Postgrad Med J: first published as 10.1136/pgmj.29.330.215 on 1 April 1953. Downloaded from 215 ACUTE ADRENAL INSUFFICIENCY By PAUL FOURMAN, M.D., M.R.C.P. Nuffield Department of Clinical Medicine, University of Oxford In acute adrenal insufficiency we are faced with common in patients whose adrenal insufficiency is the interaction of many factors ; if in trying to due to hypopituitarism than in patients with disentangle them I have cut some knots it is for Addison's disease. the sake of brevity. Addison's disease is characterized by a failure to Acute adrenal insufficiency may result from conserve sodium and we usually think of the crisis sudden loss of adrenal function by haemorrhage, of acute adrenal insufficiency as a condition of thrombosis or ablation. More often it-occurs in a shock brought about by salt depletion. This patient with chronic adrenal insufficiency, either might be true in a patient with Addison's disease in the natural course of the illness or following who is in crisis when he first presents ; in him the an injury such as'infection, operation or exposure. crisis is the climax of a long illness during which Acute adrenal insufficiency is characterized by there has been time for the sodium stores to by copyright. prostration and collapse with low blood pressure become depleted. The sodium depletion may and rapid pulse. It is usually accompanied by represent a stress that released the crisis rather gastro-intestinal symptoms: anorexia, vomiting than the immediate cause of the shock-like state. and diarrhoea, and sometimes abdominal pain and Sodium depletion is not an essential feature of hiccup. Headache is common. The patient is at adrenal crisis. Adrenal crisis can develop in a first weak and apathetic but he may become rest- matter of hours, but it takes a few days for the loss less and confused, sometimes with high and swing- of sodium to produce a serious depletion. If the ing fever, before he finally lapses into a fatal coma. adrenal insufficiency has arisen suddenly depletion to if the Now, in patients with intact adrenal glands who of sodium has not had time develop ; http://pmj.bmj.com/ have been exposed to different types of injury or crisis has arisen in a patient already under treat- " stress " there is, underlying the specific response ment for Addison's disease depletion of sodium to each type of injury, a general response common will have been prevented by the previous treat- to all. This is the alarm reaction of Selye and is ment. These patients may show little bio- partly a result of discharge of adrenal hormone. In chemical evidence of acute adrenal insufficiency the alarm reaction adrenal hormone is liberated beyond hypoglycaemia, and even this may be in large amounts and is probably rapidly con- lacking. In our ignorance we take refuge in saying sumed by the tissues. In Addisonian patients the that stress has produced an increased demand for on September 28, 2021 by guest. Protected alarm reaction cannot occur, but the response to adrenal hormone to which the adrenal glands are stress again follows a general pattern which we unable to respond. know as an adrenal crisis, so that in Addisonian It is important to distinguish between cases with patients too there is a non-specific response to and without salt depletion, for their treatment will injury. Presumably the reaction to injury of differ. In both instances the patients will need an patients with intact adrenals combines the effects active preparation of adrenal hormone to control of a discharge of adrenal hormone and another collapse and hypoglycaemia, and the greater the mechanism which is unmasked in adrenal in- precipitating stress the greater the demand for sufficiency. This other mechanism should account hormone; but the one group will also need to be for the rapid utilization of adrenal hormone in the given salt and may need to be helped to conserve alarm reaction. What this mechanism is we do not salt ; the other may be killed by an excess of salt know. Thyroid is one hormone that may increase and salt-retaining hormone, for the patient with the need for adrenal hormone, for thyroid may adrenal insufficiency can no more excrete salt in precipitate adrenal crisis in patients with hypo- the face of excess than conserve it in the face of pituitarism ; apart from this, adrenal crisis is less depletion. Postgrad Med J: first published as 10.1136/pgmj.29.330.215 on 1 April 1953. Downloaded from 1.6 POSTGRADUATE MEDICAL JOURNAL April 1953 It is possible that there is only one adrenal freely. Fever is no guide to whether or not these hormone in nature, but in practice among