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Ovid: Oxford Handbook of Acute Medicine

Editors: Ramrakha, Punit S.; Moore, Kevin P. Title: Oxford Handbook of Acute Medicine, 2nd Edition Copyright ©1997,2004 Oxford University Press (Copyright 1997, 2004 by Punit S Ramrakha and Kevin P Moore) > Table of Contents > Chapter 9 – Endocrine emergencies > Addisonian crisis: management Addisonian crisis: management Investigations

• U&Es Hyponatraemia and hyperkalaemia (rarely greater than 6.0mM). High ur:cr ratio indicative of hypovolaemia
• FBC Anaemia (normal MCV); moderate neutropenia ± relative eosinophilia/lymphocytosis
• Glucose Hypoglycaemia (rarely severe)
• Calcium May be high
• Serum cortisol Save for routine assay. Baseline <400nmol/L. Should be >1000nmol/L in ‘sick’ patients
• ABG Metabolic acidosis, respiratory failure
• Urine MC&S for infection; urinary Na excretion often high in spite of hypovolaemia
• CXR Previous TB, bronchial carcinoma
• AXR Adrenal calcification

Management

  • Treatment may be required before the diagnosis is confirmed.
  • General measures include oxygen, continuous ECG monitoring, CVP monitoring, urinary catheter (for fluid balance), and broad spectrum antibiotics (e.g. cefotaxime) for underlying infection.
  • Treat shock (P260): give iv N saline or colloid (Haemaccel®) for hypotension: 1L stat then hourly depending on response and clinical signs. Inotropic support may be necessary.
  • Give iv 50% dextrose (50ml) if hypoglycaemic.
  • If adrenal crisis is suspected, the patient needs glucocorticoids urgently: use dexamethasone 8mg iv which will not interfere with the cortisol assay of a short Synacthen® test. If dexamethasone is unavailable use hydrocortisone (can be stopped later). This single extra dose can do little harm and may be life saving.
  • Short Synacthen® test (omit if the patient is known to have Addison’s disease): take baseline blood sample (serum) and administer tetracosactrin (Synacthen®) 250µg im or iv. Take further samples at 30 and 60 minutes for cortisol assay.
  • Continue steroid treatment as iv hydrocortisone (200mg stat), then 100mg tds. Change to oral steroids after 72 hours.
  • Fludrocortisone (100µg daily orally) when stabilized on oral replacement doses of hydrocortisone.

Prevention

  • Patients on long-term steroid therapy and/or known adrenocortical failure should be instructed to increase steroid intake for predictable stresses (e.g. elective surgery, acute illnesses with fever >38°).
  • For mild illnesses, if not vomiting, double the oral dose. Vomiting requires iv/im therapy (hydrocortisone 50mg tds).
  • For minor operations or procedures (e.g. cystoscopy) give hydrocortisone 100mg iv/im as a single dose before the procedure.
  • More serious illnesses require hydrocortisone 100mg q6–8h iv/im until recovered or for at least 72 hours.
  • Double replacement doses when stabilized if on enzyme-inducing drugs.

P.587
Equivalent doses of glucocorticoids1

Drug Equivalent dose (mg)
Dexamethasone 0.75
Methylprednisolone 4
Triamcinolone 4
Prednisolone 5
Hydrocortisone 20
Cortisone acetate 25

Footnote 1British National Formulary (1995) Pharmaceutical Press, Royal Pharmaceutical Society of Great Britain, London: Section 6.3.2.

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