What is the management of adrenal insufficiency in the emergency department?

Management of Adrenal Insufficiency in the Emergency Department

Immediately administer hydrocortisