Mon22November1200AM 8

A young adult is brought in by ambulance clinically in 'shock'. Little is known about the patient as he was found collapsed outside on the street.

The patient appears to be very slim, and is caucasian but has patches of hyperpigmentation and extensive vitiligo.

Blood pressure is 67/40 mmHg, heart rate 135/min, temperature 38C, sats 92% on air. Glasgow coma scale is E2, M4, V4. Capillary refill time is prolonged at four seconds. Blood glucose is 2 mmol/L.

Chest x ray shows a left sided consolidation. ECG shows sinus rhythm with peaked T waves.

Blood results reveal:

Hb 130 g/L

WCC 14.2 x109/L

Platelets 400 x109/L

Na 131 mmol/L

K 6.4 mmol/L

Urea 9 mmol/L

Creatinine 170 umol/L

You agree that the patient is in 'shock' and dehydrated.

Which of the following interventions should be administered after starting crystalloid fluid resuscitation?

(Please select 1 option)

Intravenous hydrocortisone Correct

Intravenous antibiotics

Intravenous dextrose 10%

Intravenous thyroxine

Noradrenaline

Explanation

Addisonian crisis presents with signs of septic shock, but there may be no infection, or the signs are disproportionate to the underlying infection.

This may well be the presentation of a previously undiagnosed patient with primary adrenal insufficiency. The trigger is likely to be the chest sepsis acting as a source of physiological stress.

The profound hypotension is the result of volume depletion secondary to aldosterone deficiency. This is reflected in the blood tests with hyponatraemia and the patient often has a 'salt craving'. Hyperpigmentation is a characteristic finding and a result of cortisol deficiency. Vitiligo is a recognised to be associated with autoimmune diseases such as Addison's disease.

Treatment is largely supportive and treatment of the underlying physiological stress, in this case the chest infection. However, the primary mode of management ought to be replacement of the glucocorticoid and this should not be delayed. Dexamethasone or hydrocortisone may be used intravenously. Dexamethasone will not interfere with blood samples taken for cortisol, renin and ACTH.

Answer Statistics

1

73%

2

9%

3

18%

4

1%

5

2%

Times answered: 277