Clinical Commander

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endo.adrenal-crisis.core.v1

Adrenal crisis

endocrinologyacuteadultpediatricacuteinpatient
Start encounter →Print handoutPRODUCTION

No problem-package folder yet under src/lib/tier3/problem-package/packages/ — design brief + atoms.* live only at the manifest level. Manifest declares calculators (calc_news2, calc_shock_index, calc_corrected_na, calc_free_water_deficit, calc_qsofa) — calc_news2 / calc_shock_index / calc_corrected_na are not yet present in clinical-tools-registry.ts; mapped to closest available (calc.qsofa, calc.map, calc.na_correction, calc.fw_deficit). Regimen axes empty — drug list lives in manifest.medications/dosing_protocols but no regimen-builder service composes them. Promotion to INTEGRATED requires either populating regimen_axes or wiring through a dedicated service.

Entry points (5)

  • vital_abnormality
    Refractory hypotension / shock (Bornstein JCEM 2016 ESE)
    hypotension
  • lab_abnormality
    Hyponatremia + hyperkalemia constellation (Bornstein JCEM 2016 ESE; Rushworth Endocr Rev 2019)
    hyponatremia_hyperkalemia
  • lab_abnormality
    Unexplained hypoglycemia (Bornstein JCEM 2016 ESE)
    hypoglycemia
  • symptom
    Altered mental status with shock (Hahner JCEM 2015)
    altered_mental_status
  • problem_list
    Known adrenal insufficiency missing stress dose (Bornstein JCEM 2016 ESE; Hahner JCEM 2015)
    adrenal_insufficiency

Required inputs (13)

  • agerequired
    demographic • used at CONTEXT
    Pediatric weight-based hydrocortisone dosing differs from adult bolus (Bornstein JCEM 2016 ESE)
  • sbprequired
    vital • used at RED_FLAGS
    Refractory hypotension defines crisis; drives fluid + vasopressor decisions (Bornstein JCEM 2016 ESE; Rushworth Endocr Rev 2019)
  • hrrequired
    vital • used at RED_FLAGS
    Tachycardia + shock index estimation (Bornstein JCEM 2016 ESE)
  • sodiumrequired
    lab • used at INITIAL_WORKUP
    Hyponatremia is hallmark; corrected Na guides fluid composition (Bornstein JCEM 2016 ESE; Rushworth Endocr Rev 2019)
  • potassiumrequired
    lab • used at INITIAL_WORKUP
    Hyperkalemia is hallmark of primary AI; gates ECG and emergency K management (Bornstein JCEM 2016 ESE)
  • glucoserequired
    lab • used at INITIAL_WORKUP
    Hypoglycemia common; pediatric especially (Bornstein JCEM 2016 ESE; Hahner JCEM 2015)
  • cortisol
    lab • used at INITIAL_WORKUP
    Random cortisol drawn pre-steroid — do NOT delay treatment for result (Bornstein JCEM 2016 ESE)
  • acth
    lab • used at INITIAL_WORKUP
    Differentiates primary vs secondary AI (Bornstein JCEM 2016 ESE)
  • known_adrenal_insufficiencyrequired
    history • used at CONTEXT
    Known AI + missed stress dose is most common precipitant (Hahner JCEM 2015; Rushworth Endocr Rev 2019)
  • chronic_steroid_userequired
    history • used at CONTEXT
    Chronic exogenous steroid HPA suppression; abrupt taper precipitates crisis (Bornstein JCEM 2016 ESE)
  • current_meds
    medication • used at CONTEXT
    Etomidate, ketoconazole, rifampin, phenytoin, checkpoint inhibitors precipitate (Bornstein JCEM 2016 ESE; Rushworth Endocr Rev 2019)
  • pregnancy_statusrequired
    history • used at CONTEXT
    Pregnancy alters dosing and triggers MFM consult (Bornstein JCEM 2016 ESE)
  • lactate
    lab • used at INITIAL_WORKUP
    Distributive vs hypovolemic shock pattern; sepsis precipitant (Bornstein JCEM 2016 ESE)

12-phase flow (12)

