eMedicine Specialties > Emergency Medicine > Endocrine & Metabolic

Adrenal Insufficiency and Adrenal Crisis: Differential Diagnoses & Workup

Author: Kevin M Klauer, DO, FACEP, Assistant Clinical Professor, Michigan State University College of Osteopathic Medicine; Director, Quality and Clinical Education, Emergency Medicine Physicians, Ltd; Director, Center for Emergency Medical Education; Editor-in-Chief, Emergency Physicians Monthly
Contributor Information and Disclosures

Updated: Dec 16, 2009

Differential Diagnoses

Abdominal Pain in Elderly Persons
Hyponatremia
Anorexia Nervosa
Hypopituitarism
Appendicitis, Acute
Hypothyroidism and Myxedema Coma
Cholecystitis and Biliary Colic
Metabolic Acidosis
Cholelithiasis
Urinary Tract Infection, Female
Gastroenteritis
Urinary Tract Infection, Male
Hypercalcemia
Hyperkalemia
Hypoglycemia

Other Problems to Be Considered

Etomidate and adrenal insufficiency

Etomidate is perhaps the most common induction agent used for rapid sequence intubation in the ED and is frequently used as an induction agent for general anesthesia. Although this agent is particularly useful in hemodynamically unstable patients, the potential for precipitation of acute adrenal insufficiency, even following a single dose, must be recognized.

Etomidate is a steroid synthesis inhibitor and, thus, may inhibit production of glucocorticoids. Of particular note is the potential to worsen hemodynamics in patients suffering from septic shock, a patient population that may benefit from supplemental corticosteroid administration.3

Workup

Laboratory Studies

The following should be assessed in patients with suspected adrenal crisis or adrenal insufficiency:

  • CBC count
  • Electrolyte levels
  • BUN level
  • Creatinine level
  • Cortisol level4
  • Serum calcium level
  • Thyroid function (possibly performed in ED but unlikely to influence immediate management)

Imaging Studies

  • Chest radiograph
  • CT scan
    • A CT scan of the abdomen may show hemorrhage in the adrenals, calcification of the adrenals (seen with tuberculosis), or metastasis.
    • In cases of secondary adrenal insufficiency, a head CT scan may show destruction of the pituitary (ie, empty sella syndrome) or a pituitary mass lesion.

Other Tests

  • Adrenocorticotropic hormone (ACTH) stimulation test
    • Note: In emergent situations, do not delay treatment of presumed adrenal insufficiency during diagnostic testing. Treatment with dexamethasone allows ACTH stimulation testing without affecting or interfering with the measurement of serum cortisol levels.
    • Obtain baseline serum cortisol and ACTH levels.
    • Administer 0.25 mg (250 mcg) of cosyntropin (synthetic ACTH) intravenously (IV) or intramuscularly (IM).
    • Repeat cortisol levels every 30 minutes (some authors recommend 60 min) and 6 hours after ACTH administration.
    • Normal response is indicated when the cortisol level doubles in response to ACTH stimulation.
    • In adrenal insufficiency, serum cortisol levels fail to rise after ACTH administration.
  • Electrocardiograph (ECG): Elevated peaked T waves may indicate hyperkalemia.
  • 24-hour urinary cortisol: Use only in nonemergent situations.

More on Adrenal Insufficiency and Adrenal Crisis

Overview: Adrenal Insufficiency and Adrenal Crisis
Differential Diagnoses & Workup: Adrenal Insufficiency and Adrenal Crisis
Treatment & Medication: Adrenal Insufficiency and Adrenal Crisis
Follow-up: Adrenal Insufficiency and Adrenal Crisis
Multimedia: Adrenal Insufficiency and Adrenal Crisis
References
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References

  1. Wyngaarden JB, Smith LH, Bennett JC. Adrenocortical hypofunction. Cecil Textbook of Medicine. 19th ed. WB Saunders; 1992:1271-1288.

  2. Hahner S, Loeffler M, Bleicken B, et al. Epidemiology of adrenal crisis in chronic adrenal insufficiency - the need for new prevention strategies. Eur J Endocrinol. Dec 2 2009;[Medline].

  3. Lundy JB, Slane ML, Frizzi JD. Acute adrenal insufficiency after a single dose of etomidate. J Intensive Care Med. Mar-Apr 2007;22(2):111-7. [Medline].

  4. [Guideline] Marik PE, Pastores SM, Annane D, et al. Recommendations for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients: consensus statements from an international task force by the American College of Critical Care Medicine. Crit Care Med. Jun 2008;36(6):1937-49. [Medline].

