Adrenal Crisis

This case is written by Dr. Kyla Caners. She is a staff emergency physician in Hamilton, Ontario and the Simulation Director of McMaster University’s FRCP-EM program. She is also one of the Editors-in-Chief here at EmSimCases.

Why it Matters

While adrenal crisis is a relatively rare presentation, shock is not. This case highlights several important points, including:

• The importance of having an approach to fluid non-responsive shock
• How difficult it can be to shift cognitive frames and resist diagnostic anchoring
• The electrolyte abnormalities associated with adrenal crisis (hyponatremia, hyperkalemia, and hypoglycemia)
• The need to treat an adrenal crisis with corticosteroids

Clinical Vignette

A 46-year-old female presents to the ED complaining of fatigue, anorexia, and weight loss over the last two weeks. She had the “stomach flu” a couple weeks ago and thought she was getting over it. But now she feels very weak and seems to be vomiting again. Her blood pressure is 80/40, so she was triaged straight to the resuscitation bay.

Case Summary

A 46-year-old female presents to the ED complaining of fatigue, anorexia, and weight loss over the last two weeks. She had the “stomach flu” a couple weeks ago and thought she was getting over it. But now she feels very weak and seems to be vomiting again. On presentation, the patient will have mild hypothermia, hypoglycemia, and hypotension. The team will have to initiate fluid resuscitation and an initial workup. The patient’s blood pressure won’t respond to 4 L of IV fluids, forcing the residents to work through the differential diagnosis of shock. Eventually, they will receive critical VBG results that indicate a mild metabolic acidosis, hyperkalemia, and hyponatremia. The team will need to treat the hyperkalemia and initiate hydrocortisone therapy.

Download the case here: Adrenal Crisis Case

ECG for the case found here:

(ECG source: http://lifeinthefastlane.com/ecg-library/basics/hyperkalaemia/)

CXR for the case found here:

(CXR source: https://radiopaedia.org/cases/normal-chest-radiograph-female-1)

Pericardial U/S for the case found here:

(U/S courtesy of the McMaster PoCUS Subspecialty Training Program)

FAST image for the case found here:

(U/S courtesy of the McMaster PoCUS Subspecialty Training Program)