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Difficulty: EasyInitial Stabilization and Triage

A 42-year-old woman is brought to the emergency department due to profound weakness, vomiting, and confusion. She has a history of systemic lupus erythematosus and has taken daily oral prednisone for the past 5 years. However, she ran out of her medication one week ago. Two days ago, she developed nausea, vomiting, and diarrhea. Her temperature is 37.8°C (100°F), heart rate is 125/min, respiratory rate is 22/min, and blood pressure is 70/40 mmHg. Physical examination reveals a lethargic and diaphoretic patient. Laboratory results show:

TestResult
Sodium128 mEq/L
Potassium5.8 mEq/L
Glucose55 mg/dL

Which of the following are the most appropriate immediate stabilization steps for this patient? (Select 2)

  1. Rapid intravenous administration of isotonic fluids containing dextroseAnswer
  2. Intravenous administration of high-dose hydrocortisoneAnswer
  3. C
    Performance of a cosyntropin (adrenocorticotropic hormone) stimulation test
  4. D
    Computed tomography scan of the abdomen and pelvis
  5. E
    Immediate admission to the general medical ward

Answer

The correct immediate stabilization steps are the rapid intravenous administration of isotonic fluids containing dextrose and the intravenous administration of high-dose hydrocortisone.
The patient is in an acute adrenal crisis, triggered by abrupt cessation of chronic exogenous glucocorticoids and the physiological stress of a gastrointestinal illness. This is a life-threatening emergency presenting with distributive shock, hypoglycemia, hyponatremia, and hyperkalemia. Immediate stabilization requires reversing the volume depletion and hypoglycemia with intravenous isotonic fluids containing dextrose, alongside the simultaneous administration of high-dose intravenous glucocorticoids (such as hydrocortisone) to restore vascular tone and correct the hormonal deficit.

Step-by-Step Solution

1
Analyze the patient's history and clinical presentation.
The patient has a history of chronic steroid use with abrupt cessation, now presenting with distributive shock, hypoglycemia, hyponatremia, and hyperkalemia.
Identifying the constellation of symptoms and history is necessary to determine the underlying cause of shock.
2
Diagnose the primary life-threatening condition.
The presentation is classic for an acute adrenal crisis.
Recognizing adrenal crisis is critical because it requires specific hormonal replacement in addition to standard fluid resuscitation.
3
Determine the most urgent stabilization priorities.
The immediate priorities are reversing the hypovolemic shock and correcting the severe hypoglycemia and cortisol deficit.
Definitive diagnostic testing and disposition must wait until the patient is hemodynamically stable.
4
Select the appropriate simultaneous interventions.
Administer rapid intravenous isotonic saline with dextrose and intravenous high-dose hydrocortisone.
Fluids with dextrose correct volume depletion and hypoglycemia, while hydrocortisone replaces the missing cortisol to restore vascular tone.

Key Concept

In a patient presenting with acute adrenal crisis (distributive shock, hypoglycemia, and electrolyte derangements following cessation of chronic steroids), immediate stabilization requires volume resuscitation with dextrose-containing isotonic fluids and immediate glucocorticoid replacement prior to any diagnostic testing.
Estimated Time:1m 0s
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Topics

Initial Stabilization and Triage

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