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I'm like, no, they're not really still
like alive, so I'm gonna try to keep them

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alive and we'll get to the other stuff.

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Okay EMR?

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and EMR's like, okay, I'll
just remind you in five minutes

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00:00:12,619 --> 00:00:15,379
.

 Hi everyone, and welcome to
another episode of EMPlify

6
00:00:15,379 --> 00:00:16,889
I'm your host, Sam Ashoo.

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Before we dive into this month's episode,
I want to say thank you for joining us.

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00:00:21,169 --> 00:00:24,709
I sincerely hope that you find it to
be helpful and informative for your

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clinical practice, and I want to remind
you that you can go to ebmedicine.net

10
00:00:29,209 --> 00:00:33,359
where you will find our three journals,
Emergency Medicine Practice, Pediatric

11
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Emergency Medicine Practice, and Evidence
Based Urgent Care, and a multitude of

12
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other resources, like the EKG course,
the laceration course, interactive

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clinical pathways, just tons of
information to support your practice

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and help you in your patient care.

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And now, let's jump into
this month's episode.

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All right, ladies and gentlemen, welcome
back to another episode of EMPlify.

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00:00:55,899 --> 00:00:58,979
I am one of your hosts, Sam
Ashoo, and on the other end of

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the microphone joining me today.

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TR Eckler, back feeling
salty, but a little sweet.

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That's, that's so apropos because
today we are reviewing the Emergency

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Medicine Practice article from
October 2025, Emergency Department

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Evaluation and Management of
Patients With Adrenal Insufficiency.

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You ever seen one of
these patients in the ED?

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A few, not many.

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Now I will tell you this is what I took
away from this article, is that the ones

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that know they have it are very smart
and will tell you exactly what they need

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and are generally very well educated.

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And then now I think there's
more people that are on so many

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different kinds of steroids.

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You're seeing those humans creep into
the emergency department and they

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creep in with sepsis or they creep in
with, you know, a nasty viral infection

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and they're a little hypotensive.

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And I think now I'm more worried about
this overlap between infection and chronic

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steroid use driving more of these patients
my way and I need to be a little quicker

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on the gun with steroids for these people.

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If I'm gonna sling antibiotics
at everybody for sepsis, I think

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I'm a little closer to slinging a
little bit of a hydrocortisone or

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Solu-Medrol at everybody as well.

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'Cause I think I'm gonna get
more hits than misses there.

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Yeah, I am fortunate or unfortunate
enough, I'm not really sure which way this

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goes, but to have seen someone go from
like death's door to awake and totally

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normal after a dose of hydrocortisone.

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Like going from, hey critical care
team, I need you to come down now.

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We're starting pressors.

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00:02:29,086 --> 00:02:32,086
This person doesn't look good,
isn't responding to fluids, and I'm

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gonna need to hand off pretty soon.

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00:02:34,036 --> 00:02:36,586
And then they show up and they're
like, hey, person looks like a rose.

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What are you, what are you panicked about?

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And I'm like, well, 30 minutes
ago it didn't look like this.

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If data serves, in a few hours, they'll
do this again, so you should probably

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be the one to catch them before that.

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They're gonna need some repeat dosing.

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But this is a, once
again, fantastic article.

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This one was authored by the Simcoes,
a husband and wife team who did

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an outstanding job reviewing all
things adrenal insufficiency and

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adrenal crisis with, as always, an
evidence-based literature search.

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And I think it was very good actually,
of them to point out that there isn't

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all that much great literature when
it comes to adrenal insufficiency and

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adrenal crises and that randomized
control trials are mostly unethical

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when we talk about, you know, do we
withhold certain lifesaving medications?

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But there are some advancements
coming down the pipeline with

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medications, I hope, and we'll get
to all of that here pretty soon.

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I did, as always, look at the
introductory epidemiology information,

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and I'm always taken back by like
the frequency of these things.

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Adrenal insufficiency is still considered
a rare condition, like 200,000 people

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in the United States with an estimated
20,000 adrenal crises events per year.

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That's not really a small
number in the country.

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And there was a study in 2010, said 67%
of patients with adrenal insufficiency

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had consulted at least three physicians
before getting the diagnosis, and

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20% had suffered symptoms for five
years before getting the diagnosis.

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So this is definitely something
that is a chronic illness and is

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really a diagnostic challenge.

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And hopefully after today's
discussion, everybody listening

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will understand why as well

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I try to put numbers like these in context
just a little bit 'cause I actually

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thought that number was a little bit low.

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But this is one of those kind of fun ones
where I like to stop for a second and

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be like, how many emergency departments
are there in the United States?

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So like, estimates are
between five and 6,000.

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So this means that somewhere around like
four times a year, you're gonna see a

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patient like this roll into your ER.

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Now that's gonna vary by size and all
kinds of stuff, but I like to go into

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every shift with the idea being like, Hey,
there's one zebra coming in today, and

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if you stay sharp, you're gonna catch it.

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Not every viral URI that's hypotensive and
every gastroenteritis that's hypotensive

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has got this adrenal crisis, but every now
and again, one of these is gonna try to

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sneak in and I kind of like that you know,
it's a seasonal catch, not a daily catch.

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Yeah.

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100 percent true.

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You're absolutely right.

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It's not an insignificant number.

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And again, if you are smart enough after
hearing this and reading this article and

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studying and taking the CME test to pick
this up, I think you do your colleagues

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and especially the patient, a huge favor.

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The foundation for adrenal
insufficiency and adrenal crises really

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starts with the physiology of it.

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And this kinda hearkens back
to medical school and what we

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learned as primary, secondary, and
tertiary adrenal insufficiency.

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And you know, I'm not sure I was that
awake when I heard this the first

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time around, but there is a fantastic
illustration, figure one, which shows

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you the brain, the hypothalamus, the
pituitary gland and the adrenal glands

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and describes in very simple detail
why this is a problem and how it works.

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And I kind of wish I'd had this
figure when I was in medical school.

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Honestly.

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There are three locations involved
in adrenal insufficiency, right?

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There's the adrenal glands, which
sit right above the kidneys.

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There's the pituitary gland, which sits
at the base of the brain, and then there's

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the hypothalamus, and any one of those
three can be problematic, and depending on

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where the problem is, you get a diagnosis
of primary, if it's at the adrenal glands,

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secondary, if it's at the pituitary and
tertiary adrenal insufficiency if it's

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at the hypothalamus further up in the
brain and the causes for those can vary.

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So primary is actually the least common
of the three and is typically autoimmune.

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It can be congenital, so you
can be born with that condition.

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You can have congenital adrenal
hyperplasia in children, or you can

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develop Addison's disease as an adult.

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But it can also be associated
with infections like tuberculosis.

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So especially in the developing world
where tuberculosis is still rampant

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this is a more common occurrence.

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Secondary adrenal insufficiency
is sort of in the middle and is

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caused by a disruption of this
hypothalamic pituitary adrenal axis.

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So it's disrupting the signals
between all three of these areas by

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affecting the pituitary gland, and
it's most commonly due to pituitary

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tumors or trauma or radiation.

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Which kind of makes sense.

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And then the tertiary, the one
that's highest up in the brain

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adrenal insufficiency is caused
by typically glucocorticoids from

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all the steroids we give people.

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So if you haven't heard that word
of caution, go back one episode and

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listen to my conversation with my guest
just a couple of weeks ago about the

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problems that occur from even short term
steroid use, and you'll understand why

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we prescribe so many of these things,
why they're causing such problems.

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So that's tertiary adrenal insufficiency
and the foundational physiology for all of

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this comes together when you think about
the adrenal gland as having three layers.

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Zone one or layer one has to do with
the mineralocorticoid, aldosterone.

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Zone two has to do with the
glucocorticoid, cortisol.

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And zone three is responsible for all
of the androgens and in the crises and

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the insufficiency we're going to be
talking about today, we're discussing

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the problems of insufficient aldosterone
and cortisol, or zone one and zone

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two, and so once you understand that
physiology, you can refer back to

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things like this table and this figure.

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And even later on when we talk about
labs and we talk about all the different

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labs you need to order, you can discern
which one of these three types they have

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and then focus the treatment correctly,
which is often a diagnosis made outside

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the emergency department, honestly,
because we're just recognizing the shock

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or the adrenal crisis and treating it.

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And then as we move to the inpatient
realm, all that testing we've ordered

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00:08:59,855 --> 00:09:03,871
comes back and somebody much smarter
than me is putting it all together

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00:09:04,231 --> 00:09:07,076
and making that formal diagnosis
and telling you where the issue is.

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Yeah, I, I think as you said, that
figure is such a great summary of this,

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and I think it really helps distill it
to like where exactly the problem is.

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I liked how I remembered this on
a whiteboard in medical school,

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and I remember the idea being
that primary is the lowest.

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It's at the level of the kidneys.

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And then as you move up higher through
the body up towards the brain, that's

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secondary and tertiary and that
follows with like where the problem is.

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So if your cortisol levels
only are low, that's primary.

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When you start seeing low
ACTH levels, that's secondary.

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And then when all your levels are
low, your corticotropin-releasing

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hormone, your ACTH, and your cortisol,
that's coming from your hypothalamus.

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So I like how the levels point
to where the problem is as you

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00:09:48,584 --> 00:09:49,814
go kind of more vertically.

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It's a great figure and something you
really need to review every now and

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then because it does get confusing if
you're not looking at this every day,

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you may remember that you have to send
these labs, but you may not recall

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00:10:00,936 --> 00:10:03,576
exactly what it is that it all means.

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And the mainstay of treatment, and
we will harp on this thousands of

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00:10:08,006 --> 00:10:10,946
times during this podcast today,
but the mainstay of treatment for

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00:10:10,946 --> 00:10:15,243
adrenal crisis is administering
corticosteroids that have both the

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00:10:15,243 --> 00:10:19,893
glucocorticoid and the mineralocorticoid
effects, which is hydrocortisone.

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So, you're gonna hear this a
million times, but the treatment,

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00:10:22,853 --> 00:10:27,083
the emergent treatment for adrenal
crisis is dosing hydrocortisone

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00:10:27,323 --> 00:10:30,923
without waiting for anything else,
especially if you're suspicion's high.

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And because it's been a while, we're
gonna bring back trivia with TR

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and start with our first question.

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Surprise.

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I didn't actually warn him ahead of time.

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This is completely spontaneous for him.

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Anyway.

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. Awesome

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00:10:45,600 --> 00:10:49,890
.
Question number one, etiologies
of adrenal insufficiency.

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00:10:50,130 --> 00:10:57,480
Which of the following is the most common
cause of tertiary adrenal insufficiency.

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00:10:57,660 --> 00:11:01,890
Now, before we jump into the answers,
tertiary is up at the hypothalamus.

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00:11:02,130 --> 00:11:05,400
Which of these is the most common
cause of adrenal insufficiency

184
00:11:05,730 --> 00:11:06,870
up at the hypothalamus?

185
00:11:06,950 --> 00:11:11,257
A, autoimmune B, chronic
corticosteroid use.

186
00:11:11,617 --> 00:11:14,647
C, pituitary apoplexy.

187
00:11:15,037 --> 00:11:20,707
D, tuberculosis, or E,
Waterhouse-Friderichsen syndrome.

188
00:11:21,407 --> 00:11:27,657
So despite my love for tuberculosis
and the recently released book,

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00:11:27,737 --> 00:11:30,857
Everything is Tuberculosis, which I
strongly recommend everyone to read,

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00:11:31,217 --> 00:11:35,567
and my love for Waterhouse-Friderichsen
syndrome because anytime you can tie

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00:11:35,837 --> 00:11:39,287
adrenal hemorrhages to meningitis and
make that diagnosis, it's awesome.

192
00:11:39,707 --> 00:11:44,177
But I know that this is chronic
corticosteroid use because it's just so

193
00:11:44,177 --> 00:11:48,587
rampant and something now that I'm much
more aware of with my steroid prescribing.

194
00:11:48,618 --> 00:11:49,048
There you go.

195
00:11:49,418 --> 00:11:53,538
Tertiary adrenal insufficiency is
the most common cause of adrenal

196
00:11:53,538 --> 00:11:58,178
insufficiency and it's caused most
often by exogenous glucocorticoids.

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00:11:58,198 --> 00:12:00,208
Well done, sir. Well done.

198
00:12:00,908 --> 00:12:01,178
All right.

199
00:12:01,178 --> 00:12:05,438
Let's step out of the pathophysiology
section for just a moment and dive

200
00:12:05,438 --> 00:12:07,538
into the differential diagnosis.

201
00:12:07,538 --> 00:12:15,278
Now, this is exceptionally challenging,
I think, because adrenal crises are

202
00:12:15,278 --> 00:12:22,574
precipitated by diseases, infections
primarily, and the presentation

203
00:12:22,664 --> 00:12:27,794
of adrenal crisis has significant
overlap in symptoms with many of

204
00:12:27,794 --> 00:12:30,494
the diseases that cause the crisis.

205
00:12:30,554 --> 00:12:36,244
So it's quite easy for us in the
emergency department to get distracted

206
00:12:36,364 --> 00:12:41,854
or maybe to stop once we've diagnosed
the precipitating disease and not take

207
00:12:41,854 --> 00:12:46,504
the extra step of figuring out, oh,
they're also adrenally insufficient,

208
00:12:46,534 --> 00:12:48,424
and now in an adrenal crisis.

209
00:12:48,604 --> 00:12:53,684
And that overlap and that lack of
moving to that extra step is where

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00:12:53,684 --> 00:12:55,184
the increased mortality comes.

211
00:12:55,214 --> 00:13:00,314
So there is once again, a fantastic
table on page six if you have access

212
00:13:00,314 --> 00:13:05,084
to the article, which lists the
differential diagnosis for adrenal

213
00:13:05,084 --> 00:13:10,364
insufficiency and not surprisingly, it
includes a bunch of things, infections

214
00:13:10,364 --> 00:13:14,814
being at the top of the list, like
chronic or long-term infections.

215
00:13:14,814 --> 00:13:20,074
Things like HIV, tuberculosis, Lyme
disease, long COVID, and hepatitis.

216
00:13:20,764 --> 00:13:24,584
But there are other things as well,
autoimmune diseases, diabetes,

217
00:13:24,704 --> 00:13:29,228
malignancy, endocrinopathies like
hypothyroidism, hyperthyroidism and

218
00:13:29,228 --> 00:13:35,288
hyperparathyroidism, psychiatric disease,
depression, anxiety, eating disorders,

219
00:13:35,948 --> 00:13:40,108
renal insufficiency, both chronic and
acute, cardiac disease like congestive

220
00:13:40,108 --> 00:13:44,648
heart failure and cardiomyopathies, and
gastrointestinal disease like chronic

221
00:13:44,648 --> 00:13:47,018
liver disease and celiac disease.

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00:13:47,648 --> 00:13:51,023
All of these are included in the
differential diagnosis for adrenal

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00:13:51,078 --> 00:13:55,388
insufficiency, but can also be
precipitating adrenal crises.

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00:13:55,675 --> 00:14:00,688
And I thought the authors actually
did a pretty good job of perusing the

225
00:14:00,688 --> 00:14:06,238
literature for case reports and noting
that relatively rare conditions, things

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00:14:06,238 --> 00:14:10,768
like tricyclic antidepressant overdoses,
and takotsubo cardiomyopathies and

227
00:14:10,918 --> 00:14:16,948
shock from anorexia have been diagnosed
in the setting of adrenal crises.

228
00:14:17,278 --> 00:14:23,623
And those diagnoses were mistakenly
settled upon in cases where the patient

229
00:14:23,623 --> 00:14:25,973
was actually suffering an adrenal crisis.

230
00:14:26,153 --> 00:14:29,693
Just further demonstrating the
overlap between all of these

231
00:14:29,693 --> 00:14:33,383
multiple disease processes and the
challenge in making that diagnosis.

232
00:14:33,383 --> 00:14:38,703
So the take home message here being
as you're entertaining multiple

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00:14:38,703 --> 00:14:42,093
diagnoses, and especially as you
entertain some of the rarer causes,

234
00:14:42,273 --> 00:14:48,786
don't forget about adrenal insufficiency
and think about crisis presenting as

235
00:14:48,786 --> 00:14:51,766
the cluster of symptoms that you're
seeing in front of you right now.

236
00:14:52,466 --> 00:14:54,536
All right, let's move
on to pre-hospital care.

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00:14:54,746 --> 00:14:59,306
As always, our pre-hospital colleagues may
be listening and do an outstanding job.

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00:14:59,306 --> 00:15:01,976
And this is, again, one of
those challenging areas.

239
00:15:02,156 --> 00:15:05,246
How is it that someone in the pre-hospital
setting is going to come up with this

240
00:15:05,246 --> 00:15:09,086
diagnosis when we even can't do it in
the emergency department quite often?

241
00:15:09,386 --> 00:15:12,906
And the answer is in ways that
you probably already understand.

242
00:15:12,906 --> 00:15:17,166
So looking for things like, are they
wearing a medical alert bracelet

243
00:15:17,166 --> 00:15:19,986
or do they have a necklace that
says, Hey, I have this condition.

244
00:15:20,236 --> 00:15:23,326
Do they have a pill box to
be dosed in emergencies?

245
00:15:23,596 --> 00:15:27,256
Did they mention that they're on
medications like hydrocortisone and that

246
00:15:27,256 --> 00:15:29,236
they've been taking their stress dose?

247
00:15:29,476 --> 00:15:32,536
All of these are important
factors that may come from the

248
00:15:32,536 --> 00:15:35,071
patient or from family members.

249
00:15:35,161 --> 00:15:37,141
If it's a child, this
may come from the parent.

250
00:15:37,141 --> 00:15:40,051
They may say, hey, yeah, they've
been ill for three or four days and

251
00:15:40,051 --> 00:15:44,161
we've been giving this stress dose
steroids, but now we're having problems.

252
00:15:44,401 --> 00:15:49,801
And so all of these are little historical
pieces that our EMS colleagues can

253
00:15:49,908 --> 00:15:54,298
extract from family members or people at
the scene or hopefully from the patient.

254
00:15:54,668 --> 00:15:59,053
And if the patient has an emergency kit
with extra pills in it, that's helpful

255
00:15:59,053 --> 00:16:01,213
to bring along so we can identify those.

256
00:16:01,663 --> 00:16:06,713
There was one questionnaire cited in
the article of 150 patients with chronic

257
00:16:06,713 --> 00:16:11,883
adrenal insufficiency and found that
59 of them had adrenal emergencies.

258
00:16:11,883 --> 00:16:15,123
So about a third of them
experienced an adrenal crisis.

259
00:16:15,243 --> 00:16:20,283
85% of those were already on their
stress dose steroids, so they may be

260
00:16:20,283 --> 00:16:21,948
able to tell you, hey, I've been sick.

261
00:16:22,423 --> 00:16:25,423
And I've been on my steroids
and I've been at the higher dose

262
00:16:25,603 --> 00:16:27,283
and I'm still having problems.

263
00:16:27,623 --> 00:16:30,263
And so that's an important
piece of history to elicit

264
00:16:30,473 --> 00:16:32,393
from the patient at the scene.

265
00:16:32,763 --> 00:16:36,603
And there is a foundation called the
CARES Foundation which has drawn attention

266
00:16:36,603 --> 00:16:41,628
to the fact that many emergency medical
services crews don't carry hydrocortisone.

267
00:16:41,658 --> 00:16:44,388
It's not something that's
typically carried on an ambulance.

268
00:16:44,608 --> 00:16:48,058
And there's usually not a protocol
for administering it pre-hospital.

269
00:16:48,268 --> 00:16:52,228
And, you know, if it's a two minute drive
to the hospital, maybe not a big deal.

270
00:16:52,228 --> 00:16:54,988
But especially if you're out in a rural
setting and you're gonna be taking

271
00:16:54,988 --> 00:16:58,888
this person on an ambulance ride for
an hour, that's a critical time where

272
00:16:58,888 --> 00:17:02,688
you may be starting an IV, doing IV
fluids, noticing that their shock is

273
00:17:02,688 --> 00:17:04,278
getting worse and they're not responding.

274
00:17:04,428 --> 00:17:08,818
And so this becomes a really important
piece of history to obtain and a really

275
00:17:08,818 --> 00:17:10,918
important medication to have on the truck.

276
00:17:11,588 --> 00:17:14,828
Or to make sure if you don't have it
on the truck that you see if they've

277
00:17:14,828 --> 00:17:18,398
got it and you consider whether or
not you wanna call med control and

278
00:17:18,398 --> 00:17:20,468
give them their dose before they go.

279
00:17:20,468 --> 00:17:22,508
If for some reason they can't
give it or they were afraid

280
00:17:22,508 --> 00:17:23,528
to or something like that.

281
00:17:23,768 --> 00:17:24,938
There's always those things.

282
00:17:25,268 --> 00:17:30,788
I think to your point, the biggest
value I get from EMS on a daily basis

283
00:17:30,788 --> 00:17:33,613
is when they come in and tell me,
Hey, these are their medications.

284
00:17:33,613 --> 00:17:35,023
This is the bag of their medications.

285
00:17:35,023 --> 00:17:38,533
And they said they've stopped this or
they haven't been able to take this, or

286
00:17:38,533 --> 00:17:42,253
they just got an injection here in their
back or in their knee or somewhere else.

287
00:17:42,403 --> 00:17:45,590
And now I've really, from this
article taken like how are the

288
00:17:45,590 --> 00:17:47,000
steroids getting into your body?

289
00:17:47,000 --> 00:17:48,140
Like are they inhaled?

290
00:17:48,140 --> 00:17:48,890
Are they nasal?

291
00:17:48,940 --> 00:17:49,780
Are they injections?

292
00:17:49,780 --> 00:17:50,380
Are they oral?

293
00:17:50,460 --> 00:17:53,590
Is there now a new combination
that you weren't on before?

294
00:17:53,590 --> 00:17:56,020
And then did you stop something
that precipitated this?

295
00:17:56,110 --> 00:17:59,800
And I think that's always gonna be
something that EMS is gonna tip that to

296
00:17:59,800 --> 00:18:04,190
you, and really save your posterior if you
just listen hard enough to what's new and

297
00:18:04,190 --> 00:18:06,080
what's actually getting taken versus not.

298
00:18:06,545 --> 00:18:13,295
I'm a big proponent of EMS presentations
directly to the clinician, so you know, to

299
00:18:13,295 --> 00:18:17,435
the nurse practitioner, PA, or physician
who's at the bedside at the time that

300
00:18:17,435 --> 00:18:20,980
they're there because oftentimes this
stuff can get lost in translation.

301
00:18:20,980 --> 00:18:22,690
You know, they may give
this to the nursing report.

302
00:18:22,690 --> 00:18:25,570
They may give it to a tech and
say, well, it's in my report,

303
00:18:25,570 --> 00:18:26,590
which will be faxed later.

304
00:18:26,590 --> 00:18:28,540
Or you may or may not get it in your EMR.

305
00:18:28,840 --> 00:18:31,540
This is a critical piece of
information that should not be

306
00:18:31,540 --> 00:18:33,540
lost in that communication gap.

307
00:18:34,240 --> 00:18:38,860
Which brings me to our second
question in trivia with TR.

308
00:18:39,060 --> 00:18:40,340
Prehospital management.

309
00:18:40,340 --> 00:18:46,210
What the main limitation in
prehospital care for adrenal

310
00:18:46,210 --> 00:18:48,070
crisis in the United States?

311
00:18:48,070 --> 00:18:51,040
So, which one of these is the
biggest stumbling block in the US?

312
00:18:51,190 --> 00:18:54,310
A, no diagnostic criteria available.

313
00:18:55,010 --> 00:19:00,500
B, EMS cannot legally administer
hydrocortisone in some states.

314
00:19:00,930 --> 00:19:04,423
C, parents are unable
to recognize symptoms.

315
00:19:05,123 --> 00:19:12,633
D, cortisol levels are too unstable, or E,
hydrocortisone causes allergic reactions.

316
00:19:13,333 --> 00:19:13,993
All right, one more time.

317
00:19:14,317 --> 00:19:17,386
Yeah, I feel like C,D, and E
I'm okay, but what was A and B?

318
00:19:17,604 --> 00:19:19,164
A was no diagnostic criteria available.

319
00:19:19,864 --> 00:19:23,944
B was EMS cannot legally administer
hydrocortisone in some states.

320
00:19:25,117 --> 00:19:27,397
C was the parents can't
recognize symptoms.

321
00:19:27,547 --> 00:19:31,357
D was cortisol levels are too
unstable, and E was hydrocortisone

322
00:19:31,357 --> 00:19:32,617
causes allergic reactions.

323
00:19:33,317 --> 00:19:36,257
Yeah, that's wild that there are
some states that don't allow EMS

324
00:19:36,257 --> 00:19:39,417
crews to administer hydrocortisone,
and this interests me, as an area

325
00:19:39,417 --> 00:19:42,657
for advocacy, like, this would not
be so different than, you know, an

326
00:19:42,657 --> 00:19:46,207
EpiPen, being able to administer
an EpiPen if it's there, you know,

327
00:19:46,717 --> 00:19:49,596
It is crazy, but the article actually does
say yes in the United States, some states

328
00:19:49,596 --> 00:19:54,756
don't allow EMS personnel to administer
hydrocortisone from the patient's own

329
00:19:54,756 --> 00:20:00,667
emergency kit, so they can't administer
it, but they may be able to open the

330
00:20:00,667 --> 00:20:04,867
kit and put the pills in their hand
and say, hey, I'm just gonna help you.

331
00:20:04,977 --> 00:20:05,787
Here are the pills.

332
00:20:06,127 --> 00:20:10,407
It's very strange that such a
law would exist for a lifesaving

333
00:20:10,407 --> 00:20:12,027
medication like hydrocortisone.

334
00:20:12,287 --> 00:20:15,902
But indeed that is one of the
stumbling blocks in the United States.

335
00:20:16,602 --> 00:20:18,017
A little bizarre, but absolutely true.

336
00:20:18,717 --> 00:20:20,967
All right, let's get to the ED evaluation.

337
00:20:21,027 --> 00:20:24,987
When they arrive in the emergency
department, you want to recognize

338
00:20:24,987 --> 00:20:28,167
the cluster of symptoms and
prioritize these patients.

339
00:20:28,167 --> 00:20:31,947
And in general, if they're in an adrenal
crisis, they're gonna be presenting

340
00:20:31,947 --> 00:20:36,712
with something like hypotension, altered
mental status, maybe multiple episodes

341
00:20:36,947 --> 00:20:42,087
of vomiting and fever with a history of
recent surgery or significant trauma.

342
00:20:42,247 --> 00:20:47,627
And hopefully they'll get that priority
and be placed in a bed or a stretcher

343
00:20:47,627 --> 00:20:50,307
or somewhere for a rapid assessment
by a physician so that they can

344
00:20:50,307 --> 00:20:51,957
quickly have those things addressed.

345
00:20:52,257 --> 00:20:56,097
Interestingly, I thought this was
another fun little tidbit, when a

346
00:20:56,097 --> 00:21:02,067
hospital implements a clinical decision
support tool in the EMR, there was one

347
00:21:02,067 --> 00:21:06,917
study that showed that the patients in
adrenal insufficiency were three times

348
00:21:06,917 --> 00:21:10,907
more likely to receive hydrocortisone
and two and a half times more likely to

349
00:21:10,907 --> 00:21:13,401
get the right dose of hydrocortisone.

350
00:21:13,541 --> 00:21:17,124
So pushing that information to the
physicians and to the clinicians who

351
00:21:17,124 --> 00:21:20,514
are doing the work at the bedside
is helpful and is a good reminder

352
00:21:20,514 --> 00:21:24,114
of the appropriate dose and to
actually give it sooner than later.

353
00:21:24,424 --> 00:21:27,724
And that's one of the benefits
of electronic health records.

354
00:21:28,424 --> 00:21:30,914
It's just such a great
hope for me, for EMR.

355
00:21:30,914 --> 00:21:34,124
Like reading this article, I could
see how if you basically could just

356
00:21:34,124 --> 00:21:38,158
pull that this patient already has
Addison's or adrenal hyperplasia, and

357
00:21:38,438 --> 00:21:40,038
you basically could then say, hey.

358
00:21:40,558 --> 00:21:43,078
This patient is hypotensive,
they have this condition.

359
00:21:43,258 --> 00:21:44,578
Would you like to give steroids?

360
00:21:44,608 --> 00:21:46,648
The recommended steroid is hydrocortisone.

361
00:21:46,708 --> 00:21:48,208
Here's the recommended dosing.

362
00:21:48,358 --> 00:21:50,458
Would you like to just click this button?

363
00:21:50,728 --> 00:21:52,408
God, God bless it.

364
00:21:52,408 --> 00:21:57,208
That would be such a wonderful,
smart tool that I would be so on

365
00:21:57,208 --> 00:22:00,118
board with because of all the times
that I'm literally trying to like do

366
00:22:00,118 --> 00:22:02,908
lifesaving things and it's like, have
you looked at the patient's COWS?

367
00:22:03,433 --> 00:22:05,923
Have you done any tobacco
cessation counseling?

368
00:22:06,013 --> 00:22:12,133
And I'm like, no, they're not really still
like alive, so I'm gonna try to keep them

369
00:22:12,133 --> 00:22:13,813
alive and we'll get to the other stuff.

370
00:22:13,843 --> 00:22:14,803
Okay EMR?

371
00:22:14,863 --> 00:22:17,047
and EMR's like, okay, I'll just
remind you in five minutes.

372
00:22:17,379 --> 00:22:20,569
I mean, I know the researchers from
Epic listen to our podcast every month.

373
00:22:20,569 --> 00:22:23,899
So once again, you know, researchers,
you're there, you're listening.

374
00:22:23,899 --> 00:22:27,139
Here's our EMR plug for the month.

375
00:22:27,289 --> 00:22:29,929
If you could please include a
big red button that would tell

376
00:22:29,929 --> 00:22:32,749
us to give hydrocortisone, we
would be greatly appreciative.

377
00:22:33,449 --> 00:22:37,379
And just while we're at it, just if you
could please, once I test the patient for

378
00:22:37,379 --> 00:22:39,899
pregnancy, stop asking me if I'm sure.

379
00:22:40,079 --> 00:22:40,709
I'm sure.

380
00:22:41,409 --> 00:22:43,779
If I have a result and
it's negative, I'm sure.

381
00:22:43,779 --> 00:22:45,699
You don't need to, you don't
need to warn me anymore.

382
00:22:45,759 --> 00:22:46,179
I'm good.

383
00:22:46,230 --> 00:22:48,550
Not related to this, but still important
for our researchers who are listening.

384
00:22:48,849 --> 00:22:49,869
Very important.

385
00:22:50,569 --> 00:22:50,899
All right.

386
00:22:50,899 --> 00:22:54,199
The next step, of course, is going to
be obtaining your history, and there are

387
00:22:54,199 --> 00:22:59,869
some things that you're going to want to
ask, especially regarding their history of

388
00:22:59,869 --> 00:23:06,199
adrenal insufficiency, their medications,
and anything regarding signs and symptoms.

389
00:23:06,199 --> 00:23:08,089
And once again, there's a handy table.

390
00:23:08,149 --> 00:23:12,679
Table three on page seven, common
precipitating factors, signs, and

391
00:23:12,679 --> 00:23:14,689
symptoms in patients with adrenal crisis.

392
00:23:14,749 --> 00:23:19,159
So you want to ask about GI illnesses
and infections and surgeries and recent

393
00:23:19,159 --> 00:23:24,829
trauma, recent physical stressors,
pain, psychological stressors because

394
00:23:24,829 --> 00:23:27,019
those can precipitate adrenal crisis.

395
00:23:27,069 --> 00:23:28,479
Inadequate medication dosing.

396
00:23:28,479 --> 00:23:32,553
You want to ask about pregnancy,
MI, pulmonary embolism, and

397
00:23:32,553 --> 00:23:34,143
other idiopathic factors.

398
00:23:34,143 --> 00:23:35,733
All of these are precipitating factors.

399
00:23:35,733 --> 00:23:38,823
And then you wanna ask those signs
and symptoms of an adrenal crisis,

400
00:23:38,823 --> 00:23:44,483
nausea, vomiting, fatigue, weakness,
anorexia, dizziness, hypotension, altered

401
00:23:44,483 --> 00:23:50,633
mental status, hyperpigmentation of
the skin and abdominal pain or fever.

402
00:23:50,723 --> 00:23:56,183
All of those, again, very nonspecific,
but taken in some total in the right

403
00:23:56,183 --> 00:24:00,323
clinical scenario should start to
ring some alarm bells in your brain.

404
00:24:01,023 --> 00:24:06,373
Interestingly, adrenal crisis is most
commonly precipitated by an infection.

405
00:24:06,613 --> 00:24:09,103
And in children it's typically viral.

406
00:24:09,223 --> 00:24:12,293
And in adults it's typically
bacterial, which I found to

407
00:24:12,293 --> 00:24:13,823
be an interesting distinction.

408
00:24:14,203 --> 00:24:19,703
And in about 10% of cases, adrenal
crises have no precipitating

409
00:24:19,703 --> 00:24:21,023
factor that we can figure out.

410
00:24:21,023 --> 00:24:24,173
It just occurs and it's kinda
like idiopathic or, or we just

411
00:24:24,203 --> 00:24:27,383
are unable to stumble upon the
correct precipitating factor.

412
00:24:27,563 --> 00:24:30,223
So don't get too frustrated if you
can't figure out why it occurred.

413
00:24:30,773 --> 00:24:33,713
Just pat yourself on the back for
having actually made the diagnosis.

414
00:24:34,413 --> 00:24:38,608
I also thought that helped me 'cause I'm
not dying to slam kids with steroids and

415
00:24:38,608 --> 00:24:42,628
antibiotics all the time, but adults in
the age of sepsis, I don't really feel bad

416
00:24:42,628 --> 00:24:44,128
about slamming anybody with antibiotics.

417
00:24:44,128 --> 00:24:47,338
So I think now chasing a little
bit of fluids with a little bit of

418
00:24:47,338 --> 00:24:50,488
steroids to make sure I'm not missing
something, feels a little bit more

419
00:24:50,488 --> 00:24:52,078
like a reasonable treatment plan.

420
00:24:52,363 --> 00:24:56,023
And again, if you're a listener, you
could go back a couple, three, four

421
00:24:56,023 --> 00:25:00,643
episodes back and listen to our podcast
on septic shock with a different author.

422
00:25:00,833 --> 00:25:03,533
And she did a great job of kind
of delineating, at least in her

423
00:25:03,533 --> 00:25:06,923
practice, at what point she gives
stress dose steroids to all of

424
00:25:06,923 --> 00:25:08,423
her patients who are on pressors.

425
00:25:08,673 --> 00:25:11,973
And, you know, whether that be
immediately on initiation or if they

426
00:25:11,973 --> 00:25:14,463
don't immediately respond to the
pressors, she's giving those stress

427
00:25:14,463 --> 00:25:18,533
dose steroids because it's just so
common and it's just so frequent that

428
00:25:18,583 --> 00:25:20,843
a dose of hydrocortisone is lifesaving.

429
00:25:21,578 --> 00:25:25,688
And of course don't forget to ask about
exogenous steroid use, and I found it very

430
00:25:25,688 --> 00:25:32,328
interesting that the authors included the
evidence from the, I don't know how to say

431
00:25:32,328 --> 00:25:37,638
this now, this is gonna be Broersen et al
performed a meta-analysis of 74 articles.

432
00:25:37,638 --> 00:25:42,768
This was like almost 4,000 patients, and
found the rate of adrenal insufficiency to

433
00:25:42,768 --> 00:25:49,308
be 4.2% for patients receiving intranasal
corticosteroids on a regular basis.

434
00:25:49,308 --> 00:25:52,938
So you know you're using the nasal
steroids for seasonal allergy disorder

435
00:25:53,028 --> 00:25:57,168
and you're on it all year round, you are
at higher risk for adrenal insufficiency

436
00:25:57,348 --> 00:26:00,228
and 6.8% for inhaled corticosteroids.

437
00:26:00,228 --> 00:26:03,888
So all of your asthmatic patients
on inhaled steroids who receive that

438
00:26:03,888 --> 00:26:08,118
for daily control are now at higher
risk for adrenal insufficiency.

439
00:26:08,118 --> 00:26:11,448
And I gotta tell you, that is
not something I ever considered

440
00:26:11,448 --> 00:26:14,053
to be a risk factor for adrenal
insufficiency or crisis.

441
00:26:14,443 --> 00:26:16,183
I think that was what I was
getting to earlier is the

442
00:26:16,183 --> 00:26:17,563
combination of those things.

443
00:26:17,833 --> 00:26:21,853
'cause I know there's a lot of people
on nasal and inhaled and now they're

444
00:26:21,853 --> 00:26:24,943
older and maybe they get an injection in
their knee or something, in their back.

445
00:26:24,973 --> 00:26:29,293
And that additional cascading
levels of steroid use exogenously

446
00:26:29,503 --> 00:26:30,677
can push them over the top.

447
00:26:30,677 --> 00:26:35,996
And to your next point, chronic opiate use
has been shown to disrupt the HPA axis.

448
00:26:36,541 --> 00:26:39,991
So now those patients are starting
to filter into my head that, you

449
00:26:39,991 --> 00:26:43,231
know, if they've been on opiates for
a long time, for their chronic back

450
00:26:43,231 --> 00:26:47,151
pain or their chronic, you know,
surgical pain that they've had, now

451
00:26:47,151 --> 00:26:50,301
I'm a little bit more cautious that
those patients aren't hypotensive just

452
00:26:50,301 --> 00:26:51,411
'cause they're always on pain meds.

453
00:26:51,411 --> 00:26:54,411
It's more that they're developing
and, you know, some sort of crisis

454
00:26:54,411 --> 00:26:55,521
and I need to intervene there.

455
00:26:55,521 --> 00:26:55,971
So,

456
00:26:56,477 --> 00:27:00,070
And again, this was a 2020 study,
cross-sectional, a hundred patients.

457
00:27:00,070 --> 00:27:05,730
So again, pretty small, but it found
that patients who were on 20 morphine

458
00:27:05,790 --> 00:27:10,940
milligram equivalents of opioids per
day or more were at a higher risk.

459
00:27:10,940 --> 00:27:14,200
If they're on less than that, then
generally they weren't associated with

460
00:27:14,200 --> 00:27:15,640
a higher risk of adrenal insufficiency.

461
00:27:15,640 --> 00:27:19,370
But definitely if they're on the
higher doses for chronic opioids, just

462
00:27:19,370 --> 00:27:21,285
one more risk factor to think about.

463
00:27:21,625 --> 00:27:25,270
And you mentioned intraarticular
injections, that's even more

464
00:27:25,390 --> 00:27:26,530
than the other steroid use.

465
00:27:26,530 --> 00:27:30,710
So 52% of those are at higher
risk for adrenal insufficiency.

466
00:27:30,710 --> 00:27:34,316
So just so many things, steroid
use, don't just think about the

467
00:27:34,316 --> 00:27:36,236
pills or recent prescriptions.

468
00:27:36,326 --> 00:27:40,056
You gotta ask about other
methods of delivery and opioids.

469
00:27:40,396 --> 00:27:44,656
And then additional risk factors for
patients during the history would be

470
00:27:44,656 --> 00:27:46,306
things like, do they have diabetes?

471
00:27:46,526 --> 00:27:49,706
Are they altered, do they have
a history of asthma or coronary

472
00:27:49,706 --> 00:27:50,936
disease or cardiac disease?

473
00:27:50,936 --> 00:27:54,306
All of those things raise
their risks for adrenal crisis.

474
00:27:55,082 --> 00:27:59,832
Five Norcos a day gets you to 20
milligrams of morphine equivalents.

475
00:28:00,012 --> 00:28:03,972
So I think that it really doesn't
take much to get over 20 morphine

476
00:28:04,032 --> 00:28:08,682
equivalents just for those of us keeping
score at home on the MME calculator.

477
00:28:08,738 --> 00:28:08,948
There you go.

478
00:28:09,012 --> 00:28:10,602
Easily available on MD calc.

479
00:28:11,302 --> 00:28:16,907
Which brings me to our next question
in trivia with TR, which of the

480
00:28:16,907 --> 00:28:23,107
following is the most reliable
predictor of a future adrenal crisis.

481
00:28:23,107 --> 00:28:24,907
So these are historical items.

482
00:28:25,027 --> 00:28:25,357
All right.

483
00:28:25,357 --> 00:28:27,817
Which of the following is
the most reliable predictor

484
00:28:27,877 --> 00:28:29,527
of a future adrenal crisis?

485
00:28:29,617 --> 00:28:32,167
A, age over 60 years.

486
00:28:32,917 --> 00:28:36,127
B, chronic opioid use.

487
00:28:36,827 --> 00:28:39,947
C, history of adrenal crises.

488
00:28:40,647 --> 00:28:45,907
D, inhaled corticosteroid
use, or E, a pituitary tumor.

489
00:28:46,337 --> 00:28:48,467
I think it's if they had a
prior adrenal crisis, that's

490
00:28:48,467 --> 00:28:49,342
gonna lead them to another one.

491
00:28:49,353 --> 00:28:49,633
There you go.

492
00:28:49,937 --> 00:28:51,557
So that's all it's, I
wanted to go with age.

493
00:28:51,707 --> 00:28:52,937
I felt like it was a trap.

494
00:28:53,057 --> 00:28:54,437
I was so excited about the first answer.

495
00:28:54,437 --> 00:28:55,337
I was like, oh, it's age.

496
00:28:55,547 --> 00:28:58,577
But like, if they've had an adrenal
crisis, which is why you gotta ask them,

497
00:28:58,937 --> 00:29:00,287
boy, have you ever had an adrenal crisis?

498
00:29:00,467 --> 00:29:02,717
And they may not know, but they'd be like,
oh, they, they kept me in the hospital

499
00:29:02,717 --> 00:29:03,977
and gave me steroids for a few days.

500
00:29:04,157 --> 00:29:04,607
Bang.

501
00:29:04,817 --> 00:29:06,317
Sounds like an adrenal crisis to me.

502
00:29:06,317 --> 00:29:07,037
Don't overthink it.

503
00:29:07,473 --> 00:29:09,153
Here's the direct quote from the authors.

504
00:29:09,153 --> 00:29:13,203
The most reliable risk factor
for adrenal crisis is a history

505
00:29:13,203 --> 00:29:14,793
of a previous adrenal crisis.

506
00:29:14,793 --> 00:29:18,163
So the most important question
you're gonna ask in the

507
00:29:18,163 --> 00:29:19,993
history portion of your exam.

508
00:29:20,693 --> 00:29:21,413
Alright, next.

509
00:29:21,878 --> 00:29:22,838
Physical examination.

510
00:29:22,838 --> 00:29:26,838
So this is gonna be brief, but there
are some things you wanna keep in mind.

511
00:29:26,838 --> 00:29:31,908
So, abdominal pain is a very frequent
presenting symptom in adrenal crisis.

512
00:29:31,908 --> 00:29:35,538
And because abdominal pain is a
frequent presenting symptom for multiple

513
00:29:35,538 --> 00:29:37,878
diseases, you just gotta be careful.

514
00:29:37,998 --> 00:29:43,158
So you need to address it, you need to
address it in your ED evaluation and

515
00:29:43,158 --> 00:29:49,693
make sure that you're not missing a
alternate or a precipitating diagnosis as

516
00:29:49,693 --> 00:29:51,073
the cause for the adrenal insufficiency.

517
00:29:51,073 --> 00:29:55,063
So yes, they may have adrenal crises
and abdominal pain, but they may have

518
00:29:55,063 --> 00:30:00,683
also had appendicitis as their inciting
incident that put them in adrenal crisis.

519
00:30:00,803 --> 00:30:02,393
So don't forget about that.

520
00:30:02,483 --> 00:30:06,353
And then there are gonna be some of
those kind of House MD clues that

521
00:30:06,353 --> 00:30:08,063
you're gonna pick up on physical exam.

522
00:30:08,273 --> 00:30:13,063
Things like skin hyperpigmentation
in the sun exposed areas, on the

523
00:30:13,063 --> 00:30:15,673
flexor surfaces, on mucus membranes.

524
00:30:15,953 --> 00:30:20,673
They might be underweight and chronically
ill with thinning hair, especially in

525
00:30:20,673 --> 00:30:25,213
the axillary areas in females, or if
they have a secondary or tertiary adrenal

526
00:30:25,213 --> 00:30:29,443
insufficiency, they're not gonna have that
hyperpigmentation and they may actually

527
00:30:29,443 --> 00:30:34,928
be overweight and have the same thinning
axillary hair or if they've been on

528
00:30:34,928 --> 00:30:40,988
long-term chronic steroid use, they may be
cushingoid not from adrenal insufficiency,

529
00:30:41,138 --> 00:30:42,878
but from the medication itself.

530
00:30:42,878 --> 00:30:46,238
So if they're cushingoid on exam,
they're gonna have the truncal obesity,

531
00:30:46,418 --> 00:30:50,483
the big buffalo hump on the upper
back and some supraclavicular fat

532
00:30:50,483 --> 00:30:53,943
pads, moon facies, and worsening acne.

533
00:30:53,943 --> 00:30:56,973
All of those are common things that
you might pick up on exam for someone

534
00:30:56,973 --> 00:30:58,313
who's had chronic steroid use.

535
00:30:58,653 --> 00:31:01,873
And really, you may be asking,
well, why is that even important?

536
00:31:01,893 --> 00:31:02,793
Can I just ask them?

537
00:31:02,793 --> 00:31:05,973
And honestly, if they're not altered,
yes, you can say, are you on steroids?

538
00:31:06,213 --> 00:31:09,663
But if they're confused or they have
altered mental status or if they're

539
00:31:09,663 --> 00:31:12,393
obtunded, you're not gonna get
that information from the patient.

540
00:31:12,553 --> 00:31:15,643
And these may be your only
physical examination clues

541
00:31:15,643 --> 00:31:16,453
that you're gonna pick up.

542
00:31:17,153 --> 00:31:20,813
And once again, brings me
to another trivia question.

543
00:31:21,203 --> 00:31:27,383
Which physical examination
finding is most specific for

544
00:31:27,383 --> 00:31:29,753
primary adrenal insufficiency.

545
00:31:30,413 --> 00:31:34,313
So the most specific exam finding
for primary adrenal insufficiency.

546
00:31:34,313 --> 00:31:36,083
This is at the adrenal gland.

547
00:31:36,573 --> 00:31:40,530
Axillary hair thinning, B buffalo hump.

548
00:31:41,230 --> 00:31:43,090
C, moon facies.

549
00:31:43,580 --> 00:31:48,920
D, skin hyperpigmentation,
or E, truncal obesity.

550
00:31:49,290 --> 00:31:50,190
Run through those one more time.

551
00:31:50,640 --> 00:31:59,660
A, axillary hair thinning, B,
buffalo hump, C, Moon facies, D, skin

552
00:31:59,750 --> 00:32:03,050
hyperpigmentation, or E, truncal obesity.

553
00:32:03,750 --> 00:32:04,410
I don't know.

554
00:32:04,750 --> 00:32:06,740
The answer is skin hyperpigmentation.

555
00:32:07,250 --> 00:32:11,300
And I'll tell you, it's kind of a
trick question, because three of these

556
00:32:11,300 --> 00:32:16,090
things are actually not associated with
primary adrenal insufficiency, but are

557
00:32:16,090 --> 00:32:17,710
side effects of chronic steroid use.

558
00:32:17,710 --> 00:32:19,095
It's that cushingoid appearance.

559
00:32:19,095 --> 00:32:22,425
So that's the buffalo hump, the
moon facies, and truncal obesity.

560
00:32:22,675 --> 00:32:26,303
Those things you can kind of put aside,
'cause that's from chronic steroid

561
00:32:26,303 --> 00:32:29,553
use which leaves us with axillary
hair thinning, which can definitely

562
00:32:29,553 --> 00:32:31,653
occur and skin hyperpigmentation.

563
00:32:31,653 --> 00:32:35,163
But it turns out that the most specific
one is the skin hyperpigmentation.

564
00:32:35,513 --> 00:32:37,403
It's so rare though,
'cause primary is so rare.

565
00:32:37,403 --> 00:32:40,133
Like you're gonna see that so, so rarely.

566
00:32:40,133 --> 00:32:42,173
It'll be one of those interesting
things if you notice it.

567
00:32:42,223 --> 00:32:43,693
It's such a cool thing to catch.

568
00:32:43,693 --> 00:32:45,703
'cause as you said, all the
rest of it you're gonna see but,

569
00:32:46,089 --> 00:32:48,779
Alright, let's drop in to
some diagnostic studies.

570
00:32:48,779 --> 00:32:53,609
So we like to order a bunch of things
in the emergency department and that is

571
00:32:53,789 --> 00:32:57,599
definitely a trend that's gonna continue
in adrenal insufficiency and crisis.

572
00:32:57,709 --> 00:33:02,179
Unfortunately the authors were quick
to point out, there's no currently

573
00:33:02,579 --> 00:33:06,239
accepted universal definition for
adrenal crisis, which is kind of

574
00:33:06,239 --> 00:33:11,069
frustrating really because it's an
important diagnosis to not miss.

575
00:33:11,189 --> 00:33:15,569
It is one that has some vague
symptomology and can be easily missed

576
00:33:15,659 --> 00:33:19,979
because of its overlap with other
diseases, and it does not have a

577
00:33:19,979 --> 00:33:21,689
universally accepted definition.

578
00:33:21,929 --> 00:33:28,249
So, the authors suggest that a
generally accepted definition would be

579
00:33:28,549 --> 00:33:32,399
someone who has absolute hypotension.

580
00:33:32,399 --> 00:33:36,059
So systolic blood pressure less than
a hundred, or relative hypotension,

581
00:33:36,209 --> 00:33:40,679
more than 20 millimeters of mercury
lower than their usual blood pressure,

582
00:33:41,105 --> 00:33:45,185
that resolves within one to two hours
after administration of hydrocortisone.

583
00:33:45,305 --> 00:33:47,225
So really they have the hypotension.

584
00:33:47,225 --> 00:33:49,715
You suspect that, you give 'em the
hydrocortisone, and then within

585
00:33:49,715 --> 00:33:51,485
an hour or two they've improved.

586
00:33:51,635 --> 00:33:55,355
That's generally accepted as, yes, they
had an adrenal crisis, but interestingly,

587
00:33:55,535 --> 00:33:59,840
it's retrospective, so you can't
make that diagnosis prospectively and

588
00:33:59,840 --> 00:34:02,030
go, oh, they have an adrenal crisis,
I'm gonna give 'em hydrocortisone.

589
00:34:02,030 --> 00:34:03,800
It's like, I think they might have it.

590
00:34:04,040 --> 00:34:08,000
I'm gonna give them the steroids and
see what happens, which is exactly

591
00:34:08,030 --> 00:34:09,830
what we want you to do in the ED.

592
00:34:10,100 --> 00:34:11,450
Act on that suspicion.

593
00:34:12,150 --> 00:34:15,090
Laboratory studies, you're gonna get
your chemistries, you're gonna get your

594
00:34:15,090 --> 00:34:19,680
metabolic profiles, and it's important
to know that it can be associated

595
00:34:19,680 --> 00:34:27,177
with hypoglycemia, hyponatremia,
hyperkalemia, hypercalcemia, and anemia.

596
00:34:27,177 --> 00:34:33,297
So low blood glucose, low sodium, high
potassium, high calcium, and anemia.

597
00:34:33,687 --> 00:34:37,707
And among your other tests, so remember,
it's important to figure out what

598
00:34:37,707 --> 00:34:39,417
their precipitating diagnosis was.

599
00:34:39,417 --> 00:34:42,447
You're gonna be sending those sepsis
labs, getting those cultures, starting

600
00:34:42,447 --> 00:34:43,947
antibiotics, doing all that other stuff.

601
00:34:44,187 --> 00:34:50,247
But you should consider something
like a serum cortisol, an ACTH level,

602
00:34:50,407 --> 00:34:55,782
renin, and aldosterone levels, and
a TSH with the reflexive T3, T4.

603
00:34:55,872 --> 00:35:00,702
All of those are markers for
the hypothalamic, pituitary,

604
00:35:00,702 --> 00:35:02,292
and adrenal functions.

605
00:35:02,502 --> 00:35:07,552
And the endocrinologist or your very adept
critical care physician or hospitalist

606
00:35:07,552 --> 00:35:10,972
is gonna come in after you and put
all that together and say, ah, the

607
00:35:10,972 --> 00:35:13,162
problem is here at the pituitary gland.

608
00:35:13,452 --> 00:35:17,752
And that may guide subsequent imaging,
which we'll get to in a minute.

609
00:35:18,012 --> 00:35:20,515
So, important to send all of those labs.

610
00:35:20,785 --> 00:35:25,555
The gold standard for diagnosing
primary adrenal insufficiency is

611
00:35:25,585 --> 00:35:27,792
the cosyntropin stimulation test.

612
00:35:28,492 --> 00:35:31,432
Which is not something that
you're gonna do in the ED because

613
00:35:31,552 --> 00:35:32,542
you don't have time for that.

614
00:35:32,852 --> 00:35:36,542
But there are other things like
morning cortisol levels, random

615
00:35:36,542 --> 00:35:38,862
cortisol levels, that can be followed.

616
00:35:39,052 --> 00:35:41,472
And again, those can be drawn later.

617
00:35:41,472 --> 00:35:43,092
They might be drawn in
the emergency department.

618
00:35:43,092 --> 00:35:45,102
Your hospitalist colleagues
may add those on.

619
00:35:45,102 --> 00:35:48,882
Just know that those are all
part of the package for trying to

620
00:35:48,882 --> 00:35:51,342
determine where the problem lies.

621
00:35:51,342 --> 00:35:53,052
Is it primary, secondary, or tertiary?

622
00:35:53,752 --> 00:35:58,432
The cosyntropin tests are
affected by exogenous steroids.

623
00:35:58,702 --> 00:36:01,612
So doing that, like in the emergency
department, when the patient's

624
00:36:01,612 --> 00:36:03,412
unstable, makes the results unreliable.

625
00:36:03,532 --> 00:36:06,892
So if your admitting team or your
endocrinologist team is trying to push

626
00:36:06,892 --> 00:36:10,042
you to do this, you're welcome to push
back and say, Hey, I think that's a

627
00:36:10,042 --> 00:36:13,192
good idea to do that when the patient's
stable, but it's not the right time to

628
00:36:13,192 --> 00:36:14,422
do that here in the emergency department.

629
00:36:14,512 --> 00:36:15,772
Save their life first.

630
00:36:15,832 --> 00:36:17,842
Worry about the blood test later.

631
00:36:18,542 --> 00:36:21,152
It's kind of very similar
to like meningitis and

632
00:36:21,152 --> 00:36:22,232
sepsis and all those things.

633
00:36:22,232 --> 00:36:23,132
Did you get the culture?

634
00:36:23,137 --> 00:36:24,812
Did, did you get some CSF yet?

635
00:36:24,872 --> 00:36:26,792
I'm like, well, I was kind of
concerned with saving their

636
00:36:26,792 --> 00:36:28,202
life, but I'll get there.

637
00:36:28,902 --> 00:36:30,222
All right, let's do another question.

638
00:36:30,272 --> 00:36:34,668
This question is ideally answered while
you are looking at figure one on page

639
00:36:34,668 --> 00:36:38,898
five, that wonderful illustration,
all right, referring to that figure in

640
00:36:38,898 --> 00:36:44,238
tertiary adrenal insufficiency, so this is
adrenal insufficiency at the hypothalamus,

641
00:36:44,508 --> 00:36:46,248
most often caused by steroids.

642
00:36:46,728 --> 00:36:52,518
What is the expected pattern
for your cortisol level, your

643
00:36:52,518 --> 00:36:55,068
ACTH, and your CRH levels?

644
00:36:55,768 --> 00:36:56,788
Can I just tell you what it is?

645
00:36:57,658 --> 00:37:00,483
Because if you're that high, so if
the dysfunction, this is tertiary

646
00:37:00,483 --> 00:37:04,443
adrenal insufficiency, then you're
gonna have low levels across the board.

647
00:37:04,443 --> 00:37:08,523
So you'll have low CRH, low
ACTH, and low cortisol levels.

648
00:37:08,808 --> 00:37:08,958
Bingo.

649
00:37:08,958 --> 00:37:09,618
Exactly right.

650
00:37:09,670 --> 00:37:14,080
So your corticotropin releasing
hormone, that hormone released by

651
00:37:14,080 --> 00:37:17,230
the hypothalamus, is gonna be low
'cause that's where the problem lies.

652
00:37:17,380 --> 00:37:23,770
But also your adrenocorticotropic hormone,
that's the ACTH released by the pituitary,

653
00:37:23,920 --> 00:37:27,910
is also going to be low because it's not
getting stimulated by the hypothalamus.

654
00:37:28,385 --> 00:37:31,205
And your cortisol level
is going to be low.

655
00:37:31,385 --> 00:37:34,565
That's released by the adrenal
gland, but also not being

656
00:37:34,565 --> 00:37:36,095
stimulated by the pituitary.

657
00:37:36,125 --> 00:37:40,085
So the downstream effects,
all low, because the problem

658
00:37:40,085 --> 00:37:41,415
lies at the hypothalamus.

659
00:37:41,415 --> 00:37:42,825
Well done, sir.

660
00:37:42,859 --> 00:37:46,584
One quick caveat, one quick thing I would
wanna add to that, which I noticed as I

661
00:37:46,584 --> 00:37:51,354
was remembering this, is your aldosterone
levels are low in primary, but they're

662
00:37:51,354 --> 00:37:53,694
usually normal in secondary and tertiary.

663
00:37:53,964 --> 00:37:57,444
So that's something to not be led
astray by, that your aldosterone

664
00:37:57,444 --> 00:38:00,924
levels can be normal, but your
cortisol levels can be low, and that

665
00:38:00,924 --> 00:38:03,684
still means you've got dysfunction
higher up in secondary and tertiary.

666
00:38:03,879 --> 00:38:08,089
And if you remember from the
physiology days, the aldosterone has

667
00:38:08,089 --> 00:38:11,629
to do with your renin aldosterone
system and your kidneys and salt.

668
00:38:11,869 --> 00:38:16,129
And that is a communication between
your adrenal glands and your kidneys.

669
00:38:16,259 --> 00:38:20,549
And much less to do with anything
pituitary or hypothalamic.

670
00:38:20,549 --> 00:38:24,449
So if the problem is not at the adrenal
glands, that portion of your adrenal

671
00:38:24,449 --> 00:38:26,399
cortex will be functioning correctly.

672
00:38:26,619 --> 00:38:30,684
Which is why the aldosterone level will
be normal if it's secondary or tertiary,

673
00:38:30,744 --> 00:38:32,364
so yes, excellent thing to point out.

674
00:38:33,064 --> 00:38:34,324
All right, let's talk about imaging.

675
00:38:34,324 --> 00:38:39,154
So again, you're gonna get imaging
that's going to guide you to exclude all

676
00:38:39,154 --> 00:38:41,464
of the other precipitating diagnoses.

677
00:38:41,524 --> 00:38:44,884
So whatever you need to make sure
they don't have some life-threatening

678
00:38:44,884 --> 00:38:48,584
infection or an abdominal infection
or whatever it is you need there.

679
00:38:48,774 --> 00:38:53,454
But also if you are able to identify
the location of the problem.

680
00:38:53,454 --> 00:38:58,479
So if you're able to say, oh, this is a
secondary or tertiary abnormality, that

681
00:38:58,479 --> 00:39:00,759
may lead to additional brain imaging.

682
00:39:00,849 --> 00:39:04,659
We're talking things like MRI imaging
of the pituitary or MRI imaging

683
00:39:04,659 --> 00:39:09,109
of the hypothalamus in order to
discern what the problem may be.

684
00:39:09,109 --> 00:39:13,079
Things like pituitary hemorrhage
or an infiltrative process like

685
00:39:13,079 --> 00:39:17,159
sarcoidosis or damage to the area
from brain radiation that they've had.

686
00:39:17,369 --> 00:39:21,579
All of those things can cause necrosis
in the brain and cause those secondary

687
00:39:21,579 --> 00:39:26,289
or tertiary effects, and that can be
ordered later by your inpatient team

688
00:39:26,469 --> 00:39:29,979
after you've done a great job saving
their life and resuscitating them.

689
00:39:30,679 --> 00:39:34,309
Or if they've had a trauma or a surgery
recently, that may be something you want

690
00:39:34,309 --> 00:39:36,169
to pursue a little bit quicker and sooner.

691
00:39:36,379 --> 00:39:39,139
And also to consider involving
your neurosurgery colleagues,

692
00:39:39,379 --> 00:39:41,989
especially if it's one of their
patients, to make sure you get the

693
00:39:41,989 --> 00:39:43,099
kind of pictures that they want.

694
00:39:43,799 --> 00:39:46,019
Alright, let's jump into treatment.

695
00:39:46,079 --> 00:39:49,439
So when we talk about treatment, we're
gonna talk about hydrocortisone, right?

696
00:39:49,439 --> 00:39:53,259
As I mentioned before, a million times,
we're talking about hydrocortisone.

697
00:39:53,379 --> 00:39:56,889
If you suspect it, you're giving
it, and the standard adult dose is

698
00:39:56,889 --> 00:39:59,259
a hundred milligrams intravenously.

699
00:39:59,409 --> 00:40:04,209
If you don't have IV access, it
can be given IM, so don't wait.

700
00:40:04,209 --> 00:40:06,849
If they're critically unstable and
you're already suspecting this, just

701
00:40:06,849 --> 00:40:11,019
give 'em the hydrocortisone IM while
you're waiting to get IV access and

702
00:40:11,019 --> 00:40:12,429
give it to 'em as soon as possible.

703
00:40:12,839 --> 00:40:15,149
Now, that's just the initial dose.

704
00:40:15,359 --> 00:40:21,779
It is later going to be followed by 200
milligrams a day as either a continuous

705
00:40:21,779 --> 00:40:26,879
infusion or as bolus dosing every
six hours at 50 milligrams a piece.

706
00:40:26,879 --> 00:40:30,059
So just know that if they're
hovering in your emergency

707
00:40:30,059 --> 00:40:33,419
department for a long period of
time, they've become more stable.

708
00:40:33,539 --> 00:40:37,139
Maybe they've been downgraded from an ICU
bed and they're waiting for a floor bed,

709
00:40:37,289 --> 00:40:38,939
and now they're becoming more unstable.

