True statements concerning hypoadrenal shock include which of the following?

A. Adrenocortical insufficiency may manifest itself as severe shock refractory to volume and pressor therapy.

D. The rapid adrenocorticotropic hormone (ACTH) stimulation test should be performed to help establish the diagnosis of acute adrenocortical insufficiency.

DISCUSSION: Shock due to acute adrenocortical insufficiency is relatively uncommon but must be considered when shock refractory to volume replacement and pressor therapy is present. Hypoglycemia may be present. Patients with high metabolic stress may exhibit adrenal insufficiency only under conditions of severe stress; thus, a history of adrenal insufficiency or steroid dependency need not be elicited. When adrenocortical insufficiency is suspected, the rapid ACTH (cosyntropin) stimulation test should be performed. Serum cortisol levels should be drawn before intravenous administration of 250 mg. of cosyntropin, and 30 and 60 minutes afterward. A peak cortisol level of less than 20 mg./100 ml. suggests abnormal adrenal function. In a hemodynamically unstable patient therapy should be instituted before the test results become available. Dexamethasone does not interfere with the cortisol assay, and it is the corticosteroid of choice while the ACTH stimulation test is being performed.