What are the initial management steps for suspected Addisonian crisis?

Diagnosis and Initial Management of Adrenal Crisis

Immediate administration of hydrocortisone 100 mg IV bolus followed by 100-300 mg/day as a continuous infusion or divided doses every 6 hours is the essential first step in managing suspected Addisonian crisis, along with rapid IV isotonic saline and blood glucose monitoring. 1

Clinical Presentation and Diagnosis

Adrenal crisis presents with:

• Hypotension (often refractory to fluids)
• Fever (can mimic sepsis)
• Nausea, vomiting, abdominal pain
• Weakness, lethargy, drowsiness
• Hyponatremia, hyperkalemia (in primary adrenal insufficiency)
• Hypoglycemia (due to impaired gluconeogenesis)

Laboratory findings to confirm diagnosis:

• Low serum cortisol
• Primary adrenal insufficiency: high ACTH, low cortisol, low sodium, high potassium, hyperpigmentation
• Secondary adrenal insufficiency: low ACTH, low cortisol, generally normal electrolytes, no hyperpigmentation 1

Immediate Management Algorithm

1. Recognize the emergency - Do not delay treatment while awaiting confirmatory tests

2. Initial resuscitation:

   • Hydrocortisone 100 mg IV bolus immediately
   • Rapid IV isotonic saline (1L within first hour)
   • Check blood glucose (hourly if fasting >4 hours)
   • Treat hypoglycemia if present 1

3. Maintenance therapy:

   • Continue hydrocortisone 100-300 mg/day as continuous infusion or divided doses every 6 hours
   • Continue IV fluids based on hemodynamic status
   • Monitor electrolytes, particularly sodium and potassium 1

4. Identify and treat precipitating factors:

   • Infection (most common trigger)
   • Trauma or surgery
   • Medication discontinuation
   • Physical or psychological stress 2

Transition to Maintenance Therapy

Once the patient is stabilized:

• Transition to oral hydrocortisone (typically 15-25 mg daily in divided doses, with 2/3 in morning and 1/3 in afternoon) 1
• Add fludrocortisone 0.1 mg daily for primary adrenal insufficiency 3
• Taper steroid doses gradually to maintenance levels

Pitfalls to Avoid

• Delayed diagnosis: Symptoms can mimic sepsis or other critical illnesses 4
• Inadequate initial dosing: Underdosing steroids can lead to continued deterioration 1
• Premature dose reduction: As demonstrated in case reports, reducing hydrocortisone too quickly can lead to recurrent crisis 5
• Failure to identify underlying cause: Pituitary apoplexy can present as adrenal crisis and requires specific management 4
• Inadequate patient education: Patients need clear instructions on stress dosing and emergency management 1

Special Considerations

• Perioperative management: Patients with known adrenal insufficiency require stress-dose steroids for procedures (hydrocortisone 100 mg IV at induction for major surgery) 1
• Infection risk: Corticosteroids may mask signs of infection and increase susceptibility to infections, including fungal infections 6
• Drug interactions: Many medications affect steroid metabolism, particularly hepatic enzyme inducers/inhibitors and estrogens 6

Patient Education

After stabilization, ensure patients:

• Wear medical alert bracelet/card
• Understand stress dosing protocols
• Have emergency injectable hydrocortisone
• Receive education on recognizing early signs of crisis 1