What is the treatment for an adrenal crisis?

Treatment of Adrenal Crisis

The immediate treatment for adrenal crisis requires intravenous hydrocortisone 100 mg bolus followed by 200-300 mg/day as continuous infusion or divided doses every 6 hours, along with rapid administration of isotonic saline (1000 ml within the first hour). 1

Initial Management

1. Immediate interventions:

   • Administer hydrocortisone 100 mg IV immediately as bolus dose 1, 2, 3
   • Follow with continuous IV infusion of hydrocortisone 200-300 mg/24 hours or divided doses every 6 hours 1, 2
   • Rapid IV administration of 0.9% isotonic saline (1000 ml within first hour) 2
   • Monitor blood glucose levels 1

2. Fluid resuscitation:

   • Continue fluid resuscitation based on hemodynamic status
   • Aim to correct hypovolemia and electrolyte abnormalities (particularly hyponatremia and hyperkalemia) 1

Ongoing Management

1. Maintenance therapy:

   • Continue parenteral glucocorticoids until patient stabilizes 1
   • Taper parenteral glucocorticoids over 1-3 days to oral maintenance therapy once patient is stable 1
   • Typical maintenance dose: 15-25 mg/day divided into 2-3 doses for adults 1

2. Post-crisis monitoring:

   • Monitor serum electrolytes, especially sodium and potassium 1
   • Check blood glucose regularly 1
   • Assess blood pressure and heart rate
   • Monitor for signs of recovery or deterioration

Special Populations

1. Children:

   • Bolus dose: 2 mg/kg IV at induction 1
   • Maintenance doses based on weight:
     • Up to 10 kg: 25 mg/24h
     • 11-20 kg: 50 mg/24h
     • Over 20 kg (prepubertal): 100 mg/24h
     • Over 20 kg (pubertal): 150 mg/24h 1
   • Children require more frequent blood glucose monitoring than adults 4

2. Pregnant patients:

   • Higher maintenance doses may be required during later stages of pregnancy (after 20 weeks) 4
   • During labor: hydrocortisone 100 mg at onset, then either continuous IV infusion of 200 mg/24h or 50 mg intramuscularly every 6 hours until after delivery 4

Addressing the Precipitating Cause

Infections are the major precipitating causes of adrenal crisis 2. Other triggers include:

• Gastrointestinal illness 5
• Major trauma
• Surgery
• Severe psychological or physical stress 3

Identify and treat the underlying cause while providing glucocorticoid support.

Prevention of Future Crises

1. Patient education:

   • Provide clear written instructions for emergency situations 1
   • Ensure patient carries an emergency card 2
   • Supply emergency kit for parenteral hydrocortisone self-administration 2

2. Stress dosing protocol for future illness:

   • Minor illness/stress: double or triple usual daily dose
   • Moderate stress: hydrocortisone 50-75 mg/day in divided doses
   • Severe stress: hydrocortisone 100 mg IV immediately followed by higher doses as outlined above 1

3. Post-surgery or major stress recovery:

   • Maintain double the usual hydrocortisone dose for 48 hours if recovery is uncomplicated
   • Continue elevated dosing for up to one week if complications occur 1

Clinical Pearls and Pitfalls

• Do not delay treatment while awaiting confirmation of diagnosis - adrenal crisis is life-threatening with significant mortality risk 3, 5
• Continuous IV hydrocortisone infusion is superior to intermittent bolus administration during major stress 6
• Hydrocortisone is preferred over other glucocorticoids for adrenal crisis as it has both glucocorticoid and mineralocorticoid activity 7
• Patients with primary adrenal insufficiency require both glucocorticoid and mineralocorticoid replacement, while secondary adrenal insufficiency requires glucocorticoid replacement only 1
• Despite patient education on "sick day rules," many patients and physicians are reluctant to increase glucocorticoid doses or switch to parenteral administration, which can lead to deterioration 5

Remember that early recognition and prompt treatment are essential for preventing mortality from adrenal crisis, with an estimated mortality rate of 0.5/100 patient years even with modern treatment 2.