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?: (A) Return to the operating room for exploratory laparotomy, (B) Administer hydrocoisone 100 mg IV, (C) Administer vancomycin and piperacillin/tazobactam, (D) Perform MRI of the spine.
Answer is B. 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.