What are the symptoms and treatment of an adrenal crisis?

Symptoms and Treatment of Adrenal Crisis

Adrenal crisis is a life-threatening emergency characterized by malaise, fatigue, nausea, vomiting, abdominal pain, muscle pain/cramps, dehydration leading to hypotension and shock, often accompanied by impaired cognitive function including confusion, loss of consciousness, and coma. 1

Clinical Presentation

• Systemic symptoms include profound malaise, fatigue, and generalized weakness 1, 2
• Gastrointestinal manifestations include nausea, vomiting, and abdominal pain (sometimes with peritoneal irritation) 1, 3
• Cardiovascular signs include dehydration, hypotension, and shock 1, 2
• Neurological symptoms include impaired cognitive function, confusion, loss of consciousness, and coma 1, 3
• Laboratory abnormalities typically show hyponatremia, hyperkalemia, increased creatinine (from prerenal renal failure), hypoglycemia (especially in children), and sometimes mild hypercalcemia 1

Common Precipitating Factors

• Gastrointestinal illness with vomiting and/or diarrhea is the most common trigger 1, 4
• Other common triggers include infections, surgical procedures without adequate steroid coverage, physical injuries/trauma, myocardial infarction, severe allergic reactions, and severe hypoglycemia in diabetic patients 1, 3
• Treatment failures in poorly educated or non-compliant patients can also precipitate crisis 1, 5

Emergency Management

Immediate Actions (First Hour)

• Administer hydrocortisone 100 mg IV bolus immediately without delay for diagnostic testing 2, 3
• Draw blood for serum cortisol, ACTH, electrolytes, creatinine, urea, glucose, and tests for precipitating causes (especially infections) before or during treatment initiation 1, 3
• Begin rapid IV fluid resuscitation with 0.9% saline (1 L over the first hour) 1, 3
• Treat any identified precipitating conditions 1, 2

Continued Management (24-48 Hours)

• Continue hydrocortisone 100-300 mg/day as continuous infusion or divided IV/IM boluses every 6 hours 1, 3
• Continue IV isotonic saline infusion at a slower rate (additional 2-3 L over 24-48 hours) with frequent hemodynamic monitoring and electrolyte measurements 1, 3
• Consider ICU/high-dependency unit admission for severe cases 1, 2
• Consider prophylaxis for gastric stress ulcers, low-dose heparin, and antibiotic treatment depending on the severity of the intercurrent illness 1, 3

Transition to Maintenance Therapy

• Taper parenteral glucocorticoids over 1-3 days (if precipitating illness permits) to oral maintenance therapy 1, 3
• Restart mineralocorticoid replacement with fludrocortisone when the hydrocortisone dose falls below 50 mg/day 1, 2
• Transition to oral maintenance therapy with hydrocortisone 15-20 mg daily in divided doses (typically 2/3 in morning, 1/3 in early afternoon) 2, 3

Prevention of Future Crises

• Identify and address precipitating causes of the adrenal crisis 1, 5
• Provide comprehensive patient education on stress dosing during intercurrent illnesses (typically 2-3 times maintenance dose), injuries, or other stressors 1, 2
• Prescribe an emergency injectable hydrocortisone kit and provide training on self-administration 2, 5
• Recommend medical alert bracelet or necklace for adrenal insufficiency 2, 3
• Ensure patients seek medical help before reaching a state where they cannot care for themselves 1, 5
• Evaluate for potential causes of recurrent crises, including low salt consumption, chronic under-replacement with mineralocorticoid, poor compliance, and underlying psychiatric disorders 1, 5

Common Pitfalls to Avoid

• Delaying treatment while waiting for diagnostic confirmation can be fatal 2, 3
• Inadequate fluid resuscitation alongside corticosteroid administration 2, 3
• Failing to identify and treat the precipitating cause of adrenal crisis 2, 3
• Tapering corticosteroids too quickly before clinical stabilization 2, 3
• Overlooking the need for mineralocorticoid replacement in primary adrenal insufficiency when hydrocortisone dose falls below 50 mg/day 1, 2

Annual Follow-up for Patients with Adrenal Insufficiency

• Assess health, well-being, weight, blood pressure, and serum electrolytes 1, 3
• Review stress dosing knowledge and emergency preparedness 1, 2
• Evaluate for development of new autoimmune disorders, particularly hypothyroidism 1, 5
• Assess for complications of glucocorticoid therapy including monitoring bone mineral density every 3-5 years 1, 5