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Adrenal Insufficiency and Emergency Care

Adrenal Insufficiency and Emergency Care AIU is a grassroots group of affected adults and family members bridging the gap between Health Professionals and those living with Adrenal Insufficiency through education, support, collaboration and research. This publication was made possible by the contributions of several Health Care Providers dedicated to improving lives and willing to collaborate with us. Contributors to this booklet Office of the Medical Director of The AustinTravis County EMS Sys

Dedicated to all those suffering from the affects of Adrenal Insufficiency. Please help us honor them by reading and sharing this publication. Creating awareness and promoting knowledge will ensure the safety and better quality of life for those suffering from Adrenal Insufficiency. More personal stories of Adrenal Insufficiency will be in our next Publication, Our Adrenal Crisis Stories. Coming in June, 2012 You will find information about our sponsors throughout this book. Their generous dona

SO MANY TESTS...... While on vacation my two year old son became ill. He was lethargic, refusing food and drink, had a mild fever, and diarrhea. He was tested for strep, which was negative. That evening he became even more lethargic, vomited his liquid acetaminophen and we became concerned that he was dehydrating. We took him on to the closest emergency room. His glucose was at 23, had a very high heart rate, low blood pressure, developed a fever, and became hypoxic. He was treated with IV salin

After a few days my sons kidneys began to function, he became more active, and his blood counts began to improve. One evening a doctor came in and said I believe he is going to make it now. That is the first time I had realized that the doctors had even considered that he might not He was released after a week in the hospital. After a second similar episode over three years later, severe growth failure, worsening asthma, and other health issues, my son was diagnosed with adrenal insufficiency. T

IM TOO YOUNG TO DIE My name is Caitlin and I was diagnosed with Central Adrenal Insufficiency on October 31, 2011. I had lived a symptom free life until my Gastric Bypass on June 22, 2011. After my bypass I was shocked with severe fatigue, muscle pain, concentration problems, low blood pressure and other symptoms. Exactly four months after my surgery, on October 22, 2011, I was rushed to the hospital were my morning cortisol level was at a .6. An endocrinologist dubbed me with the disease...Adre

Maine has a protocol for Adrenal Insufficiency, but without awareness the protocol does no good. Read Morgans story to see why. Morgan had an adrenal crisis in October 2011. He pulled into a convenience store at 2AM and passed out. Police found him at 4AM, thought he was drunk, arrested him, and took him to the station. He told the officers that he needed his emergency shot, SoluCortef, hypodermic needle, and signed special protocols that were in a ziplock bag in his glovebox. They took the bag.

PLEASE, JUST HELP OUR SON My daughter gave birth to a premature baby that she could not care for and my husband and I adopted him. Owen was diagnosed with Congenital Adrenal hyperplasia and we were trained to give the SoluCortef injection in the event of an adrenal crisis. When he was five, Owen began throwing up late at night and could not hold down his medicine. Suspecting a crisis, I drove him straight to the hospital thinking the injection of SoluCortef would be handled expertly. The emergen

NO ONE WOULD GIVE THE INJECTION When my daughter was four years old she was very sick and went into an Adrenal Crisis. She had been vomiting and was unable to keep down her oral medication. We took her to the emergency department at our local hospital. The attending physician was not familiar with Salt Wasting Congenital Adrenal Hyperplasia, but we had a letter from the endocrinologist with instructions for care and the administration of SoluCortef. However, the physician to

Adrenal Clinic Prof Peter Hindmarsh

A SCARY AMBULANCE RIDE One day, when my son Alex was two, he walked into the bathroom, turned white as a sheet, and fell to the floor. I scooped up his limp body, carried him to his changing table, and immediately gave him a SoluCortef shot. I ran to the phone and called 911 because his condition was far worse than Id seen before. The ambulance was about 100 yards away from my house and I could hear their sirens within a minute. The medics got him in the ambulance and started checking his vitals

A DIFFICULT DIAGNOSIS Since my son has numerous medical issues, it took forever to diagnose his adrenal insufficiency. The first signs showed up when he began a chemo treatment. On day two of the cycle, he became pale, weak, and nauseous. Then came cold sweats and irregular breathing finally he became unconscious. We rushed him to the ER when sternum chest rubs didnt wake him up. The local ER sent him to the hospital that administered his cancer treatments. After five days in the hospital, he wa

THANKS FOR LISTENING June 19, 2008 was one of the worst days of my life. My four year old went into adrenal crisis while at his preschool. He had been a little grumpy that morning, but by the time the bus picked him up he was his normal happy self. Around 930 a.m. I got a phone call, my son had vomited and was acting very tired and sleepy. When I got to the school he looked awful so I went straight to our doctors office. As they were registering him he became cold and clammy and then went limp i

BETTER SAFE THAN SORRY It was her bedtime when my three year old daughter and walked into the living room and said Mommy, Daddy I dont feel good she spit up a little but had no temperature. We laid her down thinking she was fine, maybe a belly ache but nothing to serious. Around one oclock in the morning I heard different noises coming from the baby monitor. When I walked her room, her body was jerking very lightly, her body was hot, she was pale except for her bright red cheeks, and she couldn

