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Case #48 Medical Mystery?


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#41 Flightgypsy

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Posted 22 August 2009 - 03:53 PM

Did they do a CBC, Mike?
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#42 Mike MacKinnon

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Posted 22 August 2009 - 04:16 PM

hehe

CBC all normal ;)


Someone mentioned giving steroid as they were concerned about Addisonian Crisis.

You Tx the Sz but the pts BP is dipping again (70/50)..

Your in the aircraft and the patch phone does not work.

What are the risks of giving a steroid? What are the benefits if this was Addisonian Crisis?

Do you do it, or not?
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Mike MacKinnon MSN CRNA
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#43 Speed

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Posted 22 August 2009 - 04:31 PM

I would go ahead and intubate the kid, but I would do it with a regimen that would (1.) Not reduce the cortisol level with the looming suspicion of adrenal insufficiency (replace Etomidate with whatever you prefer), and (2.) Not induce coma or anesthesia to the point initially where I couldn't absolutely say the seizures were controlled (airway control and seizure control simultaneously). I would also go ahead and form an aggressive care plan as to what we're gonna do if the seizures are refractory to the usual interventions. Once control was attained I'd go ahead with normal sedation or anesthesia end point goals for the trip. The adrenal insufficiency state sounds like it holds water so far, whether the "chicken came before the egg" probably isn't so important right now unless we decide to try steroids, what I mean if it's truly an isolated adrenal system problem or stemming from somewhere else like the brain or who knows where or what? It would be nice to rule out other things but as most here have pointed out we can do some general ICU supportive care to counter the majority of the problems for 45 minutes. We know our major threat now is shock and seizures, I'd be comfortable heading on once we've determined how easy or not it's going to be in controlling the seizures, maybe something hanging? We'll see I guess. Oh, and re-check the sugar at the bedside too.
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Mike Williams CCEMT-P/FP-C

#44 Speed

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Posted 22 August 2009 - 04:41 PM

hehe

CBC all normal ;)
Someone mentioned giving steroid as they were concerned about Addisonian Crisis.

You Tx the Sz but the pts BP is dipping again (70/50)..

Your in the aircraft and the patch phone does not work.

What are the risks of giving a steroid? What are the benefits if this was Addisonian Crisis?

Do you do it, or not?


Ah what timing, your online I guess. Sure, I'd go ahead and give some. If he has some underlying contraindication like an infection or whatever his state of shock and risks with that would trump the exacerbation of a fungal infection. If he's developing Cushing's we should see somewhere where he would have been on steroid treatment and a one-time dose compared to the days that he would have been on them shouldn't be detrimental compared to the risk of death from shock, nor a tumor in his brain. I'd check the sugar first again. If he's got just an adrenal problem it should stabilize him.
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Mike Williams CCEMT-P/FP-C

#45 RN_mike

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Posted 22 August 2009 - 11:05 PM

Mike as always great case and great place to learn.

As far as the precautions iof administering steroids are I believe lowering potassium levels. The benefit id resolving the corticosteroid deficiency. If it is Addison I would give the steroid.

Be gentle...

Thanks,
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Michael L. Howlin RN

#46 JClayborne

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Posted 23 August 2009 - 12:41 AM

His CBC in unremarkable and there was no mention of prior fever or illness. A systemic infection with sudden onset and without an elevated white count seems unlikely to me at this point. Therefore I would start corticosteroid administration, continue aggressive fluid resuscitation and titrate vasopressor therapy to maintain a decent pressure. If I were presented with this case I would give hydrocortisone. Id have to seriously consult with my partner and the IPOD touch before straying from the standard treatment here. However, if concerned about the accepting physician wishing to confirm the diagnoses beforehand we could consider dexamethasone if Im not mistaken.
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JClayborne, NREMT-P, FP-C

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#47 Mike MacKinnon

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Posted 23 August 2009 - 01:36 AM

So...


How much steroid?
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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

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It's what we know for sure that just ain't so" - Mark Twain

#48 RN_mike

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Posted 23 August 2009 - 01:43 AM

Solu-Cortef

1-2 mg/kg IV bolus; follow by 150-250 mg/d divided q6-8h

Mike
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Michael L. Howlin RN

#49 JClayborne

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Posted 23 August 2009 - 02:43 AM

Following a quick Epocrates consult, did I mention I don't know how I functioned without pre-IPOD, I agree with Mike. I would give 1-2 mg/kg.

Dose: 1-2 mg/kg IV x1, then 150-250 mg IV qd div q6-8h; Info: taper PO to maint. dose


Epocrates Reference
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JClayborne, NREMT-P, FP-C

"There are no lessons be to learned from the ones you save...no reason to remember. Lessons are taught by the ones you lose."
- Defying Gravity

#50 MSDeltaFlt

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Posted 23 August 2009 - 08:54 PM

hehe

CBC all normal ;)
Someone mentioned giving steroid as they were concerned about Addisonian Crisis.

You Tx the Sz but the pts BP is dipping again (70/50)..

Your in the aircraft and the patch phone does not work.

What are the risks of giving a steroid? What are the benefits if this was Addisonian Crisis?

