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7/30/2019 Emergncias endocrinolgicas - Apoplexia e Insuficincia Adrenal
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Endocrine Emergencies
DG van Zyl
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Spectrum of Endocrine
Emergencies
Pituitary apoplexy
Acute adrenal insufficiency
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Pituitary Apoplexy
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Clinical Setting
Sudden crisis in a patient with known or
previously unknown pituitary tumor
It may occur in a normal gland during andafter child birth, or with head trauma, or in
patient on anticoagulation therapy
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Symptoms and Signs
Severe headache and visual disturbance
Bitemporal hemianopia
N III palsyMeningeal symptoms with neck stiffness
Symptoms of acute secondary adrenal
insufficiencyNausea vomiting , hypotension and collapse
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Diagnosis
CT scan of head and pituitary
Hormonal studies only of academic interest
Assessment of pituitary function after acutestage has settled
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Management of Pituitary
Apoplexia
Hormonal
Dexamethasone 4 mg bd (glucocorticoid
support and relief of cerebral edema)Neurosurgical
Transsphenoidal pituitary decompression
After the acute episode the patientmust be evaluated for multiple
pituitary deficiencies
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Acute Adrenal
Insufficiency
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Causes of Acute Adrenal
insufficiency (1)
Usually presents as an acute process in a
patient with underlying chronic adrenal
insufficiencyCauses of Primary adrenal insufficiency
Auto-immune
TB of adrenalsMetastatic malignancy to adrenals
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Causes of Acute Adrenal
insufficiency (2)
Causes of secondary adrenal insufficiency
Pituitary or hypothalamic disease
Acute destruction of the adrenals can occurwith bleeding in the adrenals
Sepsis
DIC orcomplication of anticoagulant therapy
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Precipitating Events (1)
Omission of medication
Precipitating illness
Severe infectionMyocardial infarction
CVI
Surgery without adrenal support
Severe trauma
Withdrawal of steroid therapy in a patienton long term steroid therapy (adrenal
atrophy)
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Precipitating Events (2)
Administration of drugs impairing adrenal
hormone synthesis e.g.. Ketoconazole
Using drugs that increase steroidmetabolism e.g. Phenytoin and rifampicin
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Clinical Presentation
Nausea and vomiting
Hyperpyrexia
Abdominal painDehydration
Hypotension and shock
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Clues to Underlying Chronic
Adrenal Insufficiency
Pigmentation in
unexposed areas of the
skin
Creases of hands
Buccal mucosa
Scars
Consider adrenalinsufficiency if
hypotension does not
respond to pressors
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Lab Diagnosis (1)
Hyponatremia and hyperkalemia
(Hyponatremia might be obscured by
dehydration)Random cortisol is not helpful unless it is
very low (
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Lab Diagnosis (2)
ACTH (cosyntropin) stimulation test
Failure of cortisol to rise above 552 nmol/L 30min after administration of 0.25 mg of synthetic
ACTH IV
Basal ACTH will be raised in primaryadrenal insufficiency but not in secondary
CT of abdomen will reveal enlargement ofadrenals in patents with adrenalhemorrhage, active TB or metastaticmalignancy
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Management of Acute Adrenal
Insufficiency (1)
Hydrocortisone
100 mg IV stat then 50 mg 4 hly for 24 h
Taper slowly over the next 72 h
When oral feeds is tolerated change to oralreplacement therapy
Overlap the first oral and last IV doses
Replace salt and fluid losses with 5%dextrose in normal saline IV
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Management of Acute Adrenal
Insufficiency (2)
Patients with primary adrenal insufficiency
may require mineralocorticoid therapy
(fludrocortisone) when shifted to oraltherapy
Treat precipitating diseases
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