I DIDNT HAVE TIME TO WAIT I went into a crisis in January 2010. I was home alone and called my sister who is a nurse. She could tell by the confused way I was talking that I needed to go to the hospital. I was able to call 911, but when I told the 911 operator that I had secondary Adrenal Insufficiency her response was you have what By the time the squad got to me I was confused and was having severe tremors. They suspected that I was having an allergic reaction to something so they gave me a bi

MY JOURNEY My experience learning to live with Addisons began with my first crisis in 1982. I passed out on the bathroom floor, my three year old found me and woke my husband. I was taken to the ER and no one could figure out why I was so ill, my temperature was 106 degrees. I extremely dehydrated, thin, very tan, and so sick. I was put on a cooling blanket and IVs and then diagnosed with probable Toxic Shock Syndrome. The Dr. told my family to make funeral arrangements. A nurse told me the nex

THE CAR ACCIDENT When my daughter was seven, our family was in a car accident. Since my daughter has Adrenal Insufficiency I was immediately worried. While we waited for paramedics to come get us out of the car I kept trying to talk to her and look to make sure she was OK The paramedics, fire, and police arrived quickly and helped us get out of the car. My daughter had hit her face on the car window and had some cuts and bruising. She was white as a ghost and shivering. She is never cold. I was

THE BIG ONE The Big One, as my mom and I refer to it, was BAD. I was 24 years old and had been having a rash of staph infections for the previous 2 months. The oral meds were not enough. The infection was to much for my immune system. THIS is what scared me. When this crisis started I was oblivious and didnt think twice about the fact that I kept falling down. Before it started, I remember throwing up, but thats it, nothing else. The morning before, I went to work not feeling good, and my boss s

Thanks to the Office of the Medical Director of The AusitnTravis County EMS System, Austin, Texas for allowing the use of this sample protocol from their system.

Thanks to the Western Regional Emergency Advisory Committee for allowing the use of this sample protocol.

Thanks to the Bureau of Emergency Medical Services of New Hampshire for allowing the use of their sample protocol.

Thanks to the Lamar Fire and Ambulance Service in Lamar, Colorado for allowing the use of their sample protocol. Continues on the next page.

Protocol continued from Lamar Fire and Ambulance Service in Lamar, Las Vegas 3500 S. Las Vegas Blvd. Suite M3 Las Vegas, NV 89109 P 7027926888 Web www.Flightlinez.com Phone 702.293.6885 bootleg, 702.410.7999 fremont

Thanks to the State of Maine EMS Department of Public Safety, in Augusta, Maine for allowing the use of their sample protocol. This protocol continues on the next page.

State of Maine EMS Department of Public Safety

The following 15 pages have been taken from a presentation created by MA EMS for Children. They have given AIU permission to reformat and use their information for our publication. AIU has added photos, stories and videos and have identified our extra content where applicable. Some of our sponsor have also been acknowledged. To see the Original PowerPoint on the MA website click HERE. ADRENAL INSUFFICIENCY MA EMS Protocol Update 2010 Table of Contents Objectives Anatomy Physiology Epidemiolog

Adrenal Anatomy Physiology The adrenals are endocrine organs that sit on top of each kidney Each adrenal gland has two parts 1. Adrenal Medulla inner area Secretes catecholamines which mediate stress response help prepare a person for emergencies Norepinephrine Epinephrine Dopamine 2. Adrenal Cortex outer area, encloses Adrenal Medulla Secretes steroid hormones Glucocorticoids exert a widespread effect on metabolism of carbohydrates and proteins Mineralocorticoids are essential

The Essential Steroids Cortisol a.k.a. hydrocortisone A glucocorticoid, frequently referred to as the stress hormone Released in response to physiological or psychological stress Examples exercise, illness, injury, starvation, extreme dehydration, electrolyte imbalance, emotional stress, surgery, etc. Rapid deterioration resulting in organ damage and shockcoma death can occur, especially in children Aldosterone A mineralocorticoid Regulates body fluid by influencing sodium balance The huma

Why we need cortisol Cortisol has a necessary effect on the vascular system blood vessels, heart and liver during episodes of physiologic stress. Vascular Reactivity In adrenallyinsufficient individuals experiencing a physiologic stressor, the vascular smooth muscle will become nonresponsive to the effects of norepinephrine and epinephrine, resulting in vasodilation and capillary leaking. The patient may be unable to maintain an adequate blood pressure The blood vessels cannot respond to the st

Endocrinologist Testimony... ...In adrenal insufficiency, because of the inability to produce glucocorticoids and often mineralocorticoids from the adrenal glands, there is a risk of lifethreatening hyponatremia, hyperkalemia, hypoglycemia, seizures and cardiovascular collapse, in particular at times of physiologic stress to the body, such as in injury or illness... Support letter, Dr. Christine Leudke, Boston Childrens Hospital 12122009 Parent Testimony... ... People without adrenal insufficie