  1. 1FRAME
    Recognize adrenal crisis pattern: shock + hyponatremia +/- hyperkalemia +/- hypoglycemia in Addisonian/steroid-treated patient (Bornstein JCEM 2016 ESE; Rushworth Endocr Rev 2019)
    inputs: sbp, sodium, potassium
    advance: crisis pattern present and steroid candidate identified (Bornstein JCEM 2016 ESE)
  2. 2ENTRY
    Capture triggering finding (shock, electrolyte pattern, AMS) and confirm need for empiric hydrocortisone (Bornstein JCEM 2016 ESE)
    inputs: age
    advance: demographic + entry trigger documented (Bornstein JCEM 2016 ESE)
  3. 3CONTEXT
    Capture known AI status, chronic steroid history, pregnancy, precipitant screen infection/surgery/GI losses/checkpoint inhibitor (Bornstein JCEM 2016 ESE; Hahner JCEM 2015)
    inputs: known_adrenal_insufficiency, chronic_steroid_use, pregnancy_status, current_meds
    advance: comorbidity + precipitant captured (Bornstein JCEM 2016 ESE; Hahner JCEM 2015)
  4. 4RED_FLAGS
    Refractory hypotension, severe hyperkalemia with ECG changes, severe hyponatremia <125, hypoglycemia, sepsis pattern, acute abdomen mimic (Bornstein JCEM 2016 ESE; Rushworth Endocr Rev 2019)
    inputs: sbp, hr, sodium, potassium, glucose
    actions: calc.qsofa, calc.map
    advance: red flags screened; STAT hydrocortisone ordered without waiting for cortisol/ACTH (Bornstein JCEM 2016 ESE)
  5. 5INITIAL_WORKUP
    Cortisol + ACTH pre-steroid; CMP; CBC; lactate; VBG/ABG; cultures; ECG; CXR; pregnancy test; TSH/FT4 (Bornstein JCEM 2016 ESE)
    inputs: sodium, potassium, glucose, cortisol, acth, lactate
    actions: panel.hormone, panel.renal, panel.thyroid, workup.adrenal_crisis
    advance: baseline labs sent; empiric hydrocortisone given (Bornstein JCEM 2016 ESE)
  6. 6BRANCHING_WORKUP
    Etiology workup once stabilized: cosyntropin stimulation, 21-hydroxylase Ab, MRI pituitary if secondary, CT adrenal if hemorrhage suspected Waterhouse-Friderichsen (Bornstein JCEM 2016 ESE)
    advance: etiology workup queued for after stabilization (Bornstein JCEM 2016 ESE)
  7. 7DIFFERENTIAL
    Phenotype: known AI precipitated, new presentation primary AI, iatrogenic steroid withdrawal, Waterhouse-Friderichsen, checkpoint-inhibitor hypophysitis (Bornstein JCEM 2016 ESE; Rushworth Endocr Rev 2019)
    advance: phenotype assigned (Bornstein JCEM 2016 ESE; Rushworth Endocr Rev 2019)
  8. 8RISK_STRATIFICATION
    NEWS2 + shock index + qSOFA for ICU triage; severity classified by shock + hyponatremia + AMS (Bornstein JCEM 2016 ESE)
    inputs: sbp, hr
    actions: calc.qsofa, calc.map
    advance: severity documented; ICU disposition decided if shock or AMS (Bornstein JCEM 2016 ESE)
  9. 9TREATMENT
    Hydrocortisone 100 mg IV bolus then 200 mg/24h infusion or 50 mg q6h; NS 1 L over 1h then 2-3 L additional; D50 if hypoglycemic; treat precipitant; vasopressors if refractory; delay levothyroxine until hydrocortisone replete (Bornstein JCEM 2016 ESE; NICE 2018 AI)
    inputs: sbp, sodium, potassium, glucose
    advance: hydrocortisone + fluids + glucose correction + precipitant therapy in flight (Bornstein JCEM 2016 ESE; NICE 2018 AI)
  10. 10DISPOSITION
    ICU if shock or AMS; step-down once stable on q6h hydrocortisone; endocrine consult day 1 (Bornstein JCEM 2016 ESE)
    advance: ICU vs ward decided; endocrine + ID/MFM consults made as indicated (Bornstein JCEM 2016 ESE)
  11. 11MONITORING
    Continuous telemetry, hourly vitals, q4h electrolytes + glucose, strict I/Os, mental status q2h, Na correction <8 mEq/L/24h ceiling (Bornstein JCEM 2016 ESE; NICE 2018 AI)
    inputs: sodium, potassium, glucose
    actions: panel.renal
    advance: monitoring plan documented; sodium correction within safety limits (Bornstein JCEM 2016 ESE; NICE 2018 AI)
  12. 12FOLLOWUP
    Endocrine within 1 week; sick-day rules education; emergency hydrocortisone IM kit; medical alert ID; etiology workup completion; family screening if autoimmune (Bornstein JCEM 2016 ESE; Hahner JCEM 2015; NICE 2018 AI)
    advance: sick-day rules taught; emergency kit prescribed; follow-up scheduled (Bornstein JCEM 2016 ESE; Hahner JCEM 2015; NICE 2018 AI)