A middle age male patient met with a road traffic accident & is brought to emergency in an unconscious state. CT abdomen reveals a splenic laceration, emergency splenectomy is done & patient is shifted to ICU. His BP remains low in post op period even after a bolus of normal saline. O/E- he is afebrile, has moon like face with central obesity & presence of violet striae over abdomen. Repeat CT scan of the chest, abdomen, and pelvis shows no hemorrhage. What is the next best step in management of this patient?
Moon like facies, central obesity & abdominal striae are signs of glucocoicoid excess - endogenous (Cushing syndrome)/ exogenous. A physiologic stressor (trauma) may trigger adrenal crisis. Acute adrenal insufficiency requires immediate initiation of rehydration (saline infusion at initial rates of 1 L/hr) with continuous cardiac monitoring. Glucocoicoid replacement- initiated by bolus injection of 100 mg of hydrocoisone, followed by the administration of 100-200 mg of hydrocoisone over 24 hours. Mineralocoicoid replacement can be initiated once the daily hydrocoisone dose is <50 mg as at higher doses, hydrocoisone provides sufficient stimulation of mineralocoicoid receptors.
Return to the operating room for exploratory laparotomy
Administer hydrocoisone 100 mg IV
Administer vancomycin and piperacillin/tazobactam
Perform MRI of the spine.
Cushing Syndrome