What is the treatment for an adrenal crisis?

Treatment of Adrenal Crisis

Adrenal crisis requires immediate treatment with intravenous hydrocortisone 100 mg bolus followed by 100-300 mg/day as continuous infusion or divided doses every 6 hours, along with rapid administration of 3-4 L isotonic saline. 1, 2

Emergency Management Algorithm

• Immediate intervention: Do not delay treatment for diagnostic procedures. Administer hydrocortisone 100 mg IV bolus immediately 1
• Fluid resuscitation: Administer 0.9% saline 1 L over the first hour, followed by 3-4 L over 24-48 hours with frequent hemodynamic monitoring 1, 2
• Ongoing glucocorticoid administration: Continue hydrocortisone 100-300 mg/day either as:
  • Continuous IV infusion (preferred method based on pharmacokinetic studies) 3
  • OR divided IV/IM boluses every 6 hours 1
• Laboratory assessment: Draw blood for serum cortisol, ACTH, electrolytes (Na, K), creatinine, urea, glucose, and tests for precipitating causes (e.g., infections) 1
• Additional supportive care: Based on severity, consider:
  • ICU/high-dependency unit admission
  • Gastric stress ulcer prophylaxis
  • Low-dose heparin
  • Antibiotic treatment if infection is suspected 1
• Taper: Once stabilized, taper parenteral glucocorticoids over 1-3 days to oral maintenance therapy 1, 2

Clinical Presentation and Diagnosis

• Common symptoms: Malaise, fatigue, nausea, vomiting, abdominal pain (sometimes with peritoneal irritation), muscle pain/cramps, dehydration leading to hypotension and shock 1
• Neurological manifestations: Impaired cognitive function, confusion, loss of consciousness, and coma may occur 1
• Laboratory findings: Hyponatremia, hyperkalemia, increased creatinine (prerenal failure), hypoglycemia (especially in children), and sometimes mild hypercalcemia 1, 4

Common Precipitating Factors

• Gastrointestinal illness with vomiting/diarrhea (most common trigger) 1, 5
• Infections (bacterial or viral) 1
• Surgical procedures without adequate steroid coverage 1
• Physical injuries or trauma 1
• Myocardial infarction 1
• Severe allergic reactions 1
• Severe hypoglycemia in diabetic patients 1
• Treatment failures in poorly educated or non-compliant patients 1, 4

Prevention of Adrenal Crisis

• Patient education: All patients should receive comprehensive education on managing their condition during illness or stress 2, 4
• Medical identification: Patients should wear medical alert jewelry and carry a steroid/emergency card 1, 2
• Emergency kit: Provide supplies for self-injection of parenteral hydrocortisone 4
• Stress dosing guidelines:
  • For minor illness with fever: Double oral glucocorticoid dose until recovery (usually 2-3 days) 2
  • For severe illness, trauma, or persistent vomiting/diarrhea: Parenteral hydrocortisone required (100 mg IM) 4, 6
  • For major surgery: 100 mg hydrocortisone IM just before anesthesia, then 100 mg every 6 hours until able to eat and drink 1
  • For labor and delivery: 100 mg hydrocortisone IM at onset of labor, then double oral dose for 24-48 hours after delivery 1

Common Pitfalls in Management

• Delayed recognition: Failure to recognize impending adrenal crisis leads to increased mortality 7
• Inadequate initial dosing: Underdosing hydrocortisone in acute crisis can be fatal 5
• Insufficient fluid resuscitation: Patients require aggressive fluid replacement 4
• Failure to identify and treat precipitating causes: Addressing the underlying trigger is essential 1
• Premature discontinuation of parenteral therapy: Maintain parenteral therapy until clinical improvement is evident 1
• Inadequate patient education: Many adrenal crises occur because patients don't adjust doses appropriately during illness 4, 6

Follow-up After Crisis

• Evaluate the precipitating cause to prevent future episodes 1
• Review the patient's understanding of stress dosing and self-management 2
• Ensure patient has emergency supplies (injectable hydrocortisone) 4
• Consider annual follow-up with assessment of health, well-being, weight, blood pressure, and electrolytes 2