What is the management for adrenal crisis?

Management of Adrenal Crisis

Adrenal crisis requires immediate treatment with intravenous hydrocortisone 100 mg bolus followed by continuous infusion of 200 mg over 24 hours, along with rapid fluid resuscitation using isotonic saline. 1

Immediate Management

First-line Treatment

• Hydrocortisone administration:
  • Immediate IV/IM hydrocortisone 100 mg bolus 1
  • Follow with continuous IV infusion of 200 mg over 24 hours 2, 1
  • If continuous infusion not available, administer 100 mg IV/IM every 6-8 hours until clinical improvement 1

Fluid Resuscitation

• Rapid administration of isotonic (0.9%) saline:
  • 1000 ml within the first hour 1
  • Total of 3-4 L as needed based on hemodynamic status 1
  • Monitor for fluid overload in susceptible patients

Monitoring

• Continuous monitoring of:
  • Hemodynamic parameters (blood pressure, heart rate)
  • Electrolytes (particularly sodium and potassium)
  • Blood glucose
  • Clinical response to treatment

Underlying Cause Management

• Identify and treat precipitating factors:
  • Infections (most common trigger) 3
  • Gastroenteritis 1
  • Surgery or trauma
  • Medication omission
  • Emotional stress

Transition to Maintenance Therapy

Post-Crisis Management

• Once stabilized and able to take oral medications:
  • Double the regular oral replacement dose of hydrocortisone for 48 hours 2, 1
  • Continue increased dose for up to one week following major stress events 2
  • Example: If usual dose is 10-5-5 mg hydrocortisone, increase to 20-10-10 mg 2
  • Gradually taper to maintenance dose over a period of up to one week 1

Maintenance Therapy

• Resume regular replacement therapy once recovered:
  • Hydrocortisone 15-25 mg daily in divided doses 1
  • For primary adrenal insufficiency: add fludrocortisone 50-200 μg daily 1

Prevention of Future Adrenal Crises

Patient Education (Critical Component)

• Instruct patients on:
  • Early recognition of adrenal crisis symptoms 1
  • Stress dosing protocols for illness or stress 1
  • Proper use of emergency hydrocortisone injection kit 1
  • Importance of wearing medical alert identification 1
  • Carrying a steroid alert card 1

Stress Dosing Protocol

• Minor illness/stress: Double or triple usual daily dose 1
• Moderate stress: Hydrocortisone 50-75 mg/day in divided doses 1
• Severe stress: Hydrocortisone 100 mg IV immediately followed by 200-300 mg/day 1

Special Considerations

Perioperative Management

• Pre-operative: Hydrocortisone 100 mg IV just before anesthesia 1
• Post-operative: Continue hydrocortisone 100 mg IV every 6 hours until able to eat and drink 1

Common Pitfalls to Avoid

1. Delaying treatment while awaiting diagnostic confirmation - treatment should never be delayed 1
2. Inadequate fluid resuscitation - hypotension may not respond to steroids alone
3. Failure to identify and treat the underlying trigger
4. Premature reduction of steroid doses before full recovery
5. Inadequate patient education on prevention strategies

Adrenal crisis carries significant mortality risk (0.5/100 patient-years) 3, making prompt recognition and aggressive treatment essential for survival. The continuous IV infusion method has been shown to be superior to intermittent bolus administration in maintaining appropriate cortisol levels during major stress 4.