Emergency 20 h2/20/2024 ![]() All have excellent oral bioavailability, with rapid absorption. They vary in their immunosuppressive and metabolic properties 10 mg hydrocortisone is roughly equivalent to 2.0 mg prednisolone and to 0.2 mg dexamethasone. ![]() Glucocorticoid preparations include hydrocortisone (most similar to cortisol), prednisolone and dexamethasone. Glucocorticoid therapy (any route), mifepristone, chlorpromazine, imipramine Traumatic brain injury, particularly base of skull fracture ![]() Primary brain tumours or nasopharyngeal tumours Transcription factors involved in pituitary developmentĬraniopharyngiomas, germinomas, meningiomas Lymphocytic hypophysitis, sarcoidosis, histiocytosis X, haemochromatosis, TB Secondary adrenal insufficiency/pituitary disordersĪdenoma, cysts, craniopharyngioma, ependymoma, meningioma, pituitary metastases Primary adrenal lymphoma amyloidosis, haemochromatosisĪnticoagulants, adrenal enzyme inhibitors: mitotane, ketoconazole, itraconazole, voriconazole, metyrapone, etomidate, aminoglutethimidie, phenobarbital, phenytoin, rifampicinĬongenital adrenal hyperplasia (commonest cause in children), adrenoleukodystrophy Primarily metastases from lung, stomach, breast and colon cancers TB, HIV/AIDS, CMV, fungal infections, syphilisĪdrenal haemorrhage sepsis, anticoagulants, anti-phospholipid syndrome There are no adverse consequences of initiating life-saving hydrocortisone treatment. This can be performed at a later date when the patient is clinically stable. Clinical findings of patients presenting with AI and laboratory investigations are summarised in the supplementary material (S1, S2).3 If AI is suspected, then prompt treatment should not be delayed by performing or waiting for the results of diagnostic testing. Hypothalamo-pituitary disorders account for 60% of patients with AI, while 40% have primary adrenal failure due to Addison's disease (0.9–1.4 per 10,000) or congenital adrenal hyperplasia (0.7–1.0 per 10,000). ![]() Causes of secondary AI are pituitary disease, pituitary tumours and their treatment (surgery and radiotherapy), and, also termed tertiary AI, hypothalamic–pituitary–adrenal axis (HPA) suppression from exogenous steroids or, more rarely, from treatment of primary brain or nasopharyngeal tumours with radiotherapy when the hypothalamus and/or pituitary is included in the treatment field. The commonest causes of primary AI include Addison's disease, congenital adrenal hyperplasia, bilateral adrenalectomy and adrenal haemorrhage (Table (Table1). We hope the new emergency card and this guidance will increase awareness of the need to start steroids promptly in patients at risk of an adrenal crisis, particularly those presenting in the emergency department or to acute medicine teams and those undergoing surgery or invasive procedures. A new NHS Steroid Emergency Card has been developed to be carried by patients at risk of adrenal crisis. This guidance will go through causes of adrenal insufficiency, groups at risk of an adrenal crisis, emergency management and management for surgical procedures. The National Reporting and Learning System (NRLS) identified 78 incidents including two deaths and six incidents of severe harm to patients in a recent 4-year period. Omission of steroids in patients with AI, particularly during physiological stress such as an intercurrent illness or surgery, can also lead to an adrenal crisis. Adrenal insufficiency (AI) is an often-unrecognised endocrine disorder, which can lead to adrenal crisis and death if not identified and treated.
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