  5. Hahner S, Allolio B. Therapeutic management of adrenal insufficiency. Best Pract Res Clin Endocrinol Metab. Apr 2009;23(2):167-79. [Medline].

  6. Aono J, Mamiya K, Ueda W. Abrupt onset of adrenal crisis during routine preoperative examination in a patient with unknown Addison's disease. Anesthesiology. Jan 1999;90(1):313-4. [Medline].

  7. Braunwald E, Isselbacher KJ, Fauci AS, et al. Hypofunction of adrenal cortex. In: Harrison's Principles of Internal Medicine. 11th ed. McGraw-Hill; 1987:1764-1771.

  8. Carson PP. Emergency. Adrenal crisis. Am J Nurs. Jul 2000;100(7):49-50. [Medline].

  9. Chin R. Adrenal crisis. Crit Care Clin. Jan 1991;7(1):23-42. [Medline].

  10. Cronin CC, Callaghan N, Kearney PJ, et al. Addison disease in patients treated with glucocorticoid therapy. Arch Intern Med. Feb 24 1997;157(4):456-8. [Medline].

  11. Dluhy RG. Assessment of systemic corticosteroid activity. Respir Med. Nov 1997;91 Suppl A:32-3. [Medline].

  12. Duclos M, Guinot M, Colsy M, Merle F, Baudot C, Corcuff JB, et al. High risk of adrenal insufficiency after a single articular steroid injection in athletes. Med Sci Sports Exerc. Jul 2007;39(7):1036-43. [Medline].

  13. Gilliland PF. Endocrine emergencies. Adrenal crisis, myxedema coma, and thyroid storm. Postgrad Med. Nov 1983;74(5):215-20, 225-7. [Medline].

  14. Guyton AC, et al. The adrenocortical hormones. In: Textbook of Medical Physiology. 7th ed. WB Saunders; 1986:909-919.

  15. Lelubre C, Lheureux PE. Epigastric pain as presentation of an addisonian crisis in a patient with Schmidt syndrome. Am J Emerg Med. Feb 2008;26(2):251.e3-4. [Medline].

  16. Omori K, Nomura K, Shimizu S. Risk factors for adrenal crisis in patients with adrenal insufficiency. Endocr J. Dec 2003;50(6):745-52. [Medline].

  17. Reincke M. Subclinical Cushing's syndrome. Endocrinol Metab Clin North Am. Mar 2000;29(1):43-56. [Medline].

  18. Rosen P. Endocrine disorders. In: Emergency Medicine: Concepts and Clinical Practice. 3rd ed. Mosby-Year Book; 1992:2252-2259.

  19. Rusnak RA. Adrenal and pituitary emergencies. Emerg Med Clin North Am. Nov 1989;7(4):903-25. [Medline].

  20. Simm PJ, McDonnell CM, Zacharin MR. Primary adrenal insufficiency in childhood and adolescence: advances in diagnosis and management. J Paediatr Child Health. Nov 2004;40(11):596-9. [Medline].

  21. Tuchelt H, Dekker K, Bahr V, Oelkers W. Dose-response relationship between plasma ACTH and serum cortisol in the insulin-hypoglycaemia test in 25 healthy subjects and 109 patients with pituitary disease. Clin Endocrinol (Oxf). Sep 2000;53(3):301-7. [Medline].

  22. Vesely DL. Hypoglycemic coma: don't overlook acute adrenal crisis. Geriatrics. May 1982;37(5):71-3, 76-7. [Medline].

  23. Wiltshire EJ, Wilson R, Pringle KC. Addison's disease presenting with an acute abdomen and complicated by cardiomyopathy. J Paediatr Child Health. Nov 2004;40(11):644-5. [Medline].

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Further Reading

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Keywords

adrenal insufficiency, adrenal crisis, adrenocortical insufficiency, severe acute adrenocortical insufficiency, primary adrenocortical insufficiency, primary adrenal insufficiency, secondary adrenocortical insufficiency, secondary adrenal insufficiency, treatment, diagnosis, symptoms

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Contributor Information and Disclosures

Author

Kevin M Klauer, DO, FACEP, Assistant Clinical Professor, Michigan State University College of Osteopathic Medicine; Director, Quality and Clinical Education, Emergency Medicine Physicians, Ltd; Director, Center for Emergency Medical Education; Editor-in-Chief, Emergency Physicians Monthly
Kevin M Klauer, DO, FACEP is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Howard A Bessen, MD, Professor of Medicine, Department of Emergency Medicine, UCLA School of Medicine; Program Director, Harbor-UCLA Medical Center
Howard A Bessen, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

 
 
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