dl after 30-60 mins
• Cutoff for failure = Cortisol level < 16-18 µg/dl after 30-60 mins
• Plasma cortisol level
• Fasting blood sugar
• Serum Na+ & K+

9. MANAGEMENT
• CORRECTION OF VOLUME DEPLETION
• Normal saline infusion 1L/hr
• REPLACEMENT OF GLUCOCORTICOID
• 100mg Hydrocortisone IV bolus
• Followed by 200mg Hydrocortisone over 24 hours by continuous IV infusion
• Parentral Hydrocortisone untill Pt able to take orally
• CORRECTION OF OTHER METABOLIC ABNORMALITY
• Acute hypoglycaemia - IV 10% Glucose
• TREATMENT OF UNDERLYING CAUSE
• Infection, adrenal or pituitary pathology

10. TAKE HOME MESSAGES
• Critically ill Pts with HYPOTENSION REFRACTORY TO VASOPRESSOR
adrenal insufficiency to be suspected
• Clinical suspicion sufficient for a empirical trial of steroid
• Dexamethasone will not interfere with plasma cortisol can be given
before or during ACTH stimulation test
• Mineralocorticoid (Fludrocortisone) replacement given when daily
hydrocortisone dose reduces to <50 mg.