Key Points
- Stabilize ABCs; begin targeted evaluation without delaying life-saving therapy.
- Use system-specific risk tools to guide testing and disposition.
- Order high-yield tests first; escalate imaging when indicated.
- Start evidence-based initial therapy and reassess frequently.
Algorithm
- Primary survey and vitals; IV access and monitors.
- Focused history/physical; identify red flags and likely etiologies.
- Order system-appropriate labs and imaging (see Investigations).
- Initiate guideline-based empiric therapy (see Pharmacology).
- Reassess response; arrange consultation and definitive management.
Clinical Synopsis & Reasoning
For Cushing Syndrome Screening Localization, frame the differential by acuity and pathophysiology, then align diagnostics to the leading hypotheses. Prioritize stabilization while obtaining high‑yield studies such as BMP (Electrolytes/anion gap), Ketones (if DKA) (Ketoacidosis), ABG/VBG (Acid–base status). Incorporate bedside imaging and targeted labs to define severity and identify complications; synthesize results with clinical trajectory to refine the working diagnosis and disposition needs.
Treatment Strategy & Disposition
Initiate disease‑directed therapy alongside supportive care, titrating to objective response. Pharmacologic options commonly include Insulin, Dextrose, Electrolytes (K+, Mg2+). Use validated frameworks (e.g., Screening Tests — Typical Positive Thresholds) to guide escalation and site of care. Address precipitating factors, de‑escalate empiric therapies with data, and arrange follow‑up for monitoring and risk‑factor modification; admit patients with instability, high risk of deterioration, or needs for close monitoring.
Epidemiology / Risk Factors
- Diabetes and endocrine disorders depending on topic
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| BMP | Electrolytes/anion gap | Derangements | |
| Ketones (if DKA) | Ketoacidosis | Positive | |
| ABG/VBG | Acid–base status | Acidosis/alkalosis |
Screening Tests — Typical Positive Thresholds
| Test | Positive |
|---|---|
| 1‑mg DST | AM cortisol >1.8 µg/dL |
| Late‑night salivary cortisol | Above lab ULN on two samples |
| 24‑h UFC | >ULN on two collections |
| Exclude pseudo‑Cushing | Alcoholism, depression, obesity |
| Repeat/confirm | Discordant results require repetition |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Lorazepam (pre-procedure) | GABA-A agonism | Hours | Claustrophobia/anxiety during imaging | Sedation |
| Prednisone + diphenhydramine (premed) | Steroid + H1 blocker | Hours | Only for prior contrast reaction | Hyperglycemia/sedation |
Prognosis / Complications
- Improves with derangement correction; recurrence if triggers persist
Patient Education / Counseling
- Explain red flags and when to seek emergent care.
- Reinforce medication adherence and follow-up plan.
Clinical Notes
Control comorbidities (HTN, DM, osteoporosis). Medical therapy (ketoconazole, metyrapone, osilodrostat) may be used pre‑op or for recurrence; monitor for adrenal insufficiency.
References
- Endocrine Society — Cushing’s Syndrome — Link