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Adrenal Insufficiency and Adrenal Crisis: Differential Diagnoses & Workup
Updated: Aug 19, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Differential Diagnoses
Other Problems to Be Considered
Etomidate and adrenal insufficiency
Etomidate is perhaps, the most common induction agent used for rapid sequence intubation in the emergency department 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.2
Workup
Laboratory Studies
- Complete blood count
- Electrolytes
- Blood urea nitrogen
- Creatinine
- Cortisol level
- Serum calcium
- Thyroid function tests (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 TB), 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 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) IV/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 |
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References
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Further Reading
Keywords
adrenal insufficiency, adrenal crisis, adrenocortical insufficiency, severe acute adrenocortical insufficiency, primary adrenocortical insufficiency, primary adrenal insufficiency, secondary adrenocortical insufficiency, secondary adrenal insufficiency, suppression of the hypothalamic-pituitary axis, mineralocorticoid function, glucocorticoid, hypopituitarism, cortisol, aldosterone, pan-hypopituitarism, panhypopituitarism, Sheehan syndrome, endocrinedisorders, adrenocorticotropic hormone, ACTH,adrenocorticotropic hormone deficiency
ACTH deficiency, postpartum pituitary infarction, hypothalamic-pituitary disease, hypothyroidism, physiologic effects of glucocorticoids, physiologic effects of aldosterone, tuberculosis of adrenal gland, fungal infection of adrenal gland, idiopathic atrophy of adrenal gland, congenital adrenal hyperplasia, adrenal hemorrhage, septicemia-induced Waterhouse-Friderichsen syndrome, fulminant meningococcemia, steroid withdrawal, autoimmune adrenaldestruction,polyglandular autoimmune disorders, PGAs, Schmidt syndrome, idiopathic autoimmune adrenal insufficiency, myocardial infarction, psychoses, depression, hypoglycemia, alcohol abuse, hypothermia, asthma