the patients have an infection. artificial hormone preparations that are available 3. If the patient is depleted of sodium; give 5 to us two important actions are divorced. The first per cent. glucose in normal saline intravenously, is to conserve sodium and discharge potassium; but not more than 3 litres in 24 hours. Stop-the the second is to control glycogen metabolism and drip as soon as possible after the patient begins to prevent hypoglrcaemia-associated ·with this take by mouth. Control the treatment by following second action isthe ability to resist stress. The two the serum sodium and the haematocrit. Watch for types of preparation are represented by the any sign of overloading with fluid. If the patient artificial compound deoxycortone acetate (DCA) is not depleted of sodium, very little saline may be on the one hand, and by cortisone on the other. needed; give io per cent. glucose in water intra- Whole adrenal extract probably combines both venously and glucose by mouth as soon as possible. actions, but compared to the whole extract DCA Control the treatment by the blood glucose. Here has an exaggerated effect on s6dium retention. the intake of fluid should not exceed z litres in the DCA has very little action other than to restore first 24 hours and thereafter depends on the electrolyte balance, but if the balance is upset this urinary output. An intake of I litre in excess of action may be life-saving. The main action of the urinary output is safe. Do not give large deoxycortone on electrolytes is to cause retention doses of DCA routinely. If needed at all, io mg. of sodium. It cannot retain sodium unless sodium or less may suffice on the first day and 5 mg. or less is given and the effect depends not so much on the on succeeding days. dose of deoxycortone as on the amount of sodium 4. Be extravagant with whole adrenal extract. that the patient is receiving. DCA has another Give 20 or 40 cc. into the drip and then io cc. effect on electrolyte balance, to cause a discharge every hour until the systolic blood pressure is of accumulated potassium from the body. This 8o mm., and every 2 hours until nausea, vomiting, effect is greater, the greater the dose of DCA and abdominal pain and diarrhoea lhave stopped. is excessive if DCA is given in e£cess. With cortisone it is possible to use less adrenalby copyright. DCA does not bear much relation to the hor- extract than hitherto but, because the extract can mone that is normally called forth and rapidly be given intravenously and cortisone cannot, we consumed in stress. This is more nearly.repre- still rely on adrenal extract for-a rapid effect. Two sented by the whole extract of the gland, and milligrams of cortisone are equivalent to I0 c.c. nowadays by cortisone, and perhaps in the future of extract. Cortisone acts more rapidly by mouth by hydrocortisone (compound F) if it should be than intramuscularly, but if the patient cannot economically synthesized. These preparations swallow, cortisone must be given intramuscularly, ckuse a discharge of potassium but have only say 00oo or 200 mg. if no excess of DCA has been minor effects on sodium. We know that this type given. As soon as the patient can take by mouth, http://pmj.bmj.com/ of hormone will prevent the hypoglycaemia of give 50 mg. followed by 25 mg. every 6 hours. adrenal insufficiency, but this is not enough to When symptoms have receded and for 3 days after explain why it should be essential to survival in that, the patient should have either extract, Io c.c. the face of stress such as exposure, operation, or every 4 hours, or cortisone I2.5 mg. every 6'hours. infection. It is hardly possible to give an overdose The patient is then ready for maintenance therapy of adrenal extract, but an' excess of DCA will and a small dose of cortisone, say 12.5 or 25 mg. limit the amount of cortisone that can safely be daily, can be given partly to replace DCA. The given, owing to the risk of potassium deficiency. cbrtisone may be given by mouth in four divided on September 28, 2021 by guest. Protected Adrenal crisis is an emergency during which the doses daily, in a mixture, or as an intramuscular patient may at any moment die ; treatment must injection of 50-Ioo mg. twice a week. These be prompt. In treatment our aim is: dosage schemes provide only a rough guide. In I. To treat the shock. particular the patient may require more adrenal 2. To remove the stress. hormone if there is persistent infection or other 3. To replenish sodium and give sugar. stress such as operation. 4. To supply adrenal hormone as required, and Some patients have a very stormy course and the 5.