Transcript Adrenal Protocol - Southern Nevada Health District

ADRENAL INSUFFICIENCY
Office of Emergency Medical Services
& Trauma System
About This Presentation
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This presentation is intended for EMTs of all
certification levels. We recommend that you review
the slides from start to finish, however hyperlinks
are provided in the table of contents for fast
reference. Certain slides have additional
information in the ‘notes’ section.
This presentation was created by MA EMS for
Children using materials and intellectual content
provided by sources and individuals cited in the
“Resources” section.
Table of Contents
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Objectives
Anatomy & Physiology
Epidemiology
Presentation
Management
Medication Profiles
Protocol Updates
Resources
OBJECTIVES
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At the end of this program, EMTs will have
increased awareness of:
 Epidemiology
 Anatomy & Physiology
• Pathophysiology
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Presentation
• Signs & Symptoms
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Treatment
• Family-centered care
• Effective medications
Adrenal Anatomy &
Physiology
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The adrenals are endocrine organs that sit on top of
each kidney
Adrenal Anatomy &
Physiology
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Each adrenal gland has two parts
 Adrenal Medulla (inner area)
• Secretes catecholamines which mediate stress
response (help prepare a person for
emergencies).
• Norepinephrine
• Epinephrine
• Dopamine
Adrenal Anatomy &
Physiology
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Adrenal Cortex (outer area, encloses Adrenal
Medulla)
 Secretes steroid hormones
• Glucocorticoids: exert a widespread effect on
metabolism of carbohydrates and proteins
• Mineralocorticoids: are essential to maintain
sodium and fluid balance
• sex hormones (secondary source)
Adrenal Anatomy &
Physiology
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A person can survive without a functioning
adrenal medulla
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A functioning adrenal cortex (or the steady
availability of replacement hormone) is
essential for survival
The Essential Steroids
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Primary glucocorticoid:
 Cortisol (a.k.a. hydrocortisone)
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Primary mineralocorticoid:
 Aldosterone
Cortisol
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A glucocorticoid
Frequently referred to as the ‘stress
hormone’
 Released in response to physiological or
psychological stress
• Examples: exercise, illness, injury,
starvation, extreme dehydration,
electrolyte imbalance, emotional
stress, surgery, etc.
Cortisol
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Critical actions on many physiologic systems,
including:
 Maintains cardiovascular function
 Provides blood pressure regulation
 Enables carbohydrate metabolism
• acts on the liver to maintain normal
glucose levels
 Immune function actions
• Reduces inflammation
• Suppresses immune system
Cortisol
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When cortisol is not produced or released
by the adrenal glands, humans are unable to
respond appropriately to physiologic
stressors
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Rapid deterioration resulting in organ
damage and shock/coma/death can occur,
especially in children
Aldosterone
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A mineralocorticoid
Regulates body fluid by influencing sodium
balance
The human body requires certain amounts
of sodium and water in order to maintain
normal metabolism of fats, carbohydrates
and proteins
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Water/sodium balance is maintained by
aldosterone
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Without aldosterone, significant water and
sodium imbalances can result in organ
failure/death
Why we need cortisol
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Cortisol has a necessary effect on the
vascular system (blood vessels, heart) and
liver during episodes of physiologic stress
Who has Adrenal Insufficiency?
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Anyone whose adrenal glands have stopped
producing steroids as a result of:
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Long-term administration of steroids
Pituitary gland problems or tumor
Head trauma
Loss of circulation to adrenals/removal of tissue
Auto-immune disease
Cancer and other diseases (TB and HIV may cause)
Adrenal Insufficiency
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Can occur from long-term administration of
steroids (over-rides body’s own steroid
production) Examples:
Organ transplant patients
 Long-term COPD
 Long-term Asthma
 Severe arthritis
 Certain cancer treatments
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Why?
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Adrenal glands tend to get ‘lazy’ when
steroids are regularly administered by
mouth, I.M. injection or I.V. infusion
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To illustrate how quickly…Just 2-4 weeks of
daily oral cortisone administration is
sufficient to cause the adrenals to be slightly
less responsive to stressors
Primary Adrenal Insufficiency =
Addison’s Disease
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The adrenal glands are damaged and cannot
produce sufficient steroid
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80% of the time, damage is caused by an autoimmune response that destroys the adrenal cortex
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Addison’s can affect both sexes and all age groups
Congenital Adrenal Hyperplasia
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There is also an inherited form of adrenal
insufficiency (CAH)
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Diagnosed by newborn screening; prior to successful
screening techniques most children died
Daily replacement oral hormones are required at a
maintenance dose for LIFE
I.M. or I.V. hormones necessary for stressors (illness,
surgery, fever, trauma, etc.)
