Adrenal Crisis in Emergency Medicine Workup

  • Author: Kevin M Klauer, DO, FACEP; Chief Editor: Erik D Schraga, MD   more...
 
Updated: Mar 9, 2012
 

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 level[6]
  • Serum calcium level
  • Thyroid function (possibly performed in ED but unlikely to influence immediate management)
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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.
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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.
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Contributor Information and Disclosures
Author

Kevin M Klauer, DO, FACEP  Assistant Clinical Professor, Michigan State University College of Osteopathic Medicine; Chief Medical Officer, Emergency Medicine Physicians, Ltd; Director, Center for Emergency Medical Education; Editor-in-Chief, Emergency Physicians Monthly, EJD from Concord Law School, 2011

Kevin M Klauer, DO, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Erik D Schraga, MD  Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Howard A Bessen, MD  Professor of Medicine, Department of Emergency Medicine, University of California, Los Angeles, David Geffen 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.

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  Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

References

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