What is the management for a patient presenting with symptoms of adrenal crisis?

Management of Adrenal Crisis

Immediately administer hydrocortisone 100 mg IV bolus without delay, followed by aggressive fluid resuscitation with 0.9% saline at 1 liter over the first hour—treatment must never be delayed for diagnostic procedures when adrenal crisis is suspected. 1, 2, 3, 4

Immediate Emergency Management (First Hour)

Glucocorticoid Administration

• Give hydrocortisone 100 mg IV bolus immediately upon clinical suspicion—this high dose saturates 11β-hydroxysteroid dehydrogenase type 2 to provide necessary mineralocorticoid effect, eliminating the need for separate fludrocortisone during acute crisis 2, 3, 4
• If IV access cannot be established quickly, administer hydrocortisone via intramuscular route without delay 5
• Draw blood for cortisol, ACTH, electrolytes, creatinine, urea, and glucose before treatment begins, but never postpone therapy waiting for results 2, 3, 4

Fluid Resuscitation

• Infuse 0.9% isotonic saline 1 liter over the first hour to address profound volume depletion and hypotension 1, 2, 3, 4
• Total fluid requirement is typically 3-4 liters of isotonic saline (or 5% dextrose in isotonic saline) over the first 24 hours 1, 2
• Perform frequent hemodynamic monitoring and measure serum electrolytes to avoid fluid overload 1, 2

Ongoing Management (24-48 Hours)

Continued Glucocorticoid Therapy

• Administer hydrocortisone 100-300 mg per day either as continuous IV infusion (preferred) or as frequent IV/IM boluses every 6 hours 1, 2, 3, 4
• Continuous IV infusion of 200 mg hydrocortisone over 24 hours, preceded by the initial 50-100 mg bolus, is the most effective delivery mode for maintaining cortisol concentrations in the required range during major stress 6
• Continue slower isotonic saline infusion for 24-48 hours with ongoing hemodynamic monitoring 1

Critical Care Considerations

• Admit to ICU or high-dependency unit for severe cases with persistent hypotension, shock, or end-organ dysfunction 1, 2, 3
• Provide prophylaxis for gastric stress ulcers 1, 2, 3
• Consider low-dose heparin for thromboprophylaxis depending on severity of intercurrent illness 1, 2, 3
• Treat precipitating conditions (most commonly gastrointestinal illness or infections) with appropriate antimicrobial therapy 1, 2, 3

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, 2, 3, 4
• Restart fludrocortisone (mineralocorticoid replacement) when the hydrocortisone dose falls below 50 mg per day 1

Maintenance Dosing

• Transition to maintenance hydrocortisone 15-25 mg daily divided into 2-3 doses, with preference for short-acting hydrocortisone over longer-acting agents like prednisone 2, 4

Clinical Recognition and Common Pitfalls

Key Clinical Features

• Adrenal crisis presents with hypotension (often severe), dehydration, malaise, fatigue, nausea, vomiting, abdominal pain, and muscle pain/cramps 2, 3
• Neurological manifestations include impaired cognitive function, confusion, loss of consciousness, and potentially coma in severe cases 2, 3
• Laboratory findings typically include hyponatremia (90% of cases), hyperkalemia (50% of cases), increased creatinine, hypoglycemia (more common in children), and mild hypercalcemia 2, 3

Critical Pitfalls to Avoid

• Never postpone treatment to obtain diagnostic confirmation—mortality increases with delayed intervention 2, 3, 4
• Do not add separate mineralocorticoid (fludrocortisone) during acute crisis—the high-dose hydrocortisone provides adequate mineralocorticoid activity 2, 4
• The absence of hyperkalemia does not exclude adrenal crisis, as it is present in only half of cases 2
• Even mild gastrointestinal upset may precipitate crisis as patients cannot absorb oral medication when they need it most 2
• Never start thyroid hormone replacement before adequate glucocorticoid replacement in patients with multiple hormone deficiencies, as this can trigger adrenal crisis 2, 4

Prevention of Future Crises

Patient Education and Emergency Preparedness

• Reinforce patient education to empower patients to increase steroid doses during intercurrent illnesses, vomiting, injuries, or other stressors 1
• Instruct patients to double or triple their glucocorticoid dose during minor illness and use parenteral hydrocortisone during severe illness or inability to take oral medications 2, 4
• Ensure patients have emergency supplies including injectable hydrocortisone and receive self-injection training 2, 4, 7, 5
• Recommend medical alert jewelry and emergency steroid card to trigger stress-dose corticosteroids by emergency medical personnel 2, 3, 4, 5

Common Precipitating Factors to Address

• Gastrointestinal illness with vomiting/diarrhea is the most common trigger 2, 3
• Other precipitants include infections (any type), surgical procedures without adequate steroid coverage, physical injuries, myocardial infarction, and severe allergic reactions 2, 3
• Chronic under-replacement with fludrocortisone combined with low salt consumption can contribute to recurrent crises 1, 2
• Poor compliance and underlying psychiatric disorders should be investigated in patients with recurrent crises 1, 2

Follow-up After Crisis

• Arrange early endocrinology consultation for ongoing management, education on emergency injectables, and planning before surgery or high-stress treatments 2
• Evaluate the precipitating cause and review the patient's understanding of stress dosing and self-management 3, 4
• Diagnose precipitating causes to prevent future events 1