Who has adrenal insufficiency Anyone whose adrenal glands have stopped producing steroids as a result of Longterm administration of steroids Pituitary gland problems, including growth hormone deficiency, tumor, etc. Trauma, including head trauma that affects pituitary Loss of circulation to adrenalsremoval of tissue Autoimmune disease Cancer and other diseases TB and HIV may cause There is also an inherited form of adrenal insufficiency Congenital Adrenal Hyperplasia CAH Adrenal Insuffi

Why Adrenal glands tend to get lazy when steroids are regularly administered by mouth, I.M. injection or I.V. infusion. To illustrate how quickly...Just 4 weeks of daily oral cortisone administration is sufficient to cause the adrenals to be slightly less responsive to stressors. Organ Transplant Patients These individuals must take immunosuppressive medications usually steroids DAILY for life. Their own adrenal glands stop producing cortisol because of external source of steroid. Longterm Asthm

Primary Adrenal Insufficiency Addisons Disease The adrenal glands are damaged and cannot produce sufficient steroid. 80 of the time, damage is caused by an autoimmune response that destroys the adrenal cortex Addisons can affect both sexes and all age groups Addisons symptoms This disease has a gradual onset and can be difficult to diagnose Chronic, worsening fatigue Weight loss Muscle weakness Loss of appetite Nauseavomiting Low blood pressure Low blood sugar Skin hyperpigmentation Sa

Presentation of Adrenal Crisis The patient may present with any illness or injury as the precipitating event. A patient history of adrenal insufficiency warrants a careful assessment under specific protocols Children may deteriorate into adrenal crisis from a simple fever, a gastrointestinal illness, a fall from a bicycle or some other injury. A mild illness or injury can easily precipitate an adrenal crisis in any age group Critical Clinical Presentation The early indicators of an adrenalcr

Clearly, the signssymptoms of adrenal crisis are similar to other serious shocktype presentations. For these patients, standard shock management requires supplementation with corticosteroid medication SoluCortef or SoluMedrol It is important to ANTICIPATE the evolution of an adrenal crisis and medicate appropriately under the specific protocols. Do not wait until a full adrenal crisis has developed. Organ damage or death may result from delays. Patient Management Follow standard ABC and shoc

MA EMS Protocol Updates This phrase has been added to Paramedic Standing Orders in certain ADULT treatment protocols For patients with confirmed adrenal insufficiency, give hydrocortisone 100 mg IV, IM or IO OR methylprednisolone 125 mg IV, IM or IO Relevant ADULT treatment protocols 3.3 Altered MentalNeurological Emergencies 3.10 Shock Hypoperfusion of Unknown Etiology 4.5 Multisystems Trauma This phrase has been added to Paramedic Standing Orders in certain PEDIATRIC protocols For patients

Please define Confirmed Adrenal Insufficiency Confirmation of a pediatric patients condition is determined by the presence of a medicalert braceletnecklace, OR by the child, parent or care provider verbally confirming a history of adrenal insufficiency In a school or daycare setting, it is acceptable for the school nurse or daycare provider to relay this information to you Document manner of confirmation on PCR. Confirmation of adrenal insufficiency in adults is achieved by viewing a medic alert

Profile SoluCortef Trade name SoluCortef Generic name hydrocortisone sodium succinate Class corticosteroid, Pregnancy Class C Mechanism acts to suppress inflammation replaces absent glucocorticoids, acts to suppress immune response MA EMS Indications replacement of absent corticosteroid in identified adrenallyinsufficient patients being managed under specific treatment protocol many other uses as well. ContraIndications Do not use in the newlyborn or any individual with a known hypersensiti

Using ActOVial SoluCortef and SoluMedrol Press down on plastic activator to force diluent into the lower compartment. Gently agitate to effect solution. Remove plastic tab covering center of stopper. Swab top of stopper with a suitable antiseptic. Insert needle squarely through centre of plungerstopper until tip is just visible. Invert vial and withdraw the required dose. VIEW A VIDEO DEMONSTRATION by Traci Schaeffer from THE SUCCEED CLINIC IN OKLAHOMA. Added to this presentation by AIU and

SoluMedrol Generic methylpredisolone sodium succinate Trade SoluMedrol Class steroid Pregnancy Class C Indications Ma EMS Protocol replacement of absent corticosteroid in identified adrenallyinsufficient patients being managed under specific treatment protocol Other many uses, including acute bronchial asthma not firstline anaphylaxis not firstline acute exacerbation of multiple sclerosis Contraindications any patient with systemic fungal infection, any person with known hypersensitivity to

MA EMS gives their Heartfelt Appreciation...... is extended to the many people whose hard work helped make these protocol changes possible, including Alex Dubois and son James MA CAH family advocates Dr. Christine Leudke and the many other pediatric endocrinologists across the state of Massachusetts Dr. Jon Burstein, OEMS staff and members of the MA Medical Services Committee Gretchen Alger Lin, CARES Foundation Family members, state legislators and others for their letters of support and ki

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