Endocrine shock
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"adrenal crisis" AND management
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adrenal crisis emergency management guideline hydrocortisone shock Society for Endocrinology
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https://pmc.ncbi.nlm.nih.gov/articles/PMC5314805
Endocrine shock is a form of distributive shock caused by severe hormone deficiency. The two classic emergencies are:
- Adrenal crisis (Addisonian crisis)
- Myxedema coma from profound hypothyroidism
1. Adrenal crisis
Acute cortisol deficiency reduces vascular responsiveness to catecholamines. In primary adrenal insufficiency, aldosterone deficiency also causes sodium and water loss, worsening hypotension.
Clinical features
- Severe hypotension or shock, sometimes refractory to fluids/vasopressors
- Fever, weakness, confusion
- Nausea, vomiting, abdominal pain
- Hypoglycemia, hyponatremia, hyperkalemia
- Possible hyperpigmentation in primary adrenal insufficiency
- Often resembles septic shock
Common triggers: infection, surgery, trauma, vomiting/diarrhea, sudden cessation of chronic glucocorticoids, and unrecognized adrenal insufficiency. Acute adrenal crisis can occur with either primary or secondary adrenal insufficiency. Symptom to Diagnosis, lines 7381-7400.
Immediate management
- ABC resuscitation, monitoring, IV access
- Draw cortisol and ACTH if this does not delay care
- Hydrocortisone 100 mg IV or IM immediately
- Then 200 mg hydrocortisone over 24 hours by continuous IV infusion, or 50 mg IV/IM every 6 hours
- Rapid isotonic saline resuscitation, typically 1 L in the first hour in adults if no fluid-overload risk
- Check and correct hypoglycemia with IV dextrose
- Identify and treat the precipitant, especially sepsis
- Add vasopressors if shock persists after fluids and steroids
Treatment must not wait for diagnostic confirmation. The Society for Endocrinology emergency guidance advises immediate hydrocortisone and fluid resuscitation in suspected adrenal crisis.
2. Myxedema coma
This is decompensated severe hypothyroidism. It causes low cardiac output, impaired vasoconstriction, hypoventilation, and reduced metabolism, producing shock.
Clinical features
- Altered mental state: confusion, stupor, or coma
- Hypothermia
- Bradycardia and hypotension
- Hypoventilation with hypercapnia
- Hyponatremia, hypoglycemia
- Dry/coarse skin, non-pitting edema, delayed reflexes
- A precipitant is common: infection, myocardial infarction, stroke, trauma, surgery, or sedative drugs
Lippincott Illustrated Reviews: Pharmacology describes myxedema coma as associated with stupor, hypothermia, hypoventilation, hypoglycemia, hyponatremia, shock, and death. Lippincott Illustrated Reviews: Pharmacology, lines 1156-1160.
Management
- ICU care, airway and ventilatory support when needed
- Gentle warming only. Avoid aggressive external rewarming because vasodilation can worsen hypotension.
- Careful IV fluids, dextrose for hypoglycemia, correction of electrolytes
- IV thyroid hormone, usually levothyroxine, with regimen individualized to age and cardiac risk
- Empiric IV hydrocortisone first or concurrently until coexisting adrenal insufficiency is excluded
- Treat the precipitating illness, commonly infection
Key distinction
| Feature | Adrenal crisis | Myxedema coma |
|---|---|---|
| Main hormonal deficit | Cortisol, often aldosterone | Thyroid hormone |
| Temperature | Fever or normal | Marked hypothermia |
| Heart rate | Often tachycardia, though variable | Bradycardia |
| Electrolytes | Hyponatremia, hyperkalemia in primary disease, hypoglycemia | Hyponatremia, hypoglycemia |
| Core treatment | Hydrocortisone + saline + dextrose | IV thyroid hormone + hydrocortisone + ICU support |
Clinical rule: In unexplained shock with hypoglycemia, hyponatremia, hyperkalemia, vomiting, or a history of steroid exposure, treat possible adrenal crisis immediately while continuing the sepsis and shock workup.
Iv thyroxin
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myxedema coma intravenous levothyroxine dose guideline ATA 200 400 mcg
IV thyroxine = IV levothyroxine (T4). It is used mainly for myxedema coma, not routine hypothyroidism.
Adult myxedema coma regimen
- Loading: levothyroxine 200-400 micrograms IV once
- Use the lower end, such as 200 micrograms, in older adults or patients with coronary artery disease/arrhythmia.
- Maintenance: about 1.6 micrograms/kg/day, but give 75% of this dose when IV.
- Often practical maintenance is 50-100 micrograms IV daily, depending on body size and cardiac risk.
- Switch to oral levothyroxine once the patient is clinically stable and absorbing medications reliably.
Important sequence
- Send blood for cortisol, TSH, free T4, glucose, electrolytes if feasible.
- Give IV hydrocortisone first or at least concurrently, commonly 100 mg IV then stress-dose coverage, because thyroid hormone can precipitate adrenal crisis if occult adrenal insufficiency is present.
- Give IV levothyroxine.
- ICU supportive care: airway/ventilation, cautious fluids, IV dextrose if hypoglycemic, passive rewarming, and treatment of infection or other precipitant.
IV T3 (liothyronine) may be considered in selected severe cases, but it has greater arrhythmia and ischemia risk, especially in elderly or cardiac patients. ATA hypothyroidism guideline recommends IV T4 200-400 micrograms loading, followed by weight-based replacement at 75% of the oral dose while IV.
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