ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
نسخه الکترونیک
medimedia.ir

Rapid overview: Adrenal crisis in children and adolescents

Rapid overview: Adrenal crisis in children and adolescents
Signs and symptoms that may indicate adrenal crisis:
  • Vomiting and diarrhea, sometimes with severe abdominal pain or unexplained fever, weight loss, and anorexia.
  • Serum electrolyte abnormalities:
  • Hyponatremia with or without hyperkalemia.
  • Metabolic acidosis.
  • Hypoglycemia (especially in young children).
  • Hypotension or shock, particularly if disproportionate to apparent underlying illness.
Consider the diagnosis in:
  • Neonates with atypical genitalia and/or electrolyte abnormalities, lethargy, hypoglycemia, hypotension or shock, or failure to thrive. These may be presenting features of CAH due to 21-hydroxylase deficiency* or (very rarely) other causes of adrenal insufficiency.
  • In the United States, 21-hydroxylase deficiency is part of the newborn screen in all states, so most affected infants will be diagnosed prior to presentation with adrenal crisis. Adrenal crisis usually presents between 10 and 20 days of life. Affected females usually have atypical genitalia (varying severity). Males usually do not have genital abnormalities.
  • The presentation of adrenal crisis in an infant may mimic that of pyloric stenosis. However, infants with pyloric stenosis typically have hypokalemic alkalosis rather than the hyperkalemic acidosis that is typical of adrenal crisis.
  • Any patient with known disorders of adrenal insufficiency (eg, CAH), especially if exposed to stress (illness).
  • Patients on chronic treatment with corticosteroids, especially if exposed to stress or during a tapering of the corticosteroid dose.
  • Patients with other autoimmune endocrine deficiencies, such as type 1 diabetes mellitus, hypothyroidism, or gonadal failure.
  • Critically ill patients with septic shock, who are unresponsive to fluid resuscitation and inotropic medications (in this case, adrenal crisis can be caused by bilateral adrenal hemorrhage).
  • Other patients presenting with the above signs, especially those with hyperpigmentation or vitiligo.
Evaluation:
  • If adrenal crisis is suspected, then patients should be treated empirically with stress doses of glucocorticoids, as outlined below.
  • For patients without a preexisting diagnosis of adrenal insufficiency, draw baseline blood samples prior to the administration of glucocorticoids for subsequent testing for electrolytes, glucose, cortisol and other adrenal steroids (17-hydroxyprogesterone if CAH is suspected)*, ACTH, and plasma renin activity. Treatment with glucocorticoids can be initiated presumptively once blood samples are drawn. If the blood samples cannot be rapidly obtained and the patient is acutely ill, proceed immediately to treatment.
Treatment:
  • Shock – Give a bolus of normal saline (0.9%), 20 mL/kg IV over 1 hour. If shock is persistent, repeat up to a total of 60 mL/kg within 2 hours.
  • Hypoglycemia – Give an initial bolus of 0.5 to 1 g/kg of dextrose IV (maximum single dose 25 g). The glucose bolus is infused slowly, at 2 to 3 mL per minute.
  • For all age groups, this can be given as 25% dextrose solution (D25W), 2 to 4 mL/kg. (D25W is 250 mg dextrose/mL.)
  • An alternative for infants and children up to 12 years of age is to use 10% dextrose solution (D10W), 5 to 10 mL/kg. (D10W is 100 mg dextrose/mL.)
  • Stress glucocorticoids – Administer hydrocortisone (Solu-Cortef) as a bolus, using a dose of 50 to 100 mg/m2 IV.Δ If body surface area is not available, age-based dosing may be used as follows:
  • Infants and toddlers 0 to 3 years old – 25 mg IV.
  • Children 3 to 12 years – 50 mg IV.
  • Children and adolescents 12 years and older – 100 mg IV.
  • Continue glucocorticoids at the same dose given as a constant rate or as 4 divided doses over the following 24 hours. The subsequent dose and duration depend on the patient's clinical status.
  • Electrolytes – If hyperkalemia is present, perform EKG to evaluate:
  • EKG changes consistent with hyperkalemia – Initially a tall, peaked T wave with shortened QT interval, followed by progressive lengthening of the PR interval and QRS duration.
  • Hyperkalemia typically improves promptly with fluids and hydrocortisone therapy alone. Rarely, severe and symptomatic hyperkalemia requires emergency therapy (ie, IV calcium infusion followed by IV insulin and glucose infusion; refer to UpToDate topic on the management of hyperkalemia in children).
  • Monitor and treat other electrolyte abnormalities and fluid balance.
CAH: congenital adrenal hyperplasia; ACTH: adrenocorticotropic hormone (corticotropin); IV: intravenous; EKG: electrocardiogram; BSA: body surface area; IM: intramuscularly.
* Refer to UpToDate content on classic CAH due to 21-hydroxylase deficiency.
¶ Dosing based on BSA is preferred if the patient's BSA is known or if the BSA can be promptly calculated based on measured height and weight. A BSA calculator is available in the UpToDate program.
Δ Hydrocortisone also may be given IM if IV access is not readily available.
Graphic 61357 Version 28.0

آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