Do you do it, or not?


I'm going to assume we're going with prednisolone, because with dexamethasone serious side effects are adrenal insufficiency, what we're treating in the first place. With Addisonian Crisis, this can benefit by increasing both BP and glucose levels. However, side effects include hypokalemia and serious side effects include Sz. If we give the steroid, we'll need to be extra careful and closely monitor any Sz activity.
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Mike Hester, RRT/NRP/FP-C
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#51 RN_mike

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Posted 25 August 2009 - 01:26 PM

Mike,
Any updates? Did we give the steroids? Also the last b/p we saw was 70/50 which needs to be corrected. I would give a fluid bolus and possibly start on a Dopamnie drip @ 5mcg/kg/min and titrate to effect. With the seizure controlled I would agree with Speed and treat for shock and transport.

Thanks,
Mike
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Michael L. Howlin RN

#52 Mike MacKinnon

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Posted 25 August 2009 - 02:37 PM

Bp begins to stabilize throughout flight. Pt is turning a corner.


Addisonian crisis is a medical emergency which must be Tx'd with steroid immediately.

Because the symptoms progress slowly, they are usually ignored until a stressful event like an illness or an accident causes them to become worse. This is called an addisonian crisis, or acute adrenal insufficiency. In most cases, symptoms are severe enough that patients seek medical treatment before a crisis occurs. However, in about 25 percent of patients, symptoms first appear during an addisonian crisis.

Symptoms of an addisonian crisis include

* sudden penetrating pain in the lower back, abdomen, or legs
* severe vomiting and diarrhea
* dehydration
* low blood pressure
* loss of consciousness

Left untreated, an addisonian crisis can be fatal.

Causes, incidence, and risk factors:
The two adrenal glands are located on top of the kidneys. They consist of the outer portion, called the cortex, and the inner portion, called the medulla. The cortex produces three types of hormones, all of which are called corticosteroids.

Cortisol is a glucocortoid, a corticosteroid that maintains glucose (blood sugar) regulation, suppresses the immune response, and is released as part of the body's response to stress. Cortisol production is regulated by a small gland just below the brain called the pituitary gland. Cortisol is essential for life.

Acute adrenal crisis is a medical emergency caused by a lack of cortisol. Patients may experience lightheadedness or dizziness, weakness, sweating, abdominal pain, nausea and vomiting, or even loss of consciousness.

Adrenal crisis occurs if the adrenal gland is deteriorating (Addison's disease, primary adrenal insufficiency), if there is pituitary gland injury (secondary adrenal insufficiency), or if adrenal insufficiency is not adequately treated.

Risk factors for adrenal crisis include physical stress such as infection, dehydration, trauma, or surgery, adrenal gland or pituitary gland injury, and ending treatment with steroids such as prednisone or hydrocortisone too early.

Symptoms:

* Headache
* Profound weakness
* Fatigue
* Slow, sluggish movement
* Nausea
* Vomiting
* Low blood pressure
* Dehydration
* High fever
* Shaking chills
* Confusion or coma
* Darkening of the skin
* Rapid heart rate
* Joint pain
* Abdominal pain
* Unintentional weight loss
* Rapid respiratory rate (see tachypnea)
* Unusual and excessive sweating on face and/or palms
* Skin rash or lesions may be present
* Flank pain
* Loss of appetite

Signs and tests:

* An ACTH (cortrosyn) stimulation test shows low cortisol.
* The baseline cortisol level is low.
* Fasting blood sugar may be low.
* Serum potassium is elevated ( usually primary adrenal insufficiency).
* Serum sodium is decreased (usually primary adrenal insufficiency).

Treatment:
In adrenal crisis, an intravenous or intramuscular injection of hydrocortisone (an injectable corticosteroid) must be given immediately. Supportive treatment of low blood pressure with intravenous fluids is usually necessary. Hospitalization is required for adequate treatment and monitoring. If infection is the cause of the crisis, antibiotic therapy may be needed.

Expectations (prognosis):
Death may occur due to overwhelming shock if early treatment is not provided.

Complications:

* shock
* coma
* seizures

Pathophysiology

The adrenal cortex produces 3 steroid hormones: glucocorticoids (cortisol), mineralocorticoids (aldosterone, 11-deoxycorticosterone), and androgens (dehydroepiandrosterone). The androgens are relatively unimportant in adults, and 11-deoxycorticosterone is a fairly weak mineralocorticoid in comparison with aldosterone. The primary hormone of importance in acute adrenal crisis is cortisol; adrenal aldosterone production is relatively minor.

Cortisol enhances gluconeogenesis and provides substrate through proteolysis, protein synthesis inhibition, fatty acid mobilization, and enhanced hepatic amino acid uptake. Cortisol indirectly induces insulin secretion to counterbalance hyperglycemia but also decreases insulin sensitivity. Cortisol exercises a significant anti-inflammatory effect by stabilizing lysosomes, reducing leukocytic responses, and blocking cytokine production. Phagocytic activity is preserved, but cell-mediated immunity is diminished, in situations of cortisol deficiency. Finally, cortisol facilitates free-water clearance, enhances appetite, and suppresses adrenocorticotropic hormone (ACTH) synthesis.

