Adrenal Insufficiency Scenario

You enter the room where the patient is lying in a recovery position. You see she is unconscious, very pale, and rapidly breathing. You try to get a response from her but there is nothing. There is vomit pooling from her mouth with gurgling noises, her respiratory rate is around 40, and she has a weak radial pulse around 135 bpm.

What management should you look at first

There is a lot of vomit in the airway with gurgling at the back of the throat. You attempt postural drainage and suction the airway with some success, but there is still some compromise. What further action in the stepwise airway approach can you do next

You place an OPA and the patient’s airway is now under control. Your colleague has started to conduct observations while you continue with your assessment. You assess breathing and note a rapid respiratory rate, around 40, with bilateral air entry. You auscultate crackles on all lobes and query the patient has aspirated some vomit. SP02 levels are reading 89% on air, what further action should you do

You apply O2 and the SP02 climbs to 96%, and the patient’s colour is less pale now. As you move onto circulation, your colleague reads out observations: Respiratory rate 38, Heart rate 132, BP 79/43, CRT 4 seconds, temperature 37.9°c, blood sugar 3.7 mmol.

Working through circulation, you note no obvious causes for haemorrhage. You start to cannulate the patient. What action would you complete next

You start administering Sodium Chloride and site a second cannula to start some Glucose 10%. Given the observations, what is the patient’s NEWS Score: Respiratory rate 38, Heart rate 132, 96% SP02 on O2, BP 79/43, CRT 4 seconds, temperature 37.9°c, blood sugar 3.7 mmol, U on AVPU

You have a number of differentials for what may be happening. Your colleague completes a 12 lead ECG but the rhythm is sinus tachycardia, no other obvious abnormalities. You have your medications running but the patient remains in the same state. Your colleague goes to get extrication equipment while you manage the patient. The parents are standing in the doorway watching your efforts. You ask if there is any more info they can give about the patient, medical history, medications, allergies…

They explain she has no allergies, but had Pituitary gland surgery when she was very young and has to have regular hormone replacement therapy. This past week she has been under the weather and missed several doses, but this has never been a problem in the past.

Given this new information, what may be the cause for the patient’s unwell state

Given the information of Pituitary Gland surgery requiring hormone replacement therapy, what type of Adrenal Insufficiency is this

What management is required for Adrenal Crisis

What dosage of Hydrocortisone IM is recommended

You administer the Hydrocortisone as your colleague returns with the scoop and stretcher. You safely extricate the patient from the house into the Ambulance. In the back you conduct further primary survey and observations. The patient’s condition has seemed to stabilise. Is a pre-alert still necessary for the patient and condition