INTRODUCTION
Adrenal gland injury is a rare complication of blunt abdominal trauma as a result of motor vehicle collisions, falls, or injuries in sports.[1,2] The incidence rate of adrenal injury is estimated to be approximately 2%–3%.[2–4] Isolated adrenal haemorrhage is an even rare subset of this injury and usually has limited clinical significance,[5] with the majority of adrenal gland injuries being treated conservatively. But if untreated and unrecognised in a patient with shock, this condition can be fatal for the patient. We report a case of traumatic isolated adrenal haemorrhage that presented with occult shock to the Emergency Department (ED).
CASE REPORT
A 33-year-old male was brought into our ED with a history of motor vehicle accident in a drowsy state. The patient was riding a motorcycle and had a head on collision with 4-wheeler vehicle. He had a helmet on as reported by the family. He was taken to a primary centre by onlookers where he was given basic first aid– intravenous fluids, limb splinting and cervical collar. He was then referred to our centre for advanced management. The patient did not have any past comorbidities and presented 5 h post trauma. On arrival, the patient was agitated and had the following vital signs– Heart rate– 155/min, Respiratory rate– 24/min, Oxygen saturation of 96% on room air, Blood pressure– 140/80 mmHg and blood sugar of 99 mg/dL. Trauma examination revealed a clear chest, nondistended and soft abdomen, Glasgow coma scale of 10 and a crushed left ankle and foot with degloving injury. A trauma code was announced and the patient was intubated in view of impending airway compromise and anticipated clinical deterioration. Post intubation the patient’s heart settled to 100/min and blood pressure of 110/80 mmHg. A Focussed Assessment with Sonography for Trauma (FAST) scan and bedside Xray chest were negative for any injuries. A polytrauma non contrast computed tomography (NCCT) revealed a small brain contusion, suspected right upper lobe lung laceration, comminuted fracture of right scapula and severely comminuted fracture of the left calcaneum, talus and navicular bones. The patient was planned for admission in the Intensive Care Unit (ICU) for conservative management. Post NCCT (an hour into resuscitation), the patient’s blood pressure dropped to 80/40 mmhg, Respiratory rate-30/min, Heart Rate-150 bpm and Oxygen saturation of-90% on FIO2-100%.
Repeat FAST and E-FAST examination was negative for any intra-abdominal collection with shock index of the patient being more than 1. Massive transfusion Protocol (1:1:1 of packed red cells: fresh frozen plasma: platelets) were arranged and initiated for cryptic shock. The patient was transfused with 3 units each of packed red cells, fresh frozen plasma and platelets in the ED. The patient was again shifted for a Computed Tomography Aortogram (CTA) in view of a suspected Traumatic Aortic Dissection, keeping in mind the mechanism of injury sustained. The CTA revealed a bulky adrenal gland with hyperdense attenuation with streakiness of the adjoining fat including the perinephric region suggestive of right adrenal gland haemorrhage [Figure 1].
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Figure 1: Computed tomography aorta revealing a bulky adrenal gland with hyperdense attenuation with streakiness of the adjoining fat including the perinephric region suggestive of right adrenal gland haemorrhage
He was seen by the surgical team and advised conservative management with blood pressure control. Blood transfusion was continued. In view of a suspected adrenal crisis, chemistry for adrenal crisis was sent. Initial CPK was found to be 2700 IU, with a low serum aldosterone 8.30 pg/dL (Normal range 25–315 pg/dL) and an extremely high serum renin activity of 258.4 mIU/mL (Normal range 2.8–46.1 mIU/mL). Supportive steroid treatment was initiated in the ED for adrenal crisis and shifted to the ICU for further management. Patient was continued on steroids for 5 days till the blood pressure stabilised. The patient underwent foot debridement and K-wire fixation of the foot. Magnetic Resonance Imaging of the brain performed later revealed a diffuse axonal injury. The patient succumbed to his injuries 10 days post admission.
DISCUSSION
The incidence rate of adrenal gland injury after abdominal trauma is estimated at approximately 2%–3%.[2,3] Unilateral right-sided adrenal injuries are seen in approximately 86% of traumatic isolated adrenal injuries.[6] Most adrenal injuries are seen with concomitant organ or skeletal injuries, and an isolated adrenal injury is even rarer.[7] Being a highly vascularized organ, rupture of small vessels resulting in acute or delayed haemorrhage are likely to occur when traumatic shearing forces are in play.[5,7–8] The most frequent presentation of adrenal injury is abdominal pain, but the patient may also present with nausea, vomiting, hypo-or hypertension, flank mass, altered mental states, fever, etc.[9] Usually adrenal haemorrhage can be managed conservatively but active adrenal haemorrhage have required trans-arterial embolization to control bleeding in some cases.[10] Adrenal crisis due to adrenal injury or haemorrhage has rarely been reported and is often overlooked as a reason for shock in a trauma patient.[11] This may further complicate management of shock in such trauma patients. Quick turn-around times for biochemistry in aiding to the diagnosis of adrenal crisis is usually not available in the ED further complicating the management of such patients. In case of suspicion of adrenal injury/crisis as a cause of shock in a trauma patient, steroids may be initiated.
Shock in trauma can be attributed to adrenal haemorrhage but one should first rule out other obvious causes like tension pneumothorax, cardiac tamponade, aortic dissection, splenic and liver lacerations, haemoperitoneum, etc., Singh etal. in their report diagnosed a suspected Type B aortic dissection with adrenal haemorrhage on computed tomography in a trauma patient.[12] Retroperitoneal hematoma caused by injuries to either the major vasculature or injury to retroperitoneal organs can mask acute adrenal haemorrhages. Usually adrenal crisis is associated with bilateral adrenal hemorrhage,[11] but our case was unusual as adrenal crisis was noted with unilateral adrenal haemorrhage. Steroids were initiated along with other supportive measures but our patient unfortunately succumbed to his injuries.
CONCLUSION
Our case highlights a rare unilateral adrenal haemorrhage as a cause of shock in trauma. It would be prudent for emergency physicians to have a high index of suspicion for adrenal haemorrhage in trauma patients with unexplained shock especially in blunt abdominal traumas.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
Research quality and ethics statement
The authors followed applicable EQUATOR Network guidelines, notably the CARE guideline, during the conduct of this report.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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