Adrenal Insufficiency

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Introduction

Adrenal insufficiency is an endocrine disorder that includes reduced levels of hormone secretion from the adrenal glands. These hormones include cortisol and aldosterone. Adrenal insufficiency may lead to an adrenal crisis which is a life-threatening emergency caused by the adrenal glands inability to produce sufficient cortisol in response to major stress.
An adrenal crisis can be precipitated by a significant illness, trauma, stress, infection, and/or non-compliance with medications. An adrenal crisis usually takes several hours to develop but can occur more quickly. If left untreated, it can be fatal.
Types of Adrenal Insufficiency:

Primary: Diseases of the adrenal gland eg. Addison’s Disease, Congenital Adrenal Hyperplasia, Adrenoleukodystrophy.
Secondary: Diseases of the pituitary gland or hypothalamus eg. Hypopituitarism, Craniopharyngiomas and head injuries.
Iatrogenic: Chronic corticosteroid treatment, Crohn’s Disease, Juvenile arthritis, Asthma, Nephrotic syndrome, haemangiomas.

Commonly known diseases relating to adrenal insufficiency are Addison’s Disease, Congenital Adrenal Hyperplasia, Hypopituitarism, and Craniopharyngiomas.
Hydrocortisone is life saving, do not unreasonably delay administration - IM and IV are equally as effective.

Clinical Presentation

Known adrenal insufficiency presenting with any of the following signs and symptoms:

Exclusion Criteria

Risk Assessment

Monitor for signs of hypovolaemic shock, cardiac arrest, stroke or cardiac dysrhythmia.
Hypoglycaemia may present pre or post administration of Hydrocortisone – manage as per CPG.
Consider patient may present with Hyperkalaemia and/or Hyponaetremia.
Rarely, Adrenal Insufficiency patients may present with psychosis in an acute crisis - history taking is important.

Management

Primary Care

Intermediate Care (EMT / Level 2)

Apply cardiac monitor if trained and authorised
Monitor patient persistently, recording full observations every 10 minutes (or 5 minutes if time critical)

Advanced Care (AP)

Administer Hydrocortisone as per CPG. IM and IV both equally effective.
Apply cardiac monitoring with 12 lead ECG
Establish vascular access
Consider obtaining prehospital blood sample
Consider fluid therapy as per CPG
Consider Oral Glucose, IV Glucose or Glucagon as per CPG
Analgesia if required
Monitor patient persistently, recording full observations every 10 minutes (or 5 minutes if time critical)
Consider repeat BGL
Transport Priority 1 if patient time critical, pre-notifying receiving facility

Critical & Extended Care (CCP, PSO)

Additional Information

St John WA has a database of patients who have known Primary Adrenal Insufficiency (Addison's Disease) and have communicated their needs to Clinical Services.
Notification of these patients will be provided via a Medical Warning displayed on the CAD with instructions to call the Clinical Support Paramedic in the State Operations Centre. In these cases, the CSP may authorise crews to administer the patients’ own hydrocortisone (known as Solu-cortef) if the patient is found to be experiencing an adrenal crisis.
A CSP may be tasked as an additional resource to known patients.
There is a subset of Addison's Disease patients' who are known as 'ultra-rapid metabolisers' of steroid medication, who may require up to 3 x the normal amount of hydrocortisone in adrenal crisis. Consider an ASMA consult if suspected.

References

Key Terms & Links

Further Information:

Colour assist:

Directorate

Clinical Services

Responsible Manager

Head of Clinical Services

Published Date

Review Date