What is the treatment for an adrenal crisis presentation with hypotension and dehydration?

Treatment of Adrenal Crisis with Hypotension and Dehydration

Immediate treatment of adrenal crisis requires prompt administration of hydrocortisone 100 mg IV bolus followed by aggressive fluid resuscitation with 0.9% saline 1L over the first hour, without delaying for diagnostic confirmation. 1, 2, 3

Emergency Management Algorithm

• Administer hydrocortisone 100 mg IV bolus immediately, without waiting for diagnostic test results 1, 2, 3
• Begin fluid resuscitation with 0.9% saline 1L over the first hour, followed by 3-4L over 24-48 hours 1, 4
• Continue glucocorticoid administration with hydrocortisone 100-300 mg/day, either as:
  • Continuous IV infusion, or
  • Divided IV/IM boluses every 6 hours 4, 1
• Obtain blood samples for laboratory assessment (before or concurrent with treatment):
  • Serum cortisol, ACTH
  • Electrolytes (Na, K)
  • Creatinine, urea, glucose
  • Tests for precipitating causes (bacterial/viral infections) 4, 1
• Monitor hemodynamic parameters and electrolytes frequently to avoid fluid overload 4
• Consider ICU/high-dependency unit admission for severe cases 4, 1
• Provide additional supportive care as needed:
  • Gastric stress ulcer prophylaxis
  • Low-dose heparin
  • Antibiotic treatment if infection is suspected 4, 1

Clinical Recognition

Adrenal crisis typically presents with:

• Hypotension and shock 4
• Dehydration 2, 5
• Malaise, fatigue, nausea, vomiting, abdominal pain 4, 2
• Impaired cognitive function, confusion, loss of consciousness 4, 2
• Laboratory findings: hyponatremia, hyperkalemia, increased creatinine, hypoglycemia (especially in children), and sometimes mild hypercalcemia 4, 6

Transition to Maintenance Therapy

• Taper parenteral glucocorticoids over 1-3 days to oral maintenance therapy once the patient is stabilized 4, 3
• Restart mineralocorticoid replacement with fludrocortisone when hydrocortisone dose falls below 50 mg/day (for primary adrenal insufficiency) 4, 7
• For maintenance therapy, hydrocortisone is the preferred glucocorticoid at a total daily dose of 15-25 mg divided into 2-3 doses 3, 7

Prevention of Future Crises

• Identify and address precipitating causes of the adrenal crisis 4, 5
• Reinforce patient education on stress dosing during illness or stress 1, 2
• Instruct patients to:
  • Double or triple oral glucocorticoid doses during minor illness
  • Use parenteral hydrocortisone during severe illness or if unable to tolerate oral medications 2, 5
• Ensure patients have emergency supplies, including injectable hydrocortisone 1, 5
• Recommend medical identification (medical alert jewelry and emergency steroid card) 1, 2

Important Considerations and Pitfalls

• Do not delay treatment while waiting for diagnostic confirmation - this can be life-threatening 1, 8
• Continuous IV hydrocortisone infusion may be superior to intermittent bolus administration in severe cases 9
• Infections are the most common precipitating cause of adrenal crisis, with gastrointestinal illness being particularly common 5, 8
• Hypercalcemia can be a rare but important manifestation of adrenal crisis that resolves with appropriate glucocorticoid treatment 6
• Patients on chronic glucocorticoid therapy are at risk for adrenal crisis if medication is abruptly discontinued 10, 7

Remember that adrenal crisis is a medical emergency with significant mortality if not promptly and appropriately treated. The cornerstone of management is immediate hydrocortisone administration and aggressive fluid resuscitation.