Are Adrenal Injuries Predictive of Adrenal Insufficiency in Patients Sustaining Blunt Trauma?

Abstract

Adrenal insufficiency (AI) is an uncommon life-threatening development in trauma patients. The aim of this study was to determine if adrenal injury sustained during blunt trauma is associated with an increased risk of AI. A single-institution retrospective cohort review was performed over a 3-year period on all patients with blunt trauma requiring intensive care admission and mechanical ventilation for longer than 24 hours. Adrenal injuries were identified on admission CT scan. All patients with AI were identified as noted by practice management guidelines. Patients were stratified by Injury Severity Score (ISS) as less than 16, 16 to 25, and greater than 25 and relative risks were calculated. Multiple logistic regression was performed using age, race, sex, Glasgow Coma Scale, ISS, length of hospitalization, and adrenal injury as covariates with AI as the outcome of interest. A secondary analysis was then performed with adrenal injury classified as bilateral versus unilateral or no adrenal injury and relative risks were calculated for ISS strata. A total of 2072 patients were identified with 71 developing AI. Adrenal injuries were noted in 113 patients with eight subsequently developing AI. Multiple logistic regression model (P < 0.01) showed that age (P < 0.01) and increasing ISS (P = 0.02) were predictive of AI. Adrenal injury was not an independent predictor of AI (P = 0.12). After controlling for age and ISS, adrenal injury was not an independent predictor of the development of AI. Adrenal insufficiency should be considered with increasing injury severity and age in the intensive care setting after blunt trauma.

Adrenal Insufficiency Overview

“…The interesting point in this study is that cosyntropin test showed cortisol levels higher than classic hypo-adrenal states so the authors concluded a functional hypoadrenalsim in these multisystem critically ill patients rather than true hypoadrenalism state [39]. So no benefit from pharmacologic cortisol doses but physiologic doses of cortisol could be beneficial [32].…”

“…This entity is known in the literature as functional adrenal insufficiency. During severe illness about 24% of cases has decreased cortisol levels [32]. The underlying mechanism is not fully understood but there are some possibilities:-The effect of cytokines and inflammatory mediators on the hypothalamus-pituitary-adrenal system This hypothesis is supported by animal studies that showed role for IL-6 on the HPA.…”

“…From the previous facts routine screening for adrenal insufficiency during critical illness is not recommended but clinicians should consider steroid replacement with physiologic doses in certain situations such as: persistent hypotension, fever for no good reason or difficult weaning from ventilator. Still further studies are required to standardize this approach and collect morbidity and mortality data [32,35].…”

A 71-year-old woman with shock and a high INR

“…4 Other causes of adrenal necrosis include emboli, sepsis, and blunt trauma. 6,7 Other causes of adrenal crisis are listed in Table 3.…”

Are traumatic bilateral adrenal injuries associated with higher morbidity and mortality?-A prospective observational study

“…Adrenal hematomas per se have also been reported to be associated with higher injury severity and mortality compared to non-adrenal gland trauma. The exact cause of the higher mortality and morbidity associated with adrenal gland trauma is unknown but adrenal insufficiency has been hypothesized to play some role [ 9 , 11 , 17 – 19 ]. The clinical significance of bilateral adrenal hematoma remains even more unknown due to the relative rarity of bilateral adrenal hematomas and the insufficient number of cases with bilateral adrenal hematomas among patients with adrenal injuries.…”