metabolic alkalosis is present in some patients with increased ACTH production. A random serum cortisol is not useful due to wide diurnal ranges.

 

In Cushing syndrome, hyperglycemia is commonly

present and is due to insulin resistance. Hypokalemic

metabolic alkalosis is present in some patients with

increased ACTH production. A random serum cortisol is

not useful due to wide diurnal ranges.

The rapid ACTH stimulation test is infrequently

performed in the ED, but may be used to test the

responsiveness of the adrenal glands. A baseline sample

of blood is drawn at time 0 for a cortisol level, then

0.25 mg of cosyntropin (synthetic ACTH) is given

intravenously (IV). Plasma cortisol levels are checked at

30 minutes and 1 hour. Dexamethasone should be given

empirically even without waiting for the results. In normal subjects, baseline cortisol (time 0) levels exceed 5

mcg/dL. Post-rapid ACTH stimulation test, plasma cortisol levels should rise at least? meg/ dL and peak at > 18

mcg/dL, which marks a normal response and rules out

primary disorders of the adrenal glands. Subsequent

measurement of the plasma ACTH level determines

whether adrenal insufficiency is primary (Addison disease) or secondary. Elevated ACTH levels indicate primary adrenal insufficiency, whereas normal or low levels

indicate secondary adrenal insufficiency.

� Imaging

Imaging studies are not routinely indicated in

adrenal insufficiency or Cushing syndrome. Chest x-ray,

electrocardiogram, or head computed tomography may

be useful depending on the clinical presentation (ie,

altered mental status, suspected pneumonia or cardiac

ischemia) .

MEDICAL DECISION MAKING

The differential diagnoses for adrenal insufficiency

include shock (cardiovascular, septic), dehydration, or

influenza infection. Consider adrenal crisis in any patient

who presents in shock, especially if they have a history of

adrenal insufficiency, withdrawal of chronic steroids,

characteristic electrolyte abnormalities (low Na, high K),

or hypoglycemia (Figure 69- 1). Acute adrenal insufficiency is usually precipitated by an underlying illness

(eg, sepsis), and it is important for the clinician to identify and treat both disorders. Polycystic ovary disease,

depression, diabetes mellitus, and hypothyroidism are

the most common differential diagnoses for Cushing

syndrome.

TREATMENT

IV 0.9 NS should be given to treat hypotension. Persistent

hypotension may require vasopressors. Dextrose is administered in the setting of hypoglycemia. An ampule of D50

is given initially and is repeated as needed. Dexamethasone

4-6 mg IV is given every 6 hours or hydrocortisone 1 00 mg

IV every 8 hours. Dexamethasone is preferred because,

unlike hydrocortisone, it does not interfere with cortisol

response to ACTH or the cortisol assay. If hydrocortisone

is given, results of the ACTH ( cosyntropin) stimulation

test will be difficult to interpret. Mineralocorticoids in the

form of fludrocortisone acetate (Florine£) 0.05-0.2 mg are

administered. Search and treat precipitating causes ( eg,

sepsis).

It is not the role of the emergency physician to make the

definitive diagnosis of Cushing syndrome but to suspect

the condition, treat the underlying cause, and refer the

patient for further testing or treatment.

CHAPTER 69

Suspect adrenal insufficiency

(history & exam)

Acute adrenal i nsufficiency

(adrenal crisis)

Emergent resuscitation and

administration of

glucocorticoids

Admission to ICU

Chronic ill ness (eg, fatigue,

hyperpigmentation, weight loss)

with normal vital signs and

electrolytes and glucose

Chron ic adrenal insufficiency

(primary or secondary adrenal

insufficiency)

If patient appears well,

discharge with fol low-up for

outpatient work-up

• Figure 69-1. Adrenal emergencies diag nostic algorithm. AMS, altered

mental status; ICU, intensive care unit.

DISPOSITION

� Admission

All patients with acute adrenal insufficiency require

hospital admission. Most patients will require an intensive

care unit setting.

� Discharge

Patients with chronic symptoms of either adrenal insufficiency or Cushing syndrome may be discharged with

close follow-up with a primary physician and

endocrinologist.

SUGGESTED READING

Idrose AM. Adrenal insufficiency and adrenal crisis. In: Tintinalli JE,

Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD.