Month: June 2019

June 19 MOTM – Hypotension

Clinical picture:

A 39 year old female was brought into resus by the ambulance service. A 999 call was made by a concerned neighbour who had not seen her in 3 days. The police forced entry into the property where there was evidence of diarrhoea and vomiting. She was pale, drowsy and hypotensive and seemed to be experiencing abdominal pain. Medications found by the paramedics include levothyroxine and hydrocortisone.

Arterial Blood Gas result:

pH 7.28                    (7.35-7.45)

pCO2 4.8                 (4.7-6.0)

pO2 22                     (9.3-13.3)

Na+ 127                   (134-146)

K+ 6.5                      (3.4-5.0)

Cl- 93                       (98-108)

Ca2+ 1.38                (1.12-1.32)

Glu 3.2                     (4.0-6.4)

Hb 128                     (110-165)

BE (ecf) -11.3          (-2-+2)

HCO3(std) 16.3      (22-26)

 

Outcome:

IV fluids (normal saline and 5% dextrose) were administered and she was started on insulin and dextrose to treat her hyperkalaemia.

After 1 hour of treatment she remained hypotensive and her condition was generally deteriorating without a clear cause. Review by intensive care was requested, but not immediately available. No senior review from A&E was requested at this time.

 

What was the mistake?

 Diagnosis of adrenal crisis was not recognised and senior help was not requested from an emergency senior when ITU consultation was not immediately available.

This patient has Addison’s disease and having developed a vomiting illness she has been unable to tolerate her hydrocortisone tablets. Patients with adrenal crisis will continue to deteriorate until supplementary steroids are administered.

Adrenal crisis is a life-threatening condition caused by insufficient levels of cortisol. It can occur in:

  • Patients with Addison’s disease or secondary adrenal failure
  • Patients with congential adrenal hyperplasia
  • Patients on ≥5mg prednisolone or equivalent for >1 month
  • Patients on long term inhaled or topical steroids

It can be precipitated by:

  • Illness
  • Surgery
  • Trauma
  • Impaired steroid absorption eg vomiting

Patients with increased physiological stress eg. concurrent infection, require increased cortisol dose.

Adrenal crisis should be suspected in someone known to have impaired endogenous cortisol production if they have any 2 of the following:

  • Nausea or vomiting
  • Severe fatigue
  • Severe headache
  • Confusion
  • Hypotension (SBP<100mgHg)
  • Hyponatraemia
  • Hyperkalaemia
  • Hypoglycaemia

Emergency treatment includes:

  1. Hydrocortisone 100mg IV
  2. 9% saline 1L hourly until SBP >100mmHg
  3. 100mls 20% dextrose over 10mins if BM <4.0
  4. Treat precipitating cause