Should steroids be started routinely in patients with adrenal hemorrhage?

Management of Adrenal Hemorrhage: Steroid Therapy Approach

Steroids should not be administered routinely to all patients with adrenal hemorrhage, but should be reserved for those who demonstrate clinical or biochemical evidence of adrenal insufficiency.

Diagnostic Approach for Adrenal Hemorrhage

When evaluating a patient with suspected or confirmed adrenal hemorrhage, follow this algorithm:

1. Assess for signs and symptoms of adrenal insufficiency:

   • Hypotension (especially refractory to fluids)
   • Hyponatremia
   • Hyperkalemia
   • Unexplained fever
   • Fatigue, weakness, nausea, vomiting

2. Laboratory evaluation:

   • Morning cortisol level (baseline)
   • ACTH level
   • Electrolytes (sodium, potassium)
   • If possible, perform ACTH stimulation test

Treatment Decision Algorithm

For patients WITH signs of adrenal insufficiency:

• Immediate treatment: Hydrocortisone 100 mg IV bolus followed by 50 mg IV every 6 hours until stabilized 1
• Maintenance therapy: Once stabilized, transition to oral hydrocortisone 15-25 mg/day in divided doses (typically 10 mg in morning, 5 mg at noon, 2.5 mg in afternoon) 1

For patients WITHOUT signs of adrenal insufficiency:

• Monitor closely without routine steroid administration
• Low threshold to administer stress-dose steroids if hypotension develops 2
• Serial cortisol testing to detect developing insufficiency

Special Considerations

Bilateral vs. Unilateral Hemorrhage

• Bilateral adrenal hemorrhage more likely to cause insufficiency
• Unilateral hemorrhage rarely causes clinically significant insufficiency unless pre-existing adrenal disease exists

Anticoagulant-Related Adrenal Hemorrhage

• Requires high index of suspicion as symptoms may be nonspecific
• Prompt diagnosis and treatment with replacement doses of corticosteroids can be lifesaving 3
• Not all patients with anticoagulant-related adrenal hemorrhage require steroid therapy if adrenal function remains adequate

Trauma-Related Adrenal Hemorrhage

• Up to 60% of trauma patients may experience relative adrenal insufficiency 4
• Consider adrenal insufficiency in trauma patients with unexplained hypotension
• Do not administer empiric steroids routinely unless evidence of adrenal insufficiency exists

Long-Term Management for Those Requiring Steroids

For patients who develop adrenal insufficiency requiring long-term steroid therapy:

1. Patient education:

   • Stress dosing instructions
   • Medical alert bracelet/card identifying adrenal insufficiency 1
   • Recognition of early warning signs of adrenal crisis

2. Stress dose adjustments:

   • Minor illness with fever <38°C: Double oral dose
   • Moderate illness with fever >38°C: Triple oral dose or use parenteral hydrocortisone
   • Severe illness or surgery: 100 mg hydrocortisone IV/IM before procedure, then every 6 hours 1

3. Monitoring for adequate replacement:

   • Signs of over-replacement: weight gain, insomnia, peripheral edema
   • Signs of under-replacement: lethargy, nausea, poor appetite, weight loss 1

Conclusion

The decision to start steroids in patients with adrenal hemorrhage should be based on clinical and biochemical evidence of adrenal insufficiency rather than administered routinely. Prompt recognition and treatment of adrenal insufficiency when present is critical for preventing adrenal crisis and reducing mortality.