Medical Emergencies
Adrenal Insufficiency / Crisis
This page discusses Adrenal Insufficiency, Addison's disease, and Adrenal Crisis. An adrenal crisis is unlikely to occur in a dental practice setting, but the team should know how to reduce the risk, and recognise and manage it if it happens.
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Didactic Information:
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Adrenal Insufficiency occurs when the adrenal glands (specifically the adrenal cortex) do not produce enough steroid hormones. When there is a natural severe lack, it is sometimes known as Addison’s Disease.
It can be caused by long-term administration of steroids, which suppress the natural ability of the adrenal cortex to produce steroid hormones. It can also occur naturally, for example through auto-immune disease attacking the adrenal cortex (as in Addisons).
Adrenal Crisis
People with adrenal insufficiency may suffer a life-threatening condition called an Adrenal Crisis, or Addisonian Crisis. This occurs when the body suddenly has a need for extra steroid hormones, but is unable to produce them. Examples include surgery (including dental surgery), trauma, and infection.
If an adrenal crisis is untreated, it can be fatal.
The physiological stress caused by most dental surgery is unlikely to precipitate an Adrenal Crisis, and other possibilities should be considered before making this diagnosis.
Signs and symptoms of an Adrenal Crisis
The signs and symptoms can vary, and may include:
Confusion, slurred speech
Nausea, vomiting
Profound weakness, lethargy
Sudden penetrating pain in the legs, lower back or abdomen
Low blood pressure.
Convulsions
Loss of consciousness
Hypoglycaemia
Precautions
Ensure the medical history is up to date regarding steroid medication, adrenal insufficiency, or Addison’s disease. Check if the patient carries a steroid warning card.
Adjust the steroid dose for minor dental procedures. See our Addison's module here.
If undertaking extractions or major dental surgery (e.g. implant placement), the patient should normally be seen in secondary care and be treated under IV/IM hydrocortisone.
If the patient is being treated for a severe (i.e. systemic) infection of dental origin, an increased steroid dose should be also be considered, in addition to antibiotics.
Management of an Adrenal Crisis
This is unlikely to occur in a dental surgery – consider other diagnoses first. If you are sure of the diagnosis, the appropriate treatment is:
Maintain airway, breathing, circulation.
Call an ambulance.
Consider administration of IV or IM Hydrocortisone 100mg, if carried in the emergency drug box or by the patient.
Self Assessment
Why can some people suffer from Adrenal Insufficiency?
What can cause an Adrenal Crisis?
How likely is a sudden Adrenal Crisis to occur in a Dental Practice?
What are the Signs and symptoms of an Adrenal Crisis?
What precautions should you take to minimise the risk, and which dental procedures are most likely to increase the risk of an Adrenal Crisis?
How would you manage an acute Adrenal Crisis?