Addisonichesky crisis – the heavy endocrine frustration developing as result of the sudden expressed decrease or absolute termination of synthesis of hormones bark of adrenal glands. It is shown by an adinamiya, a lowering of arterial pressure, appetite loss, nausea, belly-aches, vomiting, diarrhea, an acetone smell from a mouth, an acetonuria, spasms. At a heavy current dehydration, a collapse, obscuring of consciousness, a lump develops. Diagnostics includes poll and survey of the patient, blood tests and urine, the ECG. Drug treatment, is directed to restoration of normal level of hormones, elimination of dehydration and its consequences.
Synonyms of addisonichesky crisis – addison crisis, sharp nadpochechnikovy insufficiency, gipoadrenalovy crisis, adrenalovy crisis, adrenokortikalny crisis, a sharp gipokortitsizm, sharp insufficiency of bark of adrenal glands. The Krizovy refusal of a cortical layer of adrenal glands is called by name the British therapist Thomas Addison who described clinic of this state in sulfurs. 19th century. In the International classification of diseases of the 10th revision gipoadrenalovy crisis is referred to category "Other Violations of Adrenal Glands" (a code – E27.2). Prevalence of this state in endocrinology makes 50 cases on 1 million people, or 0,005%. The gender ratio 2:1 is more often diagnosed for women. The peak period of incidence is the age from 55 to 63 years.
Reasons of addisonichesky crisis
The Krizovy state most often develops at patients with primary and tertiary nadpochechnikovy insufficiency, Addison's disease, Schmidt's syndrome. These categories of patients have the reasons of an exacerbation of chronic diseases various stresses, shock, intensive loadings, drug intake. The most widespread provocative factors are:
- Intoxications. Crisis arises at alcoholic and sharp food poisonings. Vomiting and a diarrhea promote loss of electrolytes and dehydration, work of target organs is broken, chronic diseases become aggravated.
- Pregnancy. During incubation of the child there is a reorganization in work of endocrine system. Activity of glands changes therefore the probability of deficiency of some hormones increases.
- Infectious diseases. The high risk of an addisonov of crisis exists at heavy sharp infections, generalized inflammatory processes. Often it is diagnosed at meningitis, diphtheria, toxic forms of flu.
- Incorrect application of drugs. Decrease in production of hormones is connected with misuse of insulin, diuretic and sedatives, narcotic analgetics. Other reason – independent replacement with the patient of one hormonal medicine to others, decrease in a dosage of glucocorticoids or complete cessation of replacement therapy.
- Stresses, shock states. Deficiency of the hormones produced by a cortical layer of adrenal glands can be caused by injuries of a waist or stomach, big blood losses at surgeries, burns, childbirth. Also crisis is provoked by long psychoemotional and physical activities.
At the persons which do not have chronic pathology of adrenal glands, addisonichesky crisis is result of autoimmune defeat of cortical substance, congenital violations of activity of enzymes, a bilateral sharp heart attack of cortical tissues of adrenal glands or hemorrhages in them, surgical removal of one or two adrenal glands. Sometimes sharp decrease in secretion of hormones becomes the first diagnosed sign of a latent form of a chronic gipokortitsizm, tireoadrenokortikalny insufficiency.
Adrenal glands – gland of endocrine secretion developing several types of hormones. Nadpochechnikovy bark makes corticosteroids, such as a cortisone, cortisol, , , . Activity of these connections ensures normal functioning of nervous and cardiovascular system, course of metabolic processes and digestion, production of connecting fabric, supports sugar level. At addisonichesky crisis production of corticosteroids decreases very quickly. Systems of an organism do not manage to adapt to sudden deficiency of hormones. As a result many types of exchange processes are broken, there is dehydration, the amount of the circulating blood decreases. Change of metabolism of potassium affects work of a cardiac muscle: it begins to be reduced worse, and arterial pressure decreases. The renal failure develops, concentration of sugar of blood falls. The condition of crisis becomes zhizneugrozhayushchy.
Adissonichesky crisis is developed during the period from several hours to several days. Allocate a predkrizovy stage at which patients feel the general weakness, muscular pains, a loss of appetite, and the stage of the developed clinical picture which is characterized by progressive deterioration in health. Other classification is based on distinctions in a clinical picture. According to it allocate five forms of addisonichesky crisis:
- Gastrointestinal. To the forefront there are sharp dispepsichesky frustration. Vomiting, nausea, diarrhea, spastic abdominal pains prevails, there is no appetite.
- Psevdoperitonealny. This form of crisis is clinically similar to a sharp stomach. It is characterized by sharp pains, tension of muscles of a stomach.
- Miokardialny. The leading symptoms are connected with violation of functions of heart and vessels. Insufficiency of blood circulation is shown by cyanosis mucous and skin, hypotonia, delay of pulse.
- Meningoentsefalicheskaya. Psychological violations dominate. The focal and hallucinatory and crazy symptomatology, spasms, oppression of consciousness, deliriya develops.
- Respiratory. It is shown by respiratory insufficiency. Short wind, the general weakness, dizzinesses accrues, there is a feeling of shortage of air.
Symptoms of addisonichesky crisis
At patients with chronic forms of insufficiency of adrenal glands symptoms of crisis accrue for several days, bystry development of serious condition in 3-6 hours is possible at infectious and shock states. In the beginning patients note decrease in working capacity, slackness, an adinamiya. Muscular weakness is so expressed that they prefer to be in a bed the most part of time, quite often need leaving (feeding, disguise, a toilet). In attempts to rise and walk about the room there is dizziness, sometimes – a faint. Sharp falling of blood pressure provokes a collapse.
