What is the treatment for an Addisonian crisis?

Addisonian Crisis: Definition and Treatment

An Addisonian crisis (adrenal crisis) is a life-threatening emergency requiring immediate treatment with intravenous hydrocortisone 100 mg bolus and aggressive fluid resuscitation with 0.9% saline, without delaying for diagnostic procedures. 1, 2, 3

Clinical Presentation

• Addisonian crisis presents with hypotension, dehydration, malaise, fatigue, nausea, vomiting, abdominal pain, muscle pain/cramps, and potentially shock 1, 2
• Neurological manifestations may include impaired cognitive function, confusion, loss of consciousness, and coma 1, 2
• Laboratory findings typically include hyponatremia (90% of cases), hyperkalemia (50% of cases), increased creatinine, hypoglycemia, and mild hypercalcemia 2
• Hyperpigmentation of skin is a classic sign of primary adrenal insufficiency due to elevated ACTH levels 2, 3

Emergency Treatment Algorithm

1. Immediate Intervention:

   • Administer hydrocortisone 100 mg IV bolus immediately, without waiting for diagnostic confirmation 1, 3
   • Begin fluid resuscitation with 0.9% saline 1L over the first hour, followed by 3-4L over 24-48 hours 1, 3

2. Ongoing Management:

   • Continue glucocorticoid administration with hydrocortisone 100-300 mg/day, either as continuous IV infusion or divided IV/IM boluses every 6 hours 1, 3
   • Monitor hemodynamic parameters frequently 1
   • Evaluate and treat precipitating causes (infection, trauma, surgery) 3
   • Consider ICU/high-dependency unit admission, gastric stress ulcer prophylaxis, and antibiotic treatment if indicated 1

3. Laboratory Assessment:

   • Secure blood samples for cortisol and ACTH prior to treatment if possible, but never delay treatment for diagnostic procedures 1, 2
   • Monitor serum electrolytes, creatinine, urea, and glucose 1

4. Transition to Maintenance Therapy:

   • Taper parenteral glucocorticoids over 1-3 days once the patient is stabilized 1, 3
   • Transition to oral maintenance therapy with hydrocortisone 15-25 mg daily in divided doses 3
   • Add fludrocortisone 0.1 mg daily (range 0.05-0.2 mg) for mineralocorticoid replacement in primary adrenal insufficiency 4

Common Precipitating Factors

• Gastrointestinal illness with vomiting/diarrhea is the most common trigger 1, 5
• Other precipitating factors include infections, surgical procedures without adequate steroid coverage, physical injuries or trauma, myocardial infarction, severe allergic reactions, and abrupt termination of glucocorticoid therapy 1, 6, 7
• Even mild upset stomach can precipitate a crisis as patients may not absorb their oral medication when they need it most 8

Prevention of Future Crises

• Patient education on managing their condition during illness or stress is essential 1, 3
• Provide specific stress dosing guidelines: double or triple oral glucocorticoid dose during minor illness and use parenteral hydrocortisone during severe illness 1, 3
• Ensure patients have emergency supplies, including injectable hydrocortisone 1, 3
• Recommend medical identification (medical alert jewelry and emergency steroid card) 1, 3

Special Situations Requiring Dose Adjustments

• Surgery: Follow stress dosing protocols based on procedure severity 8

  • Major surgery: 100 mg hydrocortisone IM before anesthesia, continue 100 mg every 6 hours until able to take oral medication 8
  • Minor surgery: 100 mg hydrocortisone IM before anesthesia, then double oral dose for 24 hours 8

• Pregnancy: Increased requirements during third trimester; during delivery, administer 100 mg hydrocortisone IM at onset of labor 8

• Physical activity: Regular activity usually doesn't require dose adjustment, but unaccustomed intense or prolonged exercise may require increased hydrocortisone and salt intake 8

Complications and Pitfalls

• Failure to recognize early symptoms can lead to increased mortality 5, 7
• Delayed or insufficient treatment can result in cardiogenic shock and respiratory failure 9
• Rapid reduction in hydrocortisone dosage after crisis can lead to cardiovascular insufficiency requiring re-escalation of therapy 6
• Secondary adrenal insufficiency from pituitary apoplexy can present as Addisonian crisis and may be overlooked 10