SAQ 383 – Endocrinology – Addisonian crisis after vomiting

Endocrinology – Addisonian crisis after vomiting.

a. Diagnosis and rationale

• Addisonian/adrenal crisis.
• Rationale: known steroid dependence with intercurrent illness and a consistent presentation of refractory shock, hypoglycaemia, non-anion gap metabolic acidosis, and hyponatraemia.

b. VBG components

• Anion gap = Na – Cl – HCO3 = 123 – 100 – 16 = 7, consistent with non-anion gap metabolic acidosis.
• Critical hypoglycaemia.
• Moderate hyponatraemia.

c. Treatments

• Correct hypoglycaemia, for example 50 mL of 50% dextrose IV.
• Give IV steroid: hydrocortisone 100 mg IV or dexamethasone 4-8 mg IV.
• Further IV normal saline bolus, then reassess.
• If persistent shock, start noradrenaline infusion 5-10 microg/min aiming systolic BP above 100 mmHg, MAP above 65, or improved end-organ perfusion.
• Give broad-spectrum antibiotics if sepsis is possible, for example a reasonable regimen covering sepsis or intra-abdominal sepsis.

d. Prevention

• Increase steroid dosing during physiological stress or illness, such as doubling or tripling oral steroids according to sick-day management.