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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