How do you diagnose and manage adrenal crisis?

Diagnosis and Management of Adrenal Crisis

Adrenal crisis is a life-threatening emergency characterized by acute adrenal insufficiency requiring immediate treatment with intravenous hydrocortisone 100mg bolus followed by continuous infusion of 200-300mg/24h, and rapid fluid resuscitation with isotonic saline to prevent mortality. 1

Diagnostic Approach

Clinical Presentation

• Typical symptoms and signs:
  • Profound impairment of well-being
  • Hypotension (often severe)
  • Nausea and vomiting
  • Fever
  • Weakness
  • Muscle/joint pain
  • Drowsiness or altered mental status 2, 3

Laboratory Findings

• Critical diagnostic tests:
  • Low serum cortisol (often <100 nmol/L)
  • Primary adrenal insufficiency: High ACTH with low cortisol
  • Secondary adrenal insufficiency: Low ACTH with low cortisol
  • Electrolyte abnormalities (primary AI): Hyponatremia, hyperkalemia
  • Hypoglycemia may be present 1, 4

Differentiating Primary vs Secondary Adrenal Insufficiency

Type	ACTH Level	Cortisol Level	Electrolytes	Hyperpigmentation
Primary	High	Low	↓Na, ↑K	Present
Secondary	Low	Low	Generally normal	Absent
[1]

Immediate Management

First-Line Treatment

1. Hydrocortisone administration:

   • 100mg IV bolus immediately
   • Follow with continuous infusion of 200mg/24h or 50mg every 6 hours until stabilized 1

2. Fluid resuscitation:

   • Rapid IV isotonic saline (0.9% NaCl) administration
   • 1000ml within the first hour 2

3. Glucose administration:

   • If hypoglycemia is present 5

4. Identify and treat the underlying trigger:

   • Infections (most common precipitating factor)
   • Trauma
   • Surgery
   • Severe psychological stress 2, 3

Dosing Adjustments Based on Patient Size

Weight	Induction Dose	Maintenance Dose
Up to 10 kg	2 mg/kg IV	25 mg/24h
11-20 kg	2 mg/kg IV	50 mg/24h
Over 20 kg (prepubertal)	2 mg/kg IV	100 mg/24h
Over 20 kg (pubertal)	2 mg/kg IV	150 mg/24h
[1]

Prevention of Adrenal Crisis

Stress Dosing Guidelines

• Minor illness with fever <38°C:

  • Double the oral hydrocortisone dose

• Moderate illness with fever >38°C, vomiting, or diarrhea:

  • Triple the oral dose or use parenteral hydrocortisone

• Severe illness or surgery:

  • 100mg hydrocortisone IV/IM before procedure, then every 6 hours 1

Patient Education (Critical for Prevention)

• Stress dosing instructions
• Emergency injectable hydrocortisone use
• Medical alert bracelet/card identification
• Recognition of early warning signs of adrenal crisis 1, 2

Common Pitfalls and Caveats

1. Delayed diagnosis:

   • Non-specific symptoms may lead to missed diagnosis
   • High index of suspicion needed, especially in patients with risk factors 5, 4

2. Inadequate treatment:

   • Insufficient hydrocortisone dosing
   • Inadequate fluid resuscitation
   • Failure to identify and treat underlying trigger 3

3. Prevention failures:

   • Insufficient patient education
   • Lack of emergency hydrocortisone kit
   • Failure to adjust doses during stress 2, 6

4. Confirmatory testing:

   • While cosyntropin stimulation test or insulin tolerance test can confirm diagnosis, treatment should never be delayed for testing when adrenal crisis is suspected 4

Special Considerations

• Pregnancy: Hydrocortisone dose may need to be increased by 2.5-10mg daily in the third trimester 1

• Night shift workers: Should adjust their schedule according to work pattern 1

• Medication interactions: Anti-epilepsy medications, barbiturates, antituberculosis drugs may require increased steroid dosing 1

Remember that adrenal crisis is associated with significant mortality (estimated at 0.5/100 patient years) and requires immediate recognition and treatment 2. The cornerstone of management is prompt administration of parenteral hydrocortisone and fluid resuscitation, followed by identification and treatment of the precipitating cause.