Vascular Reactivity
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In adrenally-insufficient individuals
experiencing a physiologic stressor, the
vascular smooth muscle will become nonresponsive to the effects of norepinephrine
and epinephrine, resulting in vasodilation
and capillary ‘leaking’
The patient may be unable to maintain an
adequate blood pressure
The blood vessels cannot respond to the
stress and will eventually collapse
Energy Metabolism
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In adrenally-insufficient individuals under
increased physiologic stress, the liver is
unable to metabolize carbohydrates
properly, which may result in profoundly
low blood sugar that is difficult to reverse
without administration of replacement
cortisol
Adrenal Insufficiency
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The speed at which patient deterioration
occurs is difficult to predict and is related to
the underlying stressor, patient age, general
health, etc.
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Young children can be at high risk for rapid
deterioration, even when experiencing a
‘simple’ gastrointestinal disorder
How Many in NV have some
form of Adrenal Insufficiency?
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Short answer: we don’t really know
The CARES Foundation estimates that the number
of adrenally-insufficient persons in NV is more than
1,300 not including visitors to the state.
Numbers will most likely continue to increase as the
number of successful organ transplants increases.
Many children are being diagnosed with severe
asthma, which increases the likelihood of long-term
steroid use. Better screening tools allow CAH
infants to survive to adulthood.
Endocrinologist Testimony…
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“rapid therapy with intravenous glucocorticoid is a
critical, life-saving intervention in patients with
adrenal insufficiency in the midst of a medical
emergency. Its absence will leave any EMS support
rendered by the response team incomplete and
inadequate”
Support letter, Dr. W. Reid Litchfield, President, Nevada Chapter
of the American Association of Clinical Endocrinologists,
2/12/2009
CARES EMS Campaign Video
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Click the link to view the video:
http://documents.virtuoso.com/cares/cares_jessica
_master_5_med_prog.wmv
Presentation of Adrenal Crisis
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The patient may present with any illness or injury
as the precipitating event
A patient history of adrenal insufficiency warrants a
careful assessment under specific protocols
Children may deteriorate into adrenal crisis from a
simple fever, a gastrointestinal illness, a fall from a
bicycle or some other injury
A mild illness or injury can easily precipitate an
adrenal crisis in any age group
Critical Clinical Presentation
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The early indicators of an adrenal-crisis onset can
be vague and non-specific. Some or all
signs/symptoms may be present.
Infants:
 Poor appetite
 Vomiting/diarrhea
 Lethargy/unresponsive
• Unexplained hypoglycemia
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Seizure/cardiovascular collapse/death
Critical Clinical Presentation
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Older Children/Adults
 Vomiting
 Hypotensive, often unresponsive to fluids/pressors
• Pallor, gray, diaphoretic
Hypoglycemia, often refractory to D50
 May have neurologic deficits
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• Headache/confusion/seizure
• Lethargy/unresponsive
Cardiovascular collapse
 Death
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Critical Clinical Presentation
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Clearly, the signs/symptoms of adrenal crisis are
similar to other serious shock-type presentations.
For these patients, standard shock management
requires supplementation with corticosteroid
medication.
It is important to ANTICIPATE the evolution of an
adrenal crisis and medicate appropriately under the
specific protocols. Do not wait until a full adrenal
crisis has developed. Organ damage or death
may result from delays.
Patient Management
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Follow standard ABC and shock management
treatment.