Amplifies "bronze", golden-brown pigmentation of skin and mucous membranes is characteristic. Appetite considerably decreases up to full intolerance of a look and a smell of food. Patients complain of nausea which when progressing symptomatology develops into unrestrained vomiting. After the next attack the health does not improve. Pain in a stomach accrues: at first it concentrates in an epigastriya, then extends on all abdominal area. Sharp pains are followed by allocation of emetic masses with blood, a black, tar-like chair or diarrhea. Less often pain is localized in a waist.
Diarrhea and vomiting provoke organism dehydration, loss of electrolytes. Decrease in level of sodium and reduction of volume of blood leads to sharp decrease in systolic and diastolic pressure. Bodies do not receive enough oxygen. The hypoxia of a brain is shown by strengthening of drowsiness and dizziness, consciousness obscuring. Because of violation of a blood-groove in kidneys the glomerular filtration worsens, urine volumes are reduced, the oliguriya develops, then – an anury. In blood urea and nitrogen collects, acidosis which main symptom is the acetone smell from a mouth and from the patient's skin is formed. From nervous system such symptoms as spasms, a psevdomeningealny syndrome, psychotic states with paranoid nonsense and/or hallucinations, deliry are possible.
Without rendering emergency medical service to the patient clinical displays of addisonichesky crisis progress. The risk of an acute heart failure with loss of consciousness, dehydration of tissues of brain, a sharp renal failure increases. Consciousness becomes dulled, skin – cold to the touch. Pulse is hardly probed, threadlike, blood pressure cannot be determined, tones of heart are sharply weakened. The coma, and then death develops. Prevalence of a lethal outcome among women makes 0,52%, among men – 0,89%.
Addisonichesky crisis represents the sharp state demanding rendering urgent medical assistance therefore express diagnostics methods – clinical data collection and several laboratory tests allowing to reveal metabolism violations, to carry out differentiation of crisis with peritonitis, heart failure, a tseliakiya, a myopathy, giperparatireozy and some other diseases are more widespread. As a rule, enters a complex of inspections of the patient:
- Poll, survey. The doctor-endocrinologist collects the anamnesis: in most cases the chronic gipokortitsizm, and also the factors capable to provoke development of crisis (infections, injuries, childbirth, a stress, physical activities) is defined. Complaints describe a clinical picture of sharp nadpochechnikovy insufficiency. At survey of the patient slowness of the speech and movements, apathy, characteristic pigmentation of integuments, the low slowed-down pulse is noted.
- Analyses of urine, blood. Full laboratory inspection included the general and biochemical blood test, the clinical analysis of urine, a glucose research in blood, hormones of adrenal glands in urine and blood. The raised indicators of leukocytes, erythrocytes and hemoglobin, increase SOE, a hypoglycemia, a giperkaliyemiya and a giponatriyemiya are characteristic. According to a research of urine emergence of protein, erythrocytes, increase in sodium is defined, acetone detection is possible.
- ECG. The electrocardiography is carried out for the purpose of identification of a giperkaliyemiya. Changes of indicators are observed at concentration of potassium in plasma from 7 mmol/l. The high pointed T tooth at a normal interval of QT is noted, the reduced amplitude of a tooth P with the extended PQ interval. Strengthening of a giperkaliyemiya is followed by expansion of the QRS complexes, an asistoliya of auricles.
Treatment of addisonichesky crisis
Help to patients is given in conditions of intensive care unit or intensive therapy. The main complex of events is held in the first days of stay of the patient in a hospital, at the end of this period it is possible to estimate efficiency of therapy and to make the forecast. The stable period of recovery proceeds 4-6 days. Treatment is conducted in four directions:
- Replacement therapy by corticosteroids. Water-soluble medicines of a hydrocortisone were widely used. To patients intravenous injections are appointed, is more rare – intramuscular.
- Elimination of dehydration, hypoglycemia. The patient appoints intravenous drop administration of solution of glucose, physiological solution, Ringer's solution. The volume of medicines pays off individually, is gradually reduced by the end of treatment.
- Restoration of balance of electrolytes. For compensation of a gipokhloremiya and a giponatriyemiya sodium chloride solution infusions, drink of saltish water are shown. For elimination of a giperkaliyemiya solution of glucose and calcium of a gluconate is entered.
- Symptomatic therapy. The events directed to desintoxication, recovery of work of heart, vessels, respiratory system, fight against a collapse, infections, shock states, violations of proteinaceous exchange are as necessary held. Experts of other directions are connected to treatment.
Forecast and forecast
The outcome of addisonichesky crisis directly depends on timeliness of treatment: the earlier therapeutic actions are begun, the forecast is more favorable. In group of the increased risk of a lethality there are patients with the accompanying autoimmune and infectious diseases. Systematic diagnostics of function of adrenal glands, medical control of efficiency of the supporting treatment is necessary for the warning of crisis to persons with a chronic gipokortitsizm. Independent cancellation of medicines, replacement of the appointed drugs with analogs is inadmissible. At the increased emotional or physical activities, sharp diseases, pregnancy needs to consult with the endocrinologist about increase in a dosage of medicines.