Adrenal Crisis in Emergency Medicine Workup

Updated: Oct 10, 2017
  • Author: Kevin M Klauer, DO, EJD, FACEP; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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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 level [9] /ACTH
  • 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 (generally not recommended).
  • Normal response is indicated when the cortisol peak exceeds 18 ug/dL 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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