I recently read an article published in European Society of Endocrinology. It was one of the best articles I have read, by a Professor of Medicine that actually listened to his patients. He also knew several AI patients personally, including several Doctors.
This article made me think about my post on Low Cortisol or an Adrenal Crisis.
I haven’t changed my thoughts on what the differences are. Having read the article, I have reviewed my thoughts on what an Adrenal Crisis is.
According to a medical definition a crisis is:
“a sudden paroxysmal intensification of symptoms in the course of a disease”
When you look at this definition of the word Crisis, if you have symptoms that require more than just a slight bump in cortisol, then can you may be “In Crisis”.
Frequently there is discussion about someone saying they are “In Crisis”, or have just had a “Crisis”, but they didn’t go to hospital or they weren’t on life support in ICU. There is then discussion on whether they were or were not in “True Crisis”.
For a while I have been a proponent of the term “Pre-Crisis” to counter this situation, a “Pre-Crisis” being a situation where you need much higher than normal stress dosing, i.e. the need for an injection or 50-100mg HC via tablet, but you can manage at home, or go to the emergency room, but are released, not admitted to hospital.
In my previous post Low Cortisol or an Adrenal Crisis – learning the difference I created a chart showing the low cortisol symptoms, and the Adrenal Crisis symptoms, and where they met.
After that I read the article by Professor Bruno Allolio, Professor of Medicine at the University of Würzburg.
His article doesn’t change what my chart says are the symptoms of a Crisis vs Low Cortisol, but it changes what my belief of a Crisis is.
Professor Allolio opens his article with:
“This narrative review on adrenal crisis is based on personal experience, own research, and comprehensive evaluation of the literature. It aims at contributing to more effectively combat morbidity and mortality from adrenal crisis.”
I won’t quote the whole article here, but will link it.
One of the key findings was:
“Definition of adrenal crisis:
When we planned a prospective study on the incidence of adrenal crisis in patients with known adrenal insufficiency, we realised the need to define what actually constitutes an adrenal crisis. However, we found neither a textbook nor a paper providing such a definition, leaving us with the task to generate our own definition. We then decided to define adrenal crisis as a profound impairment of general health and at least two of the following conditions: hypotension (systolic blood pressure <100 mmHg), nausea or vomiting, severe fatigue, hyponatraemia, hypoglycaemia and hyperkalaemia, triggering subsequent parenteral glucocorticoid administration. However, it turned out that in our prospective study hyponatraemia or hyperkalaemia contributed very little to the case finding.“
If the Dr’s doing this research could not find amongst the thousands of documents they have access to, a clearly defined and accepted definition of a Crisis, how are those suffering AI supposed to know what one is. It has always been considered to be a near death experience.
When you go to hospital, you are not considered to be in crisis by many Dr’s unless you are already suffering what can only be termed Hypovolemic Shock (HS). They may even take your Cortisol levels and say they are not low enough so you can’t be in crisis. They ignore the fact you have been stress dosing for quite some time before you get there, so of course there will be cortisol in your blood so how can you be in crisis. I use the term Hypovolemic Shock because all the symptoms match what is clearly defined as HS.
My concern is always, if you are left until you are in Hypovolemic Shock, then you have probably already done damage to your body and it will take a lot longer to recover. You are also in imminent danger of stroke, heart attack, or death. If you leave yourself to get that bad, or worse, your Doctors leave you until you get to this stage, then each crisis is causing more damage, and you will then be more susceptible to crisis. It also takes longer to recover after each crisis. Even needing just 1 emergency injection can take a week to recover.
So what was Prof Allolio’s solution to this?
He created a Medical Definition of an Adrenal Crisis. This has yet to be accepted generally, but we need to get it out there. Instead of stating that the crisis was ONLY when in HS, he has graded Crisis’ to be multi-level.
As you can see from above, he has stated that you only need TWO of the signs/symptoms. He has also suggested that the outcome after parenteral hydrocortisone is administered with clinical improvement will indicate if it was a crisis. The symptoms and outcome of the administration of parenteral steroids, changes the GRADE of a Crisis. However each one of these Grades is still classified as a Crisis.
Let me give an example.
When Derek went to hospital in 2014, he had been suffering low cortisol symptoms. We needed to get him seen because we knew that the symptoms he was showing normally meant that he had an infection of some description. He wasn’t actually showing signs of an infection but symptoms of low cortisol that were not improving with stress doses of oral Hydrocortisone.
We had tried updosing and stress dosing the previous day, and then a full days dosage on top of his morning dose, but it had not worked.
