What is the immediate treatment for adrenal infarction?

Immediate Treatment for Adrenal Infarction

The immediate treatment for adrenal infarction requires prompt administration of hydrocortisone 100 mg IV immediately, followed by a continuous infusion of hydrocortisone at 200 mg/24h, along with fluid resuscitation using normal saline (10-20 ml/kg; maximum 1,000 ml). 1

Initial Management

1. First-line interventions:

   • Administer hydrocortisone 100 mg IV immediately 1
   • Start continuous IV hydrocortisone infusion at 200 mg/24h 1
   • Alternatively, hydrocortisone 50 mg every 6 hours by IM injection if continuous infusion is not available 2
   • Provide fluid resuscitation with normal saline (10-20 ml/kg; maximum 1,000 ml) 1

2. Monitoring and supportive care:

   • Monitor vital signs, especially blood pressure and temperature
   • Assess for signs of improvement in hypotension and other symptoms
   • Consider vasopressors if hypotension persists despite adequate fluid resuscitation 1

Pediatric Dosing Considerations

For children with adrenal infarction, weight-based dosing should be used:

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

2, 1

Post-Stabilization Management

After initial stabilization:

• Continue hydrocortisone at high doses until the patient is hemodynamically stable 1
• Once stabilized, transition to oral glucocorticoid at double the pre-event therapeutic dose for 48 hours if recovery is uncomplicated 2
• If complications persist, continue double oral dose for up to a week 2
• Add mineralocorticoid replacement (fludrocortisone) once enteral feeding is established, particularly for primary adrenal insufficiency 2, 1

Clinical Pearls and Pitfalls

• Common pitfall: Delayed recognition of adrenal insufficiency can be life-threatening. Maintain a high index of suspicion in patients with risk factors such as antiphospholipid syndrome or anticoagulant therapy 3, 4
• Important caveat: Adrenal infarction from adrenal vein thrombosis or hemorrhagic infarction is a rare but potentially fatal complication that requires immediate treatment 3
• Warning sign: Hypothermia can be a presenting feature of adrenal crisis, alongside hypotension and other symptoms 1
• Diagnostic consideration: In patients with vasopressor-resistant hypotension, adrenal insufficiency should be considered 1

Patient Education

Once stabilized, provide education on:

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

Adrenal infarction is a medical emergency requiring immediate glucocorticoid replacement therapy. Delays in treatment can significantly increase morbidity and mortality, making prompt recognition and intervention essential for patient survival.