Patient came to emd with complain of multiple episodes of vomiting, reduced response, generalized weakness, reduce intake of food. Known case of Rheumatic arthritis, t2dm, htn, ckd. PR 120, Bp 80/60, spo2- 98% rbs 134, gcs 15/15
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Emergency Assessment & Management
Patient Summary: Known RA + T2DM + HTN + CKD, presenting with vomiting, generalized weakness, reduced oral intake, and reduced responsiveness.
Vitals: PR 120 bpm (tachycardia), BP 80/60 mmHg (hypotension), SpO2 98%, RBS 134 mg/dL, GCS 15/15.
MAP = (80 + 2×60) / 3 ≈ 67 mmHg - borderline, needs to be maintained >65 mmHg.
Step 1: Immediate Resuscitation (First 15 Minutes)
Airway/Breathing/Circulation
- Patient is alert (GCS 15/15) and SpO2 98% - oxygen support as needed
- 2 large-bore IV lines immediately
- IV crystalloid bolus: 250-500 mL 0.9% NS, reassess after each bolus (caution in CKD - avoid fluid overload; small titrated boluses preferred)
- Urinary catheter - monitor urine output (target >0.5 mL/kg/hr)
- Cardiac monitor + pulse oximetry continuously
- Send bloods before giving fluids if possible
Immediate Investigations (STAT)
| Test | Rationale |
|---|---|
| Serum electrolytes (Na, K) | Hyponatremia + hyperkalemia = adrenal crisis signature |
| Serum creatinine, BUN | Baseline CKD vs. acute-on-chronic |
| Serum cortisol (random) | Do BEFORE giving hydrocortisone if possible |
| Blood glucose (repeat) | RBS 134 - monitor for hypoglycemia in adrenal crisis |
| CBC with differential | Infection/sepsis workup |
| Blood cultures x2 | Before antibiotics |
| Arterial blood gas | Acidosis, lactate level |
| Serum lactate | >2 mmol/L = septic shock criterion |
| LFT, coagulation profile | Organ dysfunction |
| Serum calcium, phosphate | CKD-related derangements |
| Urine culture, urinalysis | Common precipitant |
| CXR, ECG | Cardiac causes, pneumonia |
| TSH | Hypothyroidism can mimic this |
Step 2: Critical Differential Diagnoses
This patient's background of Rheumatoid Arthritis is a major red flag. RA patients are almost universally on long-term corticosteroids (prednisolone), which causes HPA axis suppression. Under physiological stress (infection, poor intake, illness), this can precipitate adrenal crisis.
Most Likely Diagnoses (in priority order):
1. Adrenal Crisis (Highest Priority - MUST rule out/treat empirically)
- RA patients on chronic steroids are at high risk of HPA suppression
- Presentation fits perfectly: hypotension (90% of cases), vomiting (47%), weakness (100%), confusion/reduced response (42%), precipitated by poor oral intake/intercurrent illness
- Hyponatremia, hyperkalemia, and hypoglycemia may be found on labs
- Stresses such as infections, poor intake, or even missing steroid doses can precipitate crisis - Robbins Pathologic Basis of Disease
- "Treatment of adrenal crisis should begin as soon as possible and prior to diagnostic testing when crisis is suspected" - Rosen's Emergency Medicine
2. Septic Shock
- Tachycardia + hypotension in a patient with CKD, diabetes, and immunosuppression (RA on steroids) - all major risk factors
- Source: UTI, pneumonia, skin/joint infection
- Note: adrenal crisis can present identically to septic shock and is frequently missed
3. Hypovolemic Shock
- Vomiting + reduced intake = volume depletion
- CKD limits compensatory reserve
4. Cardiogenic Shock
- HTN + DM + RA = elevated cardiovascular risk; cannot exclude ACS
- ECG mandatory
5. Other considerations
