Daily Bolus of LR: Adrenal Insufficiency

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April 12, 2011 by dailybolusoflr

Adrenal Insufficiency


Primary adrenal insufficiency

·         Can be acute or chronic

·         Rare

·         May be caused by destruction of the gland (TB, fungus, hemorrhage or other infiltrating diseases) or by atrophy (usually autoimmune).

·         Also may be caused by metabolic failure ( Failure may be a result of congenital adrenal hyperplasia, or as a result of drugs that do this)

Secondary adrenal insufficiency

·         May be as a result of hypopituitarism due to hypothalamic-pituitary disease or from suppression of the hypothalamic-pituitary axis by exogenous steroids

·         Common (due to the common use of steroids )

Acute Adrenal Insufficiency usually results from exacerbation of a chronically insufficient state that is subject to a stress (surgery, infection, trauma..).  However, patients can present primarily in adrenal insufficiency.


Patients may present with any combination of the following:

·         Nausea/vomiting

·         Hypo/hyperthermia

·         Abdominal pain

·         Confusion

·         Lethargy

·         Hypotension


The classic triad found on the labs includes:

·         Hyponatremia

·         Hypoglycemia

·         Hyperkalemia



·         IVF

·         Replacement of sodium, glucose

·         Steroid replacement

o   Dexamethasone does not interfere with the cortisol stimulation test (but does not have mineralcorticoid activity so remember fluid and electrolyte replacement!)

o   In patients with known adrenal insufficiency, simply treat with stress dose hydrocortisone 100mg IV q6h


Linda Regan, MD FACEP

Program Director, Emergency Medicine Residency

Johns Hopkins Medical Institutions


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