BLS: Transport without delay
ILS/ALS: administer patient’s own steroid IM/IV/IO
as soon as possible after initial life-threat and shock
management have been initiated
 Transport without delay to appropriate
hospital with early notification
Patient Management
It is important to note that you are caring for a patient
with multiple issues:
1. The precipitating event (a trauma/illness that may
be a critical issue on its own)
and
2. The evolution towards adrenal crisis, which will
result in organ failure/death if not reversed
Patient Management
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Administration of steroid medication should
come as soon after appropriate A-B-C
assessment and interventions as possible
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Your emergency management priorities
remain the same, with the addition of
steroid administration
Clark County EMS Protocol
Update
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This phrase has been added to the “Foreword” of the
Clark County BLS/ILS/ALS Protocols concerning the
administration of a patient’s own medications which
are not part of the approved formulary :
 “ (NOTE: telemetry contact is not required for the
administration of the patient’s own Solu-Cortef in
the treatment of adrenal insufficiency). “
Many adrenally-insufficient patients carry an
emergency Act-O-Vial of Solu-Cortef
Profile: Solu-Cortef
Trade name: Solu-Cortef
Generic name: hydrocortisone sodium
succinate
Class:
corticosteroid, Pregnancy Class C
Mechanism: acts to suppress
inflammation; replaces
absent glucocorticoids, acts to
suppress immune response
Solu-Cortef
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Side Effects: in emergency use, transient
hypertension and/or headache,
sodium/water retention may occur. Not
usual in a 1-time dose
Dosage: Adult:
100 mg IV, IM, IO
Pediatric: 2 mg/kg to a max of
100 mg, IV, IM, IO
Solu-Cortef
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Administration route: IM or slow IV bolus. Give IV
bolus over 30 seconds. IV infusion is not
acceptable for emergency administration
For young children, the preferred IM site is the
vastus lateralis muscle
Solu-Cortef
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How supplied: self-contained Act-O-Vial
Dry powder is in the lower of a two-chambered
vial. Diluent is in upper chamber.
Do not reconstitute until ready to use
Using Act-O-Vial
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Press down on plastic activator to force diluent into
the lower compartment
Gently agitate to effect solution
Remove plastic tab covering center of stopper
Swab top of stopper with a suitable antiseptic
Insert needle squarely through centre of plungerstopper until tip is just visible. Invert vial and
withdraw the required dose.
Solu-Cortef
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Onset of action: for the indicated use
(emergency steroid replacement in patient
experiencing stressor) the onset of action is
minutes. Do not delay transport.
Special thanks to MA Department of
Public Health for Developing and
Sharing this Program
Dr. Jon Burstein, OEMS staff, and especially:
Deborah Clapp, EMT-P, Program Manager
EMS for Children
MA Dept of Public Health
250 Washington Street 4th floor
Boston MA 02108
617-624-5088
[email protected]
Heartfelt Appreciation…
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…is extended to the many people whose hard work helped
make this protocol change possible, including:
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Gretchen Alger Lin, CARES Foundation
Julie Tacker and son Bryce (NV CAH family advocates)
Southern NV endocrinologists: Drs. Asheesh Dewan, W. R.
Litchfield, Lewis Morrow, Alan Rice, Rola J. Saad, and
Sterling M. Tanner; and nurse practitioner Cathy Flynn
American Association of Clinical Endocrinologists-NV
Chapter
SNHD Office of EMS & Trauma System staff and Medical
Advisory Board members
Resources
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CARES Foundation (www.caresfoundation.org)
Review of Medical Physiology 17th edition. Ganong, William F.,
Appleton & Lange
Dr. W. R. Litchfield, President, NV Chapter of the American
Association of Clinical Endocrinologists, letter of support to
SNHD Medical Advisory Board; 2/12/09
Phone conference, Pfizer pharmacist, 2/25/10
Prescribing Information, Solu-Cortef, Sept 2009 Pharmacia &
Upjohn (division of Pfizer)
Prescribing information, Solu-Medrol, 2009, Pfizer
Clark County EMS System BLS/ILS/ALS Protocols
Resources, continued
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“Management of Adrenal Crisis, How Should Glucocorticoids
Be Administered?” Stanhope, et al, Journal of Pediatric
Endocrinology Vol 16, Issue 8 pp 99-100
“Mortality in Canadian Children with Growth Hormone
Deficiency Receiving GH Therapy 1967-1992” Taback, et al,
Journal of Clinical Endocrinology & Metabolism Vol 81, #5 pp
1693-1696
Support petition, MA pediatric endocrinologists, 12/ 12/09,
Medical Services Committee, on file, OEMS
Personal communication, letters of support (Luedke, Smith,
Clifford, Dubois, Bradley) Medical Services Committee
12/12/09, on file, OEMS