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3. Adrenal cortex
Zona Glomerulosa
Zona Fasciculata
Zona Reticularis
Mineralocorticoids
Glucocorticoids
Sex steroids
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5. Stress
Situation that upsets homeostasis and
threatens one’s physical or emotional well-
being
Physical stressors
− injury, surgery, hemorrhage,
infection,intense exercise, temperature
extremes, pain, and malnutrition
Emotional stressors
− anger, grief, depression,anxiety, and
guilt
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6. Stress response or general
Adaptation Syndrome (GAS)
elevated levels of epinephrine and
glucocorticoids,especially cortisol
Alarm reaction
Stage of resistance
Stage of exhaustion
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7. The Alarm Reaction
Norepinephrine - sympathetic nervous
system
Epinephrine - Adrenal medulla
Fighting or escaping danger
Uses stored glycogen
Angiotensin raise the blood pressure
Aldosterone promotes sodium and water
conservation
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8. The Stage of Resistance
Glycogen reserves exhausted
Alternative fuels for metabolism
This stage is dominated by cortisol
Cortisol - breakdown of fat and protein into
glycerol, fatty acids, and amino acids –
gluconeogenesis
Glucose-sparing effect
Inhibits protein synthesis
Long Term Effects???www.indiandentalacademy.com
10. The Stage of Exhaustion
Fat depleted
Protein breakdown – energy
Hypertension
Hypokalemia
Alkalosis
resulting in nervous and muscular system
dysfunctions
Death frequently results from heart failure,
kidney failure, or overwhelming infectionwww.indiandentalacademy.com
13. Factors • Stress (trauma, surgery, infection, or
prolonged fasting) in a patient with latent
insufficiency
• Sudden withdrawal of adrenocortical
hormone in a patient with chronic
insufficiency or in a patient with
temporary insufficiency due to
suppression by exogenous corticosteroids
• Bilateral adrenalectomy or removal of a
functioning adrenal tumor that had
suppressed the other adrenal
• Sudden destruction of the pituitary gland
(pituitary necrosis), or when thyroid
hormone is given to a patient with
hypoadrenalism
•
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15. RULE OF TWO :
ADRENAL SUPPRESSION SUSPECTED ,
Dose of 20 mg or more
Via oral or parenteral route for a continuous period of 2
weeks
Within 2 years of dental therapy
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20. Signs • Confusion or coma
• Fever ≥ 40.6 °C
• Collapse
• Bradycardia
• Hypotension
• Recurrent hypoglycemia and reduced
insulin requirements in patients with
preexisting type 1 diabetes mellitus
• Vomitting
• Cyanosis, dehydration, skin
hyperpigmentation, and sparse axillary
hair (if hypogonadism is also present)
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21. LaboratoryFindings • ↑ Eosinophil count
• Hyponatremia or hyperkalemia (or
both)
• Hypoglycemia
• Hypercalcemia
• Blood, sputum, or urine culture may
be positive if bacterial infection is the
precipitating cause of the crisis
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22. DIAGNOSIS
INSULIN TOLERANCE TEST
-GOLD STANDARD,TESTS HPA
AXIS
PROLONGED ACTH STIMULATION
TEST
CORTICOTROPIN RELEASING
HARMONE STIMULATION TEST
BASELINE CORTISOL LEVELS
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23. Diagnosis • Simplified cosyntropin stimulation test
− Parenteral Synthetic ACTH1–24
(cosyntropin), 0.25 mg
− Serum is obtained for cortisol (30 to 60
minutes later)
− Normally, serum cortisol rises to at least 20
mcg/dL
− [For patients receiving corticosteroid
treatment, hydrocortisone must not be given
for at least 8 hours before the test. Other
corticosteroids (eg, prednisone,
dexamethasone) do not interfere with
specific assays for cortisol]
• Plasma ACTH is markedly elevated if the
patient has primary adrenal disease (generally >
200 pg/mL)www.indiandentalacademy.com
24. DifferentialDiagnosis
• Other causes of shock
− septic, hemorrhagic, cardiogenic
• Hyperkalemia {gastrointestinal bleeding,
rhabdomyolysis, hyperkalemic paralysis, and
certain drugs (eg, ACE inhibitors,
spironolactone)}
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25. DifferentialDiagnosis • Acute adrenal insufficiency must be
distinguished from an acute abdomen in
which neutrophilia is the rule, whereas
adrenal insufficiency is characterized by a
relative lymphocytosis and eosinophilia
• Hyponatremia (hypothyroidism, diuretic
use, heart failure, cirrhosis, vomiting,
diarrhea, severe illness, or major surgery)
• Acute adrenal insufficiency must be
distinguished from an acute abdomen in
which neutrophilia is the rule, whereas
adrenal insufficiency is characterized by a
relative lymphocytosis and eosinophilia
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26. PREVENTION
Good history.
Awareness of the condition treated with
steroids.
Mild stress – Double daily dose.
Moderate stress – 100 mg
hydrocortisone.
Severe stress – 200 mg hydrocortisone.www.indiandentalacademy.com
27. ASOS RECOMMENDATION
Previously on cortisole for 6 months but presently
off – No supplementation.
Received steroids for more than 1 year but off for 1
year – No supplementation.
Recent course for 1 week – 200 mg Orally day
before surgery, 100 mg Orally postoperatively, 100
mg day after surgery.
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28. Management
• Lay the patient flat with legs raised
• I.V. Hydrocortisone 200mg
• Summon medical assistance
• Take Blood for glucose and electrolyte
estimation
• Glucose (25g oral or i.v.) if hypoglycemic
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29. Management
• I.V. infusion of normal saline or glucose-saline
− 1 litre (2 hour) with 200mg hydrocortisone sodium succinate
[repeat 4-6 hourly intervals]
• Monitor Blood Pressure
• Correct hyperthermia
− Initiate cooling measures
• Determine and deal with underlying cause
• Control of Pain and infection
• Steroid supplementation for atleast 3 days after
BP has returned to normal
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30. Treatment
• Since bacterial infection frequently precipitates
acute adrenal crisis, broad-spectrum
antibiotics should be administered
empirically while waiting for the results of
initial cultures
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31. UNCONSCIOUSNESS
Supine Position
Syncope - Recovery
No [Check Carotid Pulse]
Present [Sugar]
Absent – Cardiac Arrest
CPRHypoglycaemia - Recovery No [100mg Hydrocortisone]
Acute Adrenocortical Insifficiency - Recovery
No [EMS]
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33. Prognosis
• Rapid treatment will usually be life-saving
• Acute adrenal insufficiency is frequently
unrecognized and untreated since its
manifestations mimic more common conditions
• Lack of treatment leads to shock that is
unresponsive to volume replacement and
vasopressors, resulting in death
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34. Bibliography
•
Saladin: Anatomy & Physiology: The Unity of Form and Function, Third
Edition
•
Essentials of Anatomy & Physiology; Valerie C. Scanlon, Fifth Edition
•
Netter Atlas of Physiology
•
Current Medical Diagnosis and Treatment 2009 (McGraw-Hill, 2008)
•
Rosen.and.Barkins.5-Minute.Emergency.Medicine.Consult.(2007),.3Ed
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Notas del editor
Meningococcemia may be associated with purpura and adrenal insufficiency secondary to adrenal infarction (Waterhouse–Friderichsen syndrome)