710
00:40:38,939 --> 00:40:42,394
It's probably because they're due for
their next dose and you gotta make sure

711
00:40:42,394 --> 00:40:44,614
that that's a priority to be administered.

712
00:40:45,314 --> 00:40:50,117
The pediatric dosing is 50 milligrams
per meter squared of body surface area.

713
00:40:50,307 --> 00:40:53,817
And that, again, is given IV or
IM, and then followed by either

714
00:40:53,817 --> 00:40:57,447
a continuous infusion or the same
every six hours divided dosing.

715
00:40:57,507 --> 00:41:00,777
So just know, again, if they're hovering
in your department for a long period

716
00:41:00,777 --> 00:41:02,517
of time, they need that repeat dosing.

717
00:41:02,607 --> 00:41:05,517
And the best medication is hydrocortisone.

718
00:41:05,857 --> 00:41:10,567
Stress dose steroids can also
be given with other steroids.

719
00:41:10,567 --> 00:41:14,347
So for adults you can give
methylprednisolone 40 milligrams

720
00:41:14,437 --> 00:41:19,807
IV every 24 hours, or it can be
Prednisolone 25 milligrams orally,

721
00:41:19,807 --> 00:41:23,747
followed by two additional 25
milligram doses in the first 24 hours.

722
00:41:23,747 --> 00:41:26,697
There's multiple different ways
to break this up with Prednisone

723
00:41:26,697 --> 00:41:28,687
and Prednisolone as a possibility.

724
00:41:28,912 --> 00:41:33,082
But in the emergency department by far,
if they're not taking anything orally,

725
00:41:33,082 --> 00:41:35,302
it's gonna be IV or IM hydrocortisone.

726
00:41:35,722 --> 00:41:39,069
And then you're gonna need
to fix their fluid status.

727
00:41:39,069 --> 00:41:40,959
So these people are getting fluid boluses.

728
00:41:40,989 --> 00:41:42,639
You're gonna need to fix hypoglycemia.

729
00:41:42,639 --> 00:41:44,469
You may need to add some D5 in there.

730
00:41:44,709 --> 00:41:49,539
And then further treatment becomes
tailored, depending on their response,

731
00:41:49,539 --> 00:41:53,259
depending on what you find from your
adrenal crisis laboratory testing,

732
00:41:53,619 --> 00:41:57,519
and depending on what their subsequent
diagnosis to put them in the adrenal

733
00:41:57,519 --> 00:41:59,789
crisis is eventually elucidated to be.

734
00:41:59,939 --> 00:42:02,669
So you gotta treat their sepsis
or their appendicitis, or

735
00:42:02,834 --> 00:42:05,819
whatever it is that occurred to
set them in the adrenal crisis.

736
00:42:06,519 --> 00:42:11,739
There are patients who have
recommended sick day dosing.

737
00:42:11,799 --> 00:42:17,179
So they're already on hydrocortisone
at home and when they get sick,

738
00:42:17,179 --> 00:42:21,019
their endocrinologist has educated
them or the parents that this is

739
00:42:21,019 --> 00:42:24,679
your sick day dosing, meaning we're
going to double your hydrocortisone.

740
00:42:25,379 --> 00:42:30,349
Typically that's doubled for fever over
38 degrees centigrade or tripled for

741
00:42:30,349 --> 00:42:32,969
a fever over 39 degrees centigrade.

742
00:42:33,189 --> 00:42:36,039
And that's continued for the
entire duration of the illness.

743
00:42:36,039 --> 00:42:39,639
So if it's a child and they've got a URI
and they're spiking fevers, they're just

744
00:42:39,639 --> 00:42:41,409
gonna stay on that stress dose steroid.

745
00:42:41,649 --> 00:42:44,079
You might notice, well, the
parents doubled it, but the

746
00:42:44,079 --> 00:42:45,129
patient's not improving.

747
00:42:45,129 --> 00:42:47,709
And it may be just that the
fever's gotten so high, they now

748
00:42:47,709 --> 00:42:49,149
qualify for the triple dosing.

749
00:42:49,399 --> 00:42:54,159
So keep that in mind that it may just
be subtherapeutic, even at the doubled

750
00:42:54,219 --> 00:42:56,999
level and that that can be given at home.

751
00:42:56,999 --> 00:42:59,759
And when they fail that and they come
to the emergency department, we're

752
00:42:59,759 --> 00:43:01,619
switching back to hydrocortisone.

753
00:43:01,919 --> 00:43:05,369
There are some patients who
give hydrocortisone IM at home.

754
00:43:05,529 --> 00:43:09,234
Now this is not available yet in an
auto-injector, so they're drawing

755
00:43:09,234 --> 00:43:10,719
this up and injecting it themselves.

756
00:43:10,719 --> 00:43:12,609
They may have prefilled syringes at home.

757
00:43:12,829 --> 00:43:16,369
But again, another important piece
of information for our EMS colleagues

758
00:43:16,619 --> 00:43:20,829
to extract from the family, and it's
important to know when their last dose

759
00:43:20,829 --> 00:43:25,309
was because you're gonna need to repeat
it in the ED or in the hospital to make

760
00:43:25,309 --> 00:43:26,779
sure that they're not missing those doses.

761
00:43:27,479 --> 00:43:29,704
I've embraced metric for measurements.

762
00:43:29,704 --> 00:43:33,244
I'm here for that, but I refuse
to embrace Celsius temperatures.

763
00:43:33,454 --> 00:43:39,694
So for those like me, 38 celsius is
100.4, so they're getting double their

764
00:43:39,694 --> 00:43:42,784
dose if they're over a hundred, and
they're getting triple their dose

765
00:43:42,784 --> 00:43:45,184
if they've hit 39, which is 102.2.

766
00:43:45,649 --> 00:43:48,259
Over 102, they're getting
triple dose, over a hundred,

767
00:43:48,259 --> 00:43:49,279
they're getting double dose.

768
00:43:49,489 --> 00:43:52,324
For those of us that wanna live and
breathe by my friend Fahrenheit.

769
00:43:52,767 --> 00:43:54,117
. And then there's maintenance therapy.

770
00:43:54,117 --> 00:43:56,457
So typically patients who are
on maintenance therapy are

771
00:43:56,457 --> 00:43:58,737
on two different medications.

772
00:43:58,737 --> 00:44:01,707
They're taking hydrocortisone and
they're taking fludrocortisone.

773
00:44:01,917 --> 00:44:05,381
So they're maximizing both the
glucocorticoid and the mineralocorticoid

774
00:44:06,131 --> 00:44:10,181
replacement therapy in order to make
sure that they're perfectly balanced.

775
00:44:10,371 --> 00:44:13,371
And the dosing is there for you
in the article, but most cases,

776
00:44:13,371 --> 00:44:15,591
that's not really gonna apply to
us in the emergency department.

777
00:44:15,591 --> 00:44:19,528
We're giving the stress dose, adrenal
crisis dosing for the sickest of the

778
00:44:19,528 --> 00:44:21,941
sick in order to turn 'em around quickly.

779
00:44:22,641 --> 00:44:25,671
Which brings me to more trivia questions.

780
00:44:26,371 --> 00:44:26,941
Here we go.

781
00:44:26,941 --> 00:44:33,121
Which of the following is the recommended
initial IV dose of hydrocortisone for

782
00:44:33,121 --> 00:44:35,701
pediatric patients in adrenal crisis?

783
00:44:36,401 --> 00:44:39,611
So IV dose peds patient in adrenal crisis.

784
00:44:39,971 --> 00:44:40,691
Can I just give it to you?

785
00:44:40,721 --> 00:44:42,311
'cause I have it memorized in my brain.

786
00:44:42,561 --> 00:44:47,181
I know for sure that it is 50
milligrams per meter squared.

787
00:44:47,391 --> 00:44:51,711
So I believe that is not a weight-based
dose, but a surface area based dose.

788
00:44:52,101 --> 00:44:55,881
And I would tell you that my one
walk away from this is, I honestly

789
00:44:55,881 --> 00:44:58,581
need to go look up how do I measure
the surface area of a child?

790
00:44:58,851 --> 00:45:00,096
'cause I don't know that
off the top of my head.

791
00:45:00,147 --> 00:45:01,267
MD Calc is your friend,

792
00:45:02,027 --> 00:45:03,227
Hey, there you go.

793
00:45:03,227 --> 00:45:04,277
MD calc plug.

794
00:45:04,397 --> 00:45:05,357
Always your friend.

795
00:45:05,357 --> 00:45:07,457
There's always something
there to help you calculate.

796
00:45:07,457 --> 00:45:10,697
And there is a calculator for
body surface area in children.

797
00:45:11,297 --> 00:45:16,187
Which of the following actions
should be taken first when adrenal

798
00:45:16,187 --> 00:45:18,342
crisis is suspected in the ED?

799
00:45:19,042 --> 00:45:21,022
A, await cortisol lab results.

800
00:45:21,352 --> 00:45:23,692
B, consult endocrinology.

801
00:45:23,962 --> 00:45:26,182
C, order abdominal imaging.

802
00:45:26,392 --> 00:45:31,252
D, perform the cosyntropin
stimulation test, or E, administer

803
00:45:31,282 --> 00:45:33,022
parental hydrocortisone.

804
00:45:33,722 --> 00:45:34,772
Sorry, I missed the question.

805
00:45:34,772 --> 00:45:36,812
I was looking up the body
surface area calculator 'cause

806
00:45:36,812 --> 00:45:37,952
I was so excited about it.

807
00:45:38,162 --> 00:45:39,542
You're gonna have to hit me one more time.

808
00:45:39,543 --> 00:45:41,973
Which of the following actions
should be taken first when adrenal

809
00:45:41,973 --> 00:45:43,893
crisis is suspected in the ED?

810
00:45:43,923 --> 00:45:44,658
What's the first thing you gotta do?

811
00:45:45,481 --> 00:45:47,971
Give IV hydrocortisone
or IM hydrocortisone.

812
00:45:48,222 --> 00:45:50,402
Give the hydrocortisone,
do not delay therapy.

813
00:45:50,432 --> 00:45:51,572
Alright, one more question.

814
00:45:51,586 --> 00:45:55,429
100 or 40 of solumedrol if
you don't have hydrocortisone.

815
00:45:55,669 --> 00:45:58,099
'Cause sometimes I think I talk
to pharmacy and they're like,

816
00:45:58,159 --> 00:46:00,289
oh yeah, we'll get that for you,
and then it's gonna be a while.

