An important but easily overlooked medical complication of multiple trauma

A 53-year-old man was trapped under a hydraulic lift on the back of his lorry trailer. He was found to have spinal injuries with a comminuted unstable fracture of T6 and stable fracture of T12. He had further fractures of the left first rib, right second rib, and his sternum. He was admitted to the orthopaedic ward for conservative management with a spinal splint for five weeks. He remained stable until day 20 of his admission when he became hypotensive and tachycardic. Blood tests demonstrated hyponatraemia and hyperkalaemia. Despite fluid resuscitation and emergency treatment for hyperkalaemia he remained hypotensive and hyponatraemic. An endocrine opinion was requested and he was found to have an abnormal short synacthen test (cortisol of 436 nmol/L falling to 398 nmol/L at 30 min). ACTH was high at 208 ng/L, and thyroid function tests were normal (TSH 2.02 mU/L, FT4 15.4 pmol/L) indicating an intact pituitary axis. His hypotension and electrolyte abnormality rapidly responded to glucocorticoid and mineralocorticoid treatment. A repeat short synacthen test has confirmed persistent hypoadrenalism (peak cortisol 175 nmol/L at 30 min). Although the adrenal glands lie retroperitoneally at the level of T12 which was fractured, a CT scan at the time of trauma showed no signs of adrenal gland damage. A repeat scan one year post event showed no calcification to suggest previous haemorrhage.