Adrenal Crisis: Definition and Management
Adrenal crisis is a life-threatening emergency characterized by acute adrenal insufficiency requiring immediate treatment with intravenous hydrocortisone 100mg and fluid resuscitation to prevent mortality. 1, 2
Definition and Clinical Presentation
Adrenal crisis is an acute, severe manifestation of adrenal insufficiency that can rapidly progress to shock and death if not promptly recognized and treated. It typically presents with:
- Profound impairment of well-being
- Hypotension/shock
- Nausea and vomiting
- Fever
- Abdominal pain
- Altered mental status
- Electrolyte abnormalities (hyponatremia, hyperkalemia in primary adrenal insufficiency)
Even mild illnesses like an upset stomach can precipitate an adrenal crisis, as patients cannot absorb their oral medication when they need it most 1.
Common Triggers
- Infections (most common precipitant)
- Surgery or medical procedures
- Physical trauma
- Severe emotional stress
- Omission of regular glucocorticoid medication
- Vomiting or diarrhea preventing absorption of oral medication
Emergency Management
Immediate Treatment
- Hydrocortisone 100mg IV bolus immediately (dexamethasone can be used if diagnosis is uncertain and testing is needed) 1, 2
- Rapid IV isotonic saline (0.9%) infusion - 1000ml within the first hour 2, 3
- Continue hydrocortisone 100mg IV every 6 hours or 200mg/24h as continuous infusion until stabilized 1, 2, 3
- Treat underlying precipitating cause (especially infection)
- Monitor vital signs, electrolytes, and glucose
Subsequent Management
- Once able to eat and drink, transition to oral hydrocortisone at double the usual dose for 24-48 hours, then taper to maintenance dose 1
- For primary adrenal insufficiency, resume mineralocorticoid replacement (fludrocortisone) once off IV hydrocortisone
Prevention Strategies
Stress Dosing Guidelines
- Minor illness (fever <38°C): Double oral hydrocortisone dose for duration of illness
- Moderate illness (fever >38°C, vomiting, diarrhea): Triple oral dose or use parenteral hydrocortisone
- Severe illness/surgery: 100mg hydrocortisone IV/IM before procedure, then every 6 hours until recovery 1, 2
Special Situations
- Major surgery with long recovery: 100mg hydrocortisone IM pre-anesthesia, continue 100mg IM every 6 hours until able to eat/drink, then double oral dose for 48+ hours before tapering 1
- Labor and delivery: 100mg hydrocortisone IM at onset of labor, double oral dose for 24-48 hours after delivery 1, 2
- Dental procedures: Extra morning dose 1 hour prior to surgery, double oral dose for 24 hours 1
Patient Education - Critical for Prevention
Every patient with adrenal insufficiency should have:
- Medical alert bracelet/card identifying adrenal insufficiency 1, 2
- Emergency kit with injectable hydrocortisone 2, 3
- Education on stress dosing and when to seek medical attention 2
- Training on self-administration of parenteral hydrocortisone 3
Differentiating Primary vs. Secondary Adrenal Insufficiency
| Feature | Primary Adrenal Insufficiency | Secondary Adrenal Insufficiency |
|---|---|---|
| ACTH Level | High | Low |
| Electrolytes | Low sodium, high potassium | Usually normal |
| Hyperpigmentation | Present | Absent |
| Mineralocorticoid need | Yes | No |
Common Pitfalls in Management
- Delayed diagnosis due to nonspecific symptoms
- Inadequate stress dosing during illness or procedures
- Failure to recognize early signs of impending crisis
- Insufficient patient education about emergency management
- Delayed administration of parenteral hydrocortisone in emergency situations
- Inadequate fluid resuscitation during crisis
Adrenal crisis remains a significant cause of mortality in patients with adrenal insufficiency, with an estimated mortality rate of 0.5/100 patient-years 3. Prompt recognition and treatment are essential to prevent death from this treatable condition.