817
00:46:00,469 --> 00:46:03,649
So that'd be something where I'd give
pharmacy like, you know, 20 minutes and

818
00:46:03,649 --> 00:46:05,809
then I'm giving them IV, whatever I got.

819
00:46:05,860 --> 00:46:09,440
So if you're the director or if you're
involved in administration or if

820
00:46:09,440 --> 00:46:12,860
you're the pharmacy representative
for your physician team in the ED,

821
00:46:13,100 --> 00:46:15,950
this is one of those medications
you really want in at least one

822
00:46:15,950 --> 00:46:17,390
Pyxis machine in your department.

823
00:46:17,450 --> 00:46:21,470
Because you don't have the luxury
of waiting an hour for this to come

824
00:46:21,590 --> 00:46:23,210
in the tube system from pharmacy.

825
00:46:23,420 --> 00:46:24,950
You need this medication right away.

826
00:46:25,100 --> 00:46:29,420
And honestly, if they're in crisis,
an oral medication, you know, I mean

827
00:46:29,420 --> 00:46:33,290
it's better than nothing, but it's not
likely to get absorbed systemically

828
00:46:33,410 --> 00:46:36,950
in the same manner as it would if
they were just having a routine dose.

829
00:46:37,160 --> 00:46:40,370
'cause if they're having GI issues,
if they're having nausea or vomiting

830
00:46:40,370 --> 00:46:44,180
or diarrhea, all of that reduces
your absorption and is gonna reduce

831
00:46:44,180 --> 00:46:47,580
your serum levels and it's not
ideal and you're gonna be looking

832
00:46:47,580 --> 00:46:51,640
for something IM, so you want that
hydrocortisone available to you for sure.

833
00:46:52,340 --> 00:46:52,520
Okay.

834
00:46:52,520 --> 00:46:55,310
And this speaks to the last
thing that you just mentioned.

835
00:46:55,310 --> 00:47:00,080
For a patient with adrenal
insufficiency who has a fever of 39.5

836
00:47:00,080 --> 00:47:04,350
degrees Celsius, how should their
hydrocortisone dose be adjusted?

837
00:47:05,050 --> 00:47:06,405
Over 102 so you triple it.

838
00:47:06,485 --> 00:47:06,795
There you go.

839
00:47:07,015 --> 00:47:09,595
Triple the dose if they're over 39.

840
00:47:10,305 --> 00:47:13,485
. Alright, let's just talk about
a couple of special populations.

841
00:47:13,705 --> 00:47:15,025
First is pregnancy.

842
00:47:15,085 --> 00:47:20,555
So yes, people with adrenal insufficiency
can become pregnant and when they do, they

843
00:47:20,555 --> 00:47:22,775
still have to continue their medications.

844
00:47:22,865 --> 00:47:27,055
So hydrocortisone is the
glucocorticoid of choice and it

845
00:47:27,055 --> 00:47:29,325
is inactivated by the placenta.

846
00:47:29,325 --> 00:47:32,805
So it's not crossing that placental
barrier, but it's critically important.

847
00:47:32,955 --> 00:47:37,665
And depending on their stage of
pregnancy, they may need increasing

848
00:47:37,665 --> 00:47:40,245
doses as they progress through pregnancy.

849
00:47:40,365 --> 00:47:43,845
And then they may need stress
doses in certain situations.

850
00:47:44,095 --> 00:47:47,561
So during labor a huge stressor
and they're gonna need to be on

851
00:47:47,561 --> 00:47:48,881
the full stress dosing there.

852
00:47:49,061 --> 00:47:51,311
If they end up getting a
C-section or having surgery,

853
00:47:51,521 --> 00:47:53,531
again, full stress dosing there.

854
00:47:53,771 --> 00:47:59,821
But also early in pregnancy, there's
significant overlap between hyperemesis

855
00:47:59,821 --> 00:48:04,161
gravidarum and adrenal crisis because
of that persistent nausea and vomiting.

856
00:48:04,161 --> 00:48:05,991
And it can be hard to tease it out.

857
00:48:05,991 --> 00:48:10,231
So is this hyperemesis or is this
their adrenal crisis cropping up again?

858
00:48:10,441 --> 00:48:13,951
And you may need to do some stress
dosing around those times as well.

859
00:48:13,981 --> 00:48:16,681
So just understand that there's
some overlap there and it can

860
00:48:16,681 --> 00:48:17,911
be a little bit confusing.

861
00:48:18,611 --> 00:48:21,131
Not a bad idea to consult
their OBGYN as well.

862
00:48:21,281 --> 00:48:23,351
'cause they probably have
struggled with this before.

863
00:48:23,501 --> 00:48:26,621
I think that's gonna be our lasting
impression as we finish this thing up

864
00:48:26,621 --> 00:48:30,236
is, you know, do the thing, but then get
the consultant and get them admitted.

865
00:48:30,936 --> 00:48:32,526
And then your patients with septic shock.

866
00:48:32,526 --> 00:48:34,986
So there's a little paragraph here,
but again, if you want to hear more

867
00:48:34,986 --> 00:48:38,016
about this, go back a few episodes
to our septic shock episode.

868
00:48:38,016 --> 00:48:39,726
And we talked about this extensively.

869
00:48:39,846 --> 00:48:43,786
There is a role for hydrocortisone
in patients in septic

870
00:48:43,786 --> 00:48:45,076
shock who were on pressors.

871
00:48:45,386 --> 00:48:47,486
There is actually a mortality benefit.

872
00:48:47,836 --> 00:48:51,406
And that leads me to our
last two trivia questions.

873
00:48:51,886 --> 00:48:52,126
Alright.

874
00:48:52,126 --> 00:48:56,429
This one's a case, a 38-year-old
woman presenting with fatigue,

875
00:48:57,129 --> 00:49:04,585
weight loss, and craving salty foods,
appears unusually tanned and has labs

876
00:49:04,585 --> 00:49:10,235
revealing low sodium, mildly elevated
potassium and a glucose in the sixties.

877
00:49:10,935 --> 00:49:13,185
What diagnosis should
be strongly considered?

878
00:49:13,785 --> 00:49:19,260
We've got addison's disease,
diabetes insipidus, Hashimoto's

879
00:49:19,280 --> 00:49:21,980
thyroiditis, or pheochromocytoma.

880
00:49:22,680 --> 00:49:26,490
She sounds like an Addisonian
crisis to me, and I'm gonna

881
00:49:26,490 --> 00:49:27,570
give her some hydrocortisone.

882
00:49:27,750 --> 00:49:29,490
She is adrenally insufficient.

883
00:49:29,490 --> 00:49:32,250
She's not yet hypotensive, at
least not given in the case.

884
00:49:32,410 --> 00:49:36,730
But absolutely someone who sounds like she
has Addison's disease and you gotta send

885
00:49:36,730 --> 00:49:40,030
off all those labs and give her a little
dose of steroids and see how she responds.

886
00:49:40,730 --> 00:49:46,440
And then the final question, which of
the following is a documented pitfall in

887
00:49:46,740 --> 00:49:48,600
ED management of adrenal insufficiency?

888
00:49:48,600 --> 00:49:51,240
So which one of these
mistakes do we know we make.

889
00:49:51,590 --> 00:49:56,694
Administering fludrocortisone before
labs, delaying corticosteroids to

890
00:49:56,694 --> 00:50:03,614
confirm diagnosis, overtreating with
glucose before cortisol, initiating

891
00:50:03,614 --> 00:50:09,294
vasopressors too early, or administering
hydrocortisone without consent.

892
00:50:09,644 --> 00:50:13,124
Honestly, I think in this case, almost
always, it's you can talk yourself into

893
00:50:13,124 --> 00:50:16,994
something else and you delay giving
the hydrocortisone, and I think this

894
00:50:16,994 --> 00:50:20,534
is a good time to say, you know, could
be this, could be this, could be this.

895
00:50:20,534 --> 00:50:24,339
So just to cover myself for
some sort of adrenal crisis, I'm

896
00:50:24,339 --> 00:50:27,074
gonna give the steroids and then
I'll let it play out upstairs.

897
00:50:27,299 --> 00:50:30,569
And that, ladies and
gentlemen, is it for us.

898
00:50:30,629 --> 00:50:36,546
So the takeaway message being have
a high suspicion and a very low

899
00:50:36,546 --> 00:50:38,566
threshold for giving the hydrocortisone.

900
00:50:38,566 --> 00:50:40,396
And don't wait for your labs.

901
00:50:40,396 --> 00:50:41,086
Send them off.

902
00:50:41,386 --> 00:50:43,036
But give the hydrocortisone.

903
00:50:43,036 --> 00:50:47,716
Don't forget that the accepted
definition involves the treatment.

904
00:50:47,746 --> 00:50:49,586
So suspicion isn't enough.

905
00:50:49,586 --> 00:50:52,206
And if you think they have the
diagnosis, give 'em the hydrocortisone

906
00:50:52,206 --> 00:50:52,901
and see if they respond.

907
00:50:53,601 --> 00:50:58,131
And that's it for our Emergency
Medicine Practice October 2025 article.

908
00:50:58,131 --> 00:51:01,021
Thank you to the Simcoes for
authoring this outstanding

909
00:51:01,021 --> 00:51:02,731
review of adrenal insufficiency.

910
00:51:02,911 --> 00:51:05,964
Keep it in your office in
your little physician lounge.

911
00:51:05,994 --> 00:51:07,074
Keep the article handy.

912
00:51:07,284 --> 00:51:10,784
Keep the references on your phone
and just keep that diagnosis in the

913
00:51:10,784 --> 00:51:14,739
forefront of your brain next time you
see somebody who's unstable and altered.

914
00:51:15,439 --> 00:51:16,359
Good luck out there.

915
00:51:16,599 --> 00:51:18,069
You're gonna get one of these a season.

916
00:51:18,279 --> 00:51:19,254
It's a good catch if you catch it.

917
00:51:19,900 --> 00:51:22,690
All right, ladies and gentlemen,
until next time, be safe.

918
00:51:23,875 --> 00:51:25,695
And that's a wrap for
this month's episode.

919
00:51:25,735 --> 00:51:28,315
I hope you found it
educational and informative.

920
00:51:28,515 --> 00:51:33,375
Don't forget to go to ebmedicine.net
to read the article and claim your CME.

921
00:51:33,545 --> 00:51:36,735
And of course, check out all three
of the journals and the multitude of

922
00:51:36,735 --> 00:51:41,095
resources available to you, both for
emergency medicine, pediatric emergency

923
00:51:41,095 --> 00:51:43,365
medicine, and evidence based urgent care.

924
00:51:43,675 --> 00:51:45,645
Until next time, everyone be safe.