When we first reported to the Emergency Room of the hospital we did not say he was in Crisis as we didn’t believe he was at that point. What I did do was ask the Triage nurse what would happen if he went into crisis while waiting to be seen.
I didn’t know at what point I would consider him to be in crisis and therefore need an emergency injection, but I knew to watch out for symptoms. I had always had it drummed in to me that he would not be in crisis until he had multiple symptoms including low sodium, extremely low BP, vomiting that won’t stop, and diarrhea. anything less was just requiring stress dosing.
So when he suddenly needed to lay down (only 2 hours after 30mg of HC), and had trouble keeping his eyes open, we knew he was in trouble.
He didn’t feel sick, he didn’t have hypoglycemia, his sodium and potassium were in range although lower than his normal. We know this because they checked all these things out once he finally got back into a cubical. We Know his Normal for all his bloods, bp, temp, heart rate etc.
However, in the 30 minutes from him needing to lay down and close his eyes to getting the bloods, things had changed. His BP had started falling on standing (it had been slightly above his normal when he arrived at ED), and he was beginning to feel nauseous.
As soon as he said that, I pulled out his emergency letter and got some action. To me, he was either going into, or was already in, Adrenal Crisis. If he didn’t have 100mg HC urgently, he would continue to spiral downhill. what he was saying didn’t match with our conversation. He couldn’t focus on questions, he could only give yes and no answers.
According to some people (Dr’s included) this would not be classed as a “True Adrenal Crisis”, however, he was given 200mg HC (as per his emergency instructions). When he first presented to the Triage Nurse he had complained of severe upper abdominal pain, which radiated through the chest, and over the shoulder.
When the Dr first checked him, she was very suspicious of a Gallbladder issue because of this pain. The Dr came in 15 minutes later to see a completely different patient in the cubical, 90% of the pain had gone, he was sitting up talking, he no longer felt sick, basically, he was no longer at serious risk of hypovolemic shock.
He had met Prof Allolio’s criteria of
Definition A: at least two of the following signs/symptoms:
Hypotension (systolic blood pressure <100 mmHg);
Nausea or vomiting;
Hyponatraemia (<132 mmol/l). (Derek met the 3 highlighted symptoms).
Again it was about knowing your own normal. Although Derek’s sodium wasn’t below 132, it was clearly lower (by 5 points) than his normal.
He also met Definition B:
Parenteral glucocorticoid (hydrocortisone) administration followed by clinical improvement.
Derek’s medical records of that admission to hospital state he was in crisis. Whether he was a Grade 1 or Grade 2 we won’t know because he was kept in over night due to the fact they didn’t know why he went into crisis and didn’t want to send him home without an explanation. It turned out to be pneumonia, but in the very early stages. We now know that Derek’s first sign of pneumonia is always going into crisis. (it’s happened 3 times) No fever, no coughing, just rapid onset of a crisis.
So what’s the point of the Change?
If you look at the diagram I put up recently about the difference in symptoms between a Crisis and Low cortisol, it doesn’t change. I have added next to it, Professor Allolio’s Definition and Grading of Adrenal Crisis.
What has changed is the number of symptoms you need before you are classed as being in Crisis. Also Prof Allolio says that you BP only has to drop to <100 Systolic. For some, this is the norm, but for those with a normal stable BP, or high BP, you don’t have to wait until you are <90 (which is becoming dangerous). Again you need to know your own normal.
If there is any change in the amount of steroid you need, and a stress dose won’t cut it, then as long as you have 2 or more of the symptoms of Adrenal Crisis, YOU ARE IN CRISIS. It may be a Grade 1, but it is still a Crisis, and still needs urgent treatment. If you can manage at home, do so, but don’t underestimate the seriousness of this. Don’t be afraid to take a very large dose of HC (>50mg) either orally, if you can keep it down, or IM if you think you either won’t absorb it, or will throw it back up. DON’T WAIT!!!!
Treat and Street
I don’t know about you, but personally I would prefer Derek be “Treated and Street’d” for a Grade 1 crisis, than left to hit Grade 4 where the Professor states :
”As has been pointed out….., there exists ‘a point of no return’ where even optimum patient care will no longer avert death from adrenal crisis.”
Are you in adrenal crisis when you are conscious, not vomiting, and your blood pressure is around 95/60? Yes, but only a Grade 1 or 2. This doesn’t mean don’t treat it seriously, it means you have time to act, before it gets to Grade 3, or worse, Grade 4.