- Hypoglycemia (though RBS 134 argues against active hypoglycemia, watch for Addisonian drop)
- NSAID/DMARD toxicity (common in RA patients - GI bleeding, renal toxicity)
- Hyperkalemia-induced arrhythmia (CKD risk)
Step 3: Priority Treatment (Simultaneous with Workup)
A. Empiric Treatment for Adrenal Crisis - DO NOT WAIT FOR RESULTS
"If there is suspicion of adrenal crisis, treatment should be initiated immediately, prior to confirmatory tests." - Rosen's Emergency Medicine
Hydrocortisone 100 mg IV bolus STAT
- Then 200 mg/24 hours (50 mg IV every 6 hours) or as continuous infusion
- Alternative if cortisol assay is needed first: Dexamethasone 4 mg IV (does not interfere with cortisol assay - allows ACTH stimulation test later)
IV Fluid resuscitation
- 0.9% Normal Saline - replaces sodium deficit and volume
- Give in small boluses (250 mL), reassess after each - CKD requires caution to avoid pulmonary edema
- Avoid hypotonic fluids
Glucose - check frequently; give D50% if hypoglycemia detected
B. If Septic Shock is Confirmed or Cannot Be Excluded
Broad-spectrum antibiotics within 1 hour (after blood cultures):
- Empiric: Piperacillin-tazobactam or Meropenem (dose-adjust for CKD/eGFR)
- Cover gram-negatives, gram-positives, and consider source
Vasopressors - if MAP <65 mmHg despite adequate fluid resuscitation:
- Norepinephrine is first-line (target MAP ≥65 mmHg; if prior uncontrolled HTN, may need MAP 75 mmHg)
- Vasopressin as adjunct if norepinephrine doses escalating
Note: If adrenal crisis is suspected in a septic patient, hydrocortisone covers both - it treats the adrenal component AND provides adjunctive benefit in septic shock.
C. Hold Potentially Harmful Medications
- Hold NSAIDs (nephrotoxic, worsen GI mucosa, mask fever)
- Hold ACE inhibitors / ARBs (worsen hypotension + AKI in CKD)
- Hold metformin if RBS/AKI evolving (lactic acidosis risk)
- Review DMARD doses (methotrexate, hydroxychloroquine) - may need to hold
Step 4: Monitoring Targets
| Parameter | Target |
|---|---|
| MAP | ≥65 mmHg |
| SpO2 | ≥94% |
| Urine output | ≥0.5 mL/kg/hr |
| Heart rate | Trend toward <100 |
| Blood glucose | 140-180 mg/dL (ICU range) |
| Serum K+ | <5.5 mEq/L |
| Serum Na+ | Correct slowly if hyponatremia |
| Lactate | Clearance trend every 2 hours |
Step 5: Disposition
This patient requires ICU admission - hemodynamically unstable, multiple comorbidities, high risk of organ failure. ICU criteria are met by the combination of:
- Hypotension requiring vasopressors/fluid challenge
- Known immunosuppression (RA on steroids)
- CKD (risk of fluid mismanagement, hyperkalemia, acidosis)
- Possible adrenal crisis (6% case fatality rate per episode)
Key Clinical Pearl
This patient has RA - almost certainly on long-term prednisolone. When she stopped eating (reduced intake), she likely missed her steroid dose(s), triggering an adrenal crisis on top of whatever precipitant (infection, stress) brought her in. The classic teaching point: never stop steroids abruptly in a known steroid-dependent patient, and always administer stress-dose hydrocortisone in any critically ill patient with a history of long-term corticosteroid use.
Sources:
- Rosen's Emergency Medicine, Box 117.11 & Management section
- Symptom to Diagnosis: An Evidence-Based Guide, 4th ed. (Adrenal Insufficiency chapter)
- Frameworks for Internal Medicine (Hypotension chapter)
- Goldman-Cecil Medicine (Low Blood Pressure chapter)
- Robbins & Cotran Pathologic Basis of Disease (Adrenal crisis - clinical features)
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