From the Guidelines
Parents should be advised to seek immediate medical attention if their child exhibits signs of adrenal crisis, including severe fatigue, weakness, confusion, nausea, vomiting, abdominal pain, and dizziness upon standing, as these symptoms can develop quickly, especially during illness, injury, or stress. According to the guidelines for the management of glucocorticoids during the peri-operative period for patients with adrenal insufficiency 1, it is essential to recognize the warning signs of adrenal crisis, which can be precipitated by various triggers, including gastroenteritis, fever, surgical episodes, pregnancy, emotional distress, and other wide-ranging triggers.
Some key signs to look out for include:
- Low blood pressure
- Rapid heart rate
- Fever without obvious infection
- Loss of consciousness in severe cases
- Severe fatigue, weakness, and confusion
- Nausea, vomiting, and abdominal pain
- Dizziness upon standing
It is crucial for parents to be aware of these signs, especially if their child has known adrenal insufficiency, as the incidence of adrenal crisis in patients with primary and secondary adrenal insufficiency can be as high as 8.3 per 100 replacement years, with a significant risk of mortality 1. Parents should administer emergency hydrocortisone (typically Solu-Cortef) via injection at the first signs of crisis, usually at a dose of 50-100mg for older children or 25-50mg for younger children, as prescribed by their doctor. Additionally, parents should always have an emergency kit containing injectable hydrocortisone, know how to use it, and ensure their child wears a medical alert bracelet to ensure prompt treatment in case of an adrenal crisis.
From the Research
Signs of Adrenal Crisis in Children
To safety net a mum about signs to look out for in their child of adrenal crisis, it is essential to educate her on the potential symptoms and risk factors. Some of the key signs include:
- Systemic illness, such as infection, which can precipitate an adrenal crisis 2, 3
- Physical stress, including surgical procedures or trauma 2
- Forgetting or discontinuing glucocorticoid therapy 2
- Pronounced physical activity or psychological stress 2
- Gastrointestinal illness, which is a common precipitant for an adrenal crisis 3
Prevention and Management
Prevention of adrenal crisis is centered around patient education, and all patients should be educated on:
- Stress dosing and parenteral glucocorticoid administration 2
- Carrying a steroid dependency alert card and wearing a medical alert bracelet or similar identification 2
- The importance of increasing glucocorticoid doses or switching to parenteral injections during times of stress 3
- The potential risks of psychosis induced by high doses of hydrocortisone, particularly in patients with a history of mental health issues 4
Treatment
In the event of an adrenal crisis, prompt recognition and administration of parenteral hydrocortisone, rehydration, and management of electrolyte abnormalities are crucial 2. The most appropriate mode of hydrocortisone delivery during major stress is continuous intravenous infusion, which can help maintain cortisol concentrations in the required range 5.