What is the role of hydrocortisone, dexamethasone, epinephrine, and saline in managing an unconscious patient with an adrenal crisis?

Management of Adrenal Crisis in an Unconscious Patient

In an unconscious patient with adrenal crisis, immediate intravenous hydrocortisone 100 mg bolus and rapid isotonic saline infusion (1 L over the first hour) are the cornerstone treatments that directly address mortality and morbidity, while dexamethasone is inadequate for primary adrenal insufficiency due to lack of mineralocorticoid activity, and epinephrine has no role in routine adrenal crisis management. 1

Hydrocortisone: The Primary Life-Saving Intervention

Hydrocortisone serves dual critical functions in adrenal crisis:

• Immediate 100 mg IV bolus must be administered without delay—treatment should never be postponed for diagnostic procedures 1
• The high dose saturates 11β-hydroxysteroid dehydrogenase type 2 (HSD2), providing the essential mineralocorticoid effect needed to reverse hypotension and electrolyte abnormalities 1
• Following the bolus, continue 100-300 mg/day as continuous IV infusion (preferred method) or as frequent IV/IM boluses every 6 hours 1
• Hydrocortisone has a plasma half-life of approximately 90 minutes, requiring sustained administration; effects are evident within one hour and persist variably, necessitating dosing every 4-6 hours if high blood levels are required 2

The continuous infusion approach (200 mg over 24 hours) is superior to intermittent dosing for maintaining physiologic cortisol concentrations during the stress response 1

Isotonic Saline: Addressing the Circulatory Collapse

Aggressive fluid resuscitation is equally critical as glucocorticoid replacement:

• Administer 0.9% saline 1 L over the first hour to address profound dehydration and hypotension 1
• Continue 3-4 L of isotonic saline or 5% dextrose in isotonic saline over 24-48 hours at a slower rate 1
• Frequent hemodynamic monitoring and serum electrolyte measurement are mandatory to avoid fluid overload 1
• The combination of high-dose hydrocortisone (providing mineralocorticoid activity) and volume expansion addresses both the glucocorticoid and mineralocorticoid deficiency that characterizes adrenal crisis 1

Dexamethasone: Inadequate and Potentially Dangerous

Dexamethasone should NOT be used as primary treatment for adrenal crisis in patients with primary adrenal insufficiency:

• Dexamethasone completely lacks mineralocorticoid activity, failing to address the life-threatening electrolyte abnormalities (hyponatremia, hyperkalemia) and hypotension 1, 3
• While 8 mg dexamethasone provides glucocorticoid equivalence to 200 mg hydrocortisone and covers stress for 24 hours, this is only relevant in secondary adrenal insufficiency where mineralocorticoid function is preserved 1
• In an unconscious patient where the etiology of adrenal insufficiency is unknown, always assume primary adrenal insufficiency and use hydrocortisone 1

Epinephrine: No Role in Routine Adrenal Crisis Management

Epinephrine is not part of standard adrenal crisis treatment protocols:

• None of the major international guidelines (Association of Anaesthetists, Society for Endocrinology UK, Journal of Internal Medicine consensus statements) recommend epinephrine for adrenal crisis 1
• Adrenal crisis-related hypotension responds to hydrocortisone and volume resuscitation, not vasopressors as first-line therapy 1
• Epinephrine would only be considered in the rare scenario of refractory shock despite adequate hydrocortisone and fluid resuscitation, or if adrenal crisis occurs in the context of anaphylaxis (a known precipitant) 1

Critical Pitfalls to Avoid

Common errors that increase mortality:

• Never delay treatment for diagnostic testing—draw blood for cortisol, ACTH, and electrolytes, but immediately start hydrocortisone and saline without waiting for results 1
• Do not use dexamethasone when primary adrenal insufficiency is possible or the diagnosis is uncertain 1
• Do not abruptly stop glucocorticoids—taper over 1-3 days as the precipitating illness resolves 1
• Do not underestimate the severity—adrenal crisis has a mortality rate of 0.5 per 100 patient-years and requires ICU-level monitoring in severe cases 1, 4

Additional Supportive Measures

Beyond hydrocortisone and saline:

• Treat the precipitating cause (most commonly infection)—obtain cultures and initiate appropriate antibiotics 1, 4
• Monitor and correct hypoglycemia (particularly in children) 1, 5
• Consider ICU admission for severe cases with hemodynamic instability 1
• Implement gastric stress ulcer prophylaxis and low-dose heparin in critically ill patients 1