Initial Treatment for Hypotension Related to Adrenal Dysfunction
Immediately administer intravenous hydrocortisone 100 mg as a bolus followed by rapid infusion of 0.9% normal saline (1 liter over the first hour), without waiting for diagnostic test results. 1
Immediate Emergency Management
First-Line Interventions (Do Not Delay)
Administer hydrocortisone 100 mg IV bolus immediately upon clinical suspicion of adrenal crisis, as this dose saturates 11β-hydroxysteroid dehydrogenase type 2 to provide the necessary mineralocorticoid effect 1, 2
Initiate aggressive fluid resuscitation with 0.9% isotonic saline at 1 liter over the first hour, as dehydration and volume depletion are key pathophysiologic features 1, 2
Draw blood for cortisol, ACTH, electrolytes (Na, K), creatinine, urea, and glucose before treatment begins, but do not delay therapy waiting for results 1, 2
Rationale for This Approach
The 100 mg hydrocortisone bolus is critical because it provides both glucocorticoid and mineralocorticoid effects at this supraphysiologic dose. The high dose saturates the enzyme that normally inactivates cortisol in mineralocorticoid-responsive tissues, allowing cortisol to act on mineralocorticoid receptors 1. This is particularly important because patients in adrenal crisis have both glucocorticoid and mineralocorticoid deficiency contributing to their hypotension 1, 2.
The aggressive saline resuscitation addresses the severe volume depletion that results from aldosterone deficiency, which causes renal sodium wasting and subsequent hypotension 1, 2.
Subsequent Management (First 24-48 Hours)
Continued Glucocorticoid Therapy
Continue hydrocortisone 100-300 mg per day either as continuous IV infusion or as frequent IV/IM boluses every 6 hours 1
Maintain slower isotonic saline infusion for the following 24-48 hours with frequent hemodynamic monitoring to avoid fluid overload 1
Fluid Management Considerations
Administer 3-4 liters of isotonic saline or 5% dextrose in isotonic saline total over 24 hours, adjusting based on hemodynamic response and electrolyte monitoring 1
Monitor serum electrolytes frequently to guide fluid management and avoid complications 1
Special Considerations for Pediatric Patients
Modified Fluid Resuscitation
Administer initial normal saline fluid bolus of 10-20 ml/kg (maximum 1,000 ml) in children with hypotension due to adrenal dysfunction 1
Consider stress-dose hydrocortisone specifically in pediatric patients with vasopressor-resistant hypotension, as they may respond to hydrocortisone alone without requiring high doses of other lymphocytotoxic corticosteroids like dexamethasone or methylprednisolone 1
Avoid excessive fluid boluses in children with underlying cardiac dysfunction or signs of volume overload, as patients with adrenal crisis can develop capillary leak and hypoalbuminemia rapidly 1
Critical Clinical Pitfalls to Avoid
Do Not Delay Treatment
Never postpone treatment to obtain diagnostic confirmation when adrenal crisis is clinically suspected, as mortality increases with delayed intervention 1, 2
Treatment must be initiated immediately even if cortisol levels are pending, as the clinical presentation (hypotension, hyponatremia, hyperkalemia) is sufficient to warrant empiric therapy 1, 2
Mineralocorticoid Considerations
Do not add separate mineralocorticoid (fludrocortisone) during acute crisis management, as the high-dose hydrocortisone provides adequate mineralocorticoid activity 1
Restart fludrocortisone only when hydrocortisone dose is tapered below 50 mg per day during recovery phase 1
Vasopressor Use
Consider adrenal insufficiency in any patient with vasopressor-resistant hypotension, as glucocorticoid deficiency impairs β2-adrenoceptor function and reduces responsiveness to catecholamines 1, 3, 4
Patients with adrenal crisis may have reduced lymphocyte β2-adrenoceptor density and impaired cardiac diastolic function, explaining why hypotension may not respond adequately to vasopressors alone without glucocorticoid replacement 4
Transition to Maintenance Therapy
Tapering Protocol
Taper parenteral glucocorticoids over 1-3 days to oral therapy once the precipitating illness permits and the patient can tolerate oral medications 1
Transition to oral hydrocortisone 15-25 mg daily or prednisone 3-5 mg daily for long-term maintenance 5
Supportive Care
Consider ICU or high-dependency unit admission for severe cases with persistent hypotension or end-organ dysfunction 1
Provide prophylaxis for gastric stress ulcers and consider low-dose heparin depending on severity of intercurrent illness 1
Treat any precipitating conditions such as infections with appropriate antimicrobial therapy 1
Key Laboratory Findings Supporting Diagnosis
Hyponatremia is present in approximately 90% of cases and is a key diagnostic clue 2, 5
Hyperkalemia occurs in approximately 50% of patients with adrenal crisis 2, 5
Hypoglycemia is common in children but less frequent in adults 1, 2
Elevated creatinine and BUN from prerenal renal failure due to volume depletion are typical findings 1, 2