What is the treatment for an adrenal crisis?

Treatment of Adrenal Crisis

Immediately administer hydrocortisone 100 mg IV bolus without delaying for any diagnostic procedures, followed by aggressive fluid resuscitation with 0.9% saline 1 L over the first hour. 1, 2, 3

Immediate Emergency Management

Initial Resuscitation (First Hour)

• Give hydrocortisone 100 mg IV bolus immediately upon clinical suspicion—treatment must never be delayed for diagnostic testing 1, 2, 3
• Start 0.9% saline infusion at 1 L over the first hour with frequent hemodynamic monitoring 1, 2, 3
• Draw blood for serum cortisol, ACTH, electrolytes, creatinine, urea, and glucose before giving hydrocortisone if possible, but do not delay treatment waiting for results 1, 2

Ongoing Glucocorticoid Administration

• Continue hydrocortisone 100-300 mg/day (typically 200 mg/24 hours) as continuous IV infusion rather than intermittent boluses—this is the only administration mode that persistently achieves cortisol concentrations in the range observed during major stress 1, 4
• Alternative if continuous infusion unavailable: hydrocortisone 100 mg IV/IM every 6 hours 1, 3
• The continuous infusion approach is superior because intermittent boluses create peaks and troughs that fail to maintain adequate cortisol levels throughout the stress period 4

Fluid Resuscitation

• After the initial 1 L bolus, continue 0.9% saline at 3-4 L over 24-48 hours with frequent hemodynamic monitoring 1, 3
• Adjust fluid rate based on blood pressure, urine output, and clinical response 1

Supportive Care

Additional Interventions

• Consider ICU or high-dependency unit admission for severe cases with shock or altered mental status 1
• Provide gastric stress ulcer prophylaxis 1
• Administer low-dose heparin for venous thromboembolism prophylaxis 1
• Start empiric antibiotics if infection is suspected as the precipitating cause 1
• Correct hypoglycemia with IV dextrose if present 1, 2

Common Pitfall to Avoid

Do not wait for laboratory confirmation before treating—even mild symptoms like nausea can rapidly progress to cardiovascular collapse, and patients cannot absorb oral medications when vomiting 2, 5. The absence of hyperkalemia (present in only 50% of cases) or hyponatremia should not prevent treatment if clinical suspicion exists 2.

Transition to Maintenance Therapy

Tapering Protocol

• Once the patient is stabilized and can tolerate oral intake, taper parenteral glucocorticoids over 1-3 days to oral maintenance therapy 1, 3
• Transition to oral hydrocortisone 15-25 mg daily divided into 2-3 doses for long-term maintenance 3

Identifying and Treating Precipitating Causes

Most Common Triggers

• Gastrointestinal illness with vomiting/diarrhea is the most frequent precipitant 1, 2
• Infections of any type 1, 2
• Surgical procedures without adequate steroid coverage 1, 2
• Physical trauma, myocardial infarction, or severe allergic reactions 1, 2

Workup for Underlying Cause

• Evaluate for infection with appropriate cultures, imaging, and empiric antibiotics as indicated 1, 3
• If this is a new diagnosis of adrenal insufficiency, test for 21-hydroxylase autoantibodies (positive in ~85% of autoimmune Addison disease) 2
• Obtain CT scan of adrenals if autoantibodies are negative to evaluate for hemorrhage, tumor, tuberculosis, or infiltrative processes 2

Prevention of Future Crises

Patient Education and Emergency Preparedness

• Educate patients to double their oral glucocorticoid dose during minor illness (fever, infection, gastroenteritis) 1, 3
• Instruct patients to use parenteral hydrocortisone during severe illness when they cannot tolerate oral medications 1, 3
• Ensure every patient has emergency supplies including injectable hydrocortisone for self-administration 1, 3
• Patients should wear medical alert jewelry and carry a steroid emergency card at all times 1, 3

Important Caveat

Despite comprehensive patient education, studies show that education alone does not prevent many adrenal crisis events—the incidence remains 5-10 crises per 100 patient-years even with optimal education 6, 7. This highlights the need for readily accessible emergency hydrocortisone and low threshold for seeking medical care.

Follow-Up After Crisis

Post-Crisis Assessment

• Review the precipitating cause and ensure it has been adequately treated 1
• Reassess the patient's understanding of stress dosing and self-management strategies 1, 3
• Verify the patient has adequate emergency supplies and knows how to use them 1, 3
• Schedule annual follow-up with assessment of health, well-being, weight, blood pressure, and electrolytes 1