Aldosterone is released in response to angiotensin II stimulation via the renin-angiotensin-aldosterone system, hyperkalemia, hyponatremia, and dopamine antagonists. Its effect on its primary target organ, the kidney, is to promote reabsorption of sodium and secretion of potassium and hydrogen. The mechanism of action is unclear; an increase in the sodium- and potassium-activated adenosine triphosphatase (Na+/K+ ATPase) enzyme responsible for sodium transport, as well as increased carbonic anhydrase activity, has been suggested. The net effect is to increase intravascular volume. The renin-angiotensin-aldosterone system is unaffected by exogenous glucocorticoids, and ACTH deficiency has a relatively minor effect on aldosterone levels.

Adrenocortical hormone deficiency results in the reverse of these hormonal effects, producing the clinical findings of adrenal crisis.

Primary adrenocortical insufficiency occurs when the adrenal glands fail to release adequate amounts of these hormones to meet physiologic needs, despite release of ACTH from the pituitary. Infiltrative or autoimmune disorders are the most common cause, but adrenal exhaustion from severe chronic illness also may occur.

Secondary adrenocortical insufficiency occurs when exogenous steroids have suppressed the hypothalamic-pituitary-adrenal (HPA) axis. Too rapid withdrawal of exogenous steroid may precipitate adrenal crisis, or sudden stress may induce cortisol requirements in excess of the adrenal glands' ability to respond immediately. In acute illness, a normal cortisol level may actually reflect adrenal insufficiency because the cortisol level should be quite elevated.

Bilateral massive adrenal hemorrhage (BMAH) occurs under severe physiologic stress (eg, myocardial infarction, septic shock, complicated pregnancy) or with concomitant coagulopathy or thromboembolic disorders.
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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#53 Flightgypsy

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Posted 25 August 2009 - 09:38 PM

Another interesting case, thanks Mike! More fun learning through these than reading textbooks.

Good pick up, Philmoney!
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#54 Mike MacKinnon

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Posted 25 August 2009 - 11:32 PM

Yes excellent pickup!

Well done everyone great questions and ideas!

Next case Sept 15th!
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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#55 PhilMoney

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Posted 26 August 2009 - 04:53 AM

Another interesting case, thanks Mike! More fun learning through these than reading textbooks.

Good pick up, Philmoney!


Ha! Thanks Gypsy. I will give credit where it is due and say that I was spit-balling with some co-workers here in OR and throwing stuff at the wall to see what would stick. Im glad to finally have the "juevos" to post and not just admire from a distance. I definently had to look up some of the steroid doses and some of the stuff Mike posted in the summary.

Thanks to Mike for stimulating some grey matter.

See you guys in Sept.

MP.
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Matt P. B.S., A.S., CCEMT-P, FP-C

#56 medic4cqb

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Posted 26 August 2009 - 06:55 PM

Thanks Mike, keep 'em coming! Nice job PhilMoney!
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Steve A., RN, CCRN, EMT-P

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#57 blackdog21

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Posted 06 September 2009 - 01:15 AM

I would go ahead and intubate the kid, but I would do it with a regimen that would (1.) Not reduce the cortisol level with the looming suspicion of adrenal insufficiency (replace Etomidate with whatever you prefer), and (2.) Not induce coma or anesthesia to the point initially where I couldn't absolutely say the seizures were controlled (airway control and seizure control simultaneously). I would also go ahead and form an aggressive care plan as to what we're gonna do if the seizures are refractory to the usual interventions. Once control was attained I'd go ahead with normal sedation or anesthesia end point goals for the trip. The adrenal insufficiency state sounds like it holds water so far, whether the "chicken came before the egg" probably isn't so important right now unless we decide to try steroids, what I mean if it's truly an isolated adrenal system problem or stemming from somewhere else like the brain or who knows where or what? It would be nice to rule out other things but as most here have pointed out we can do some general ICU supportive care to counter the majority of the problems for 45 minutes. We know our major threat now is shock and seizures, I'd be comfortable heading on once we've determined how easy or not it's going to be in controlling the seizures, maybe something hanging? We'll see I guess. Oh, and re-check the sugar at the bedside too.


I wouldn't be overly concerned about a single dose of etomidate to facilitate intubation re: adrenal insufficiency. I agree, though, that long term neuromuscular blockade does not allow us to monitor seizure activity. So, I would choose the shortest acting paralytic I have ... recognizing he is hyperkalemic. Then opt for benzos ... as BP allows, for sedation and seizure control.
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#58 Speed

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Posted 08 September 2009 - 06:49 PM

I wouldn't be overly concerned about a single dose of etomidate to facilitate intubation re: adrenal insufficiency.


True, it's just my personal attitude and logic towards the practice in my approach. I can stand outside my own mind and say I agree and you are correct, it's more of a supposed, rhetorical, and circular debate in liability and what I call "Ok, good, better, and best practice". Semantics and court rooms, not so much clinical.
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Mike Williams CCEMT-P/FP-C