adrenal crisis
Introduction
Introduction to the adrenal crisis Adrenal crisis refers to a series of clinical symptoms caused by insufficient or absent secretion of adrenocortical hormone by various reasons, which can affect multiple systems. Mainly manifested by symptoms caused by adrenocortical hormone deficiency, such as dehydration, blood pressure drop, orthostatic hypotension, collapse, anorexia, vomiting, lack of energy, lethargy and even coma. basic knowledge The proportion of illness: 0.001% Susceptible people: no special people Mode of infection: non-infectious Complications: narcolepsy shock
Cause
Adrenal crisis
Long-term hormone therapy (30%):
Inhibition of hypothalamic-pituitary-adrenal axis function, even if it is stopped for 1 year, its function is still in a low state, especially the response to stress. Oyama study 14 patients treated with steroid for a long time before induction of anesthesia, 30 minutes after induction and surgery Blood cortisol was measured at 1 h after treatment at 107±18 g/L (10.7±1.8 g/dl), 108±15 g/L (10.8±1.5 g/dl) and 148±25 g/L (14.8±2.5 g/dl). The blood cortisol in 10 patients in the control group was 108±14g/L (10.8±1.4g/dl), 175±16g/L (17.5±1.6g/dl) and 263±18g/L. (26.3 ± 1.8 g / dl), so patients with long-term treatment with corticosteroids, when exposed to stress, if not timely supplementation or increase in hormone dose, acute adrenal insufficiency will also occur.
Other factors (20%):
Adrenalectomy depends on adrenal hyperplasia of the hypothalamic pituitary or adrenal gland disease (such as metastatic breast cancer) for adrenalectomy; or after adrenal adenoma removal, the remaining adrenal glands often atrophy, hypothalamic-pituitary-adrenal axis The function of the adenoma is inhibited due to the long-term secretion of a large amount of cortisol. The recovery of its function takes at least 9 months or more. If the hormone is not added or the hormone dose is not increased under stress, it can also cause Acute adrenal insufficiency.
Congenital factors (20%):
There are nine enzyme defects known to date, including 21 hydroxylase, 11 hydroxylase, 17 hydroxylase, 18 hydroxylase, 18 oxidase, 5-3 hydroxysteroid dehydrogenase, 22 carbon chain enzyme, 17 Hydroxysteroid dehydrogenase and 17,20 lyase, most enzymes are required for cortisol synthesis, 5-3 hydroxysteroid dehydrogenase, 22 carbon chain enzyme and 18 hydroxylase and 18 oxidase defects can also affect Synthesis of sodium strontium hormone.
Prevention
Adrenal crisis prevention
Patients with chronic adrenal insufficiency should be educated, insist on continuous administration of hormones, and should not be arbitrarily interrupted. In case of stress, it is necessary to increase the dose under the guidance of a physician. If there is upper respiratory tract infection, tooth extraction and other small stress, the hormone will be The amount is doubled until the disease is cured. Generally, control is seen within 4 to 5 days. If there is a large stress, such as surgery, myocardial infarction, severe trauma and infection, hydrocortisone should be given to 200~ 300mg / d, the amount of hormone should be increased a few hours before surgery, when the patient goes out to carry out, it is necessary to carry a sufficient amount of hormone for application.
Complication
Adrenal crisis Complications, narcolepsy, shock
Patients with adrenal crisis are obstructed by metabolism in the body, including impaired glucose metabolism, resulting in increased production of lactic acid, which can directly cause serious metabolic acidosis after exceeding the compensatory capacity of the liver. At the same time, brain edema can be caused by metabolic disorders of brain tissue, and even cerebral palsy can be induced. Therefore, patients with conscious disorders should be alert to the occurrence of this disease.
Symptom
Adrenal crisis symptoms Common symptoms Irritability Cortical dysfunction Abdominal pain Deficiency ambiguity Nausea sleepiness coma
Clinical manifestations of adrenal crisis include symptoms caused by adrenocortical hormone deficiency, and manifestations of diseases that cause or cause acute adrenal insufficiency. Adrenal cortical hormone deficiency is mostly mixed, that is, both glucocorticoids and sodium strontium hormones. Are lacking.
(A) fever is more common, can have high heat up to 40 ° C or more, sometimes body temperature can be lower than normal.
(B) digestive system anorexia, nausea, vomiting, etc. are often early symptoms, such as timely identification, treatment, often quickly improved, but also abdominal pain, diarrhea and other symptoms.
(3) The nervous system is weak, wilting, uninhibited, indifferent, lethargic, extremely debilitating, and can also be expressed as irritability, embarrassment, confusion, and even coma.
(4) The heart rate of the circulatory system is fast, up to 160 beats/min, the limbs are cold, the circulation is collapsed, the blood pressure drops, and it falls into shock. Because of the lack of both glucocorticoids and sodium strontium in the disease, it is more than the Sheehan crisis. It is easy and faster to appear peripheral circulatory failure. Most patients have changes in consciousness and blood pressure at the same time. A small number of patients have changed their minds first, and blood pressure has decreased. We have observed that changes in consciousness and blood pressure occur as early as 4 hours after the inducement. 1/3 and 2/3 patients appeared within 24, 48 hours, respectively.
(5) Dehydration signs often exist to varying degrees.
Examine
Examination of adrenal crisis
The total number of white blood cells is increased, blood concentration and infection are caused, neutral polynuclear cells are increased, hemoglobin is increased, and blood is concentrated. Hyperkalemia, hyponatremia, hypoglycemia, mild increase in blood urea nitrogen, mild acidosis and a decrease in total blood cortisol. Once an adrenergic crisis occurs, it should be treated immediately to avoid life-threatening due to multiple organ dysfunction.
Diagnosis
Diagnosis of adrenal crisis
Differential diagnosis:
Adrenal intoxication: Adrenalin and noradrenalin are commonly used first aid drugs, and excessive amounts can cause poisoning. A small number of patients are highly sensitive to adrenaline, although adverse effects can also occur with therapeutic doses. Children with pre-excessive hyperthyroidism and cardiovascular disease are also sensitive to adrenaline and are prone to poisoning.
Adrenal metastasis: Adrenal metastasis is common in adrenal metastases. Adrenal metastasis is the fourth most common site for tumor metastatic tumors, mostly from lung cancer, breast cancer, stomach cancer, liver cancer and pancreatic cancer. Therefore, in patients with the above primary malignant tumors, adrenal masses are also found, and adrenal metastases should be considered first.
Adrenal cortical hormone deficiency: Adrenal cortical hormone deficiency is one of the clinical manifestations of primary chronic adrenal insufficiency. The secretion of corticosteroids, including cortisol and aldosterone, is affected by severe destruction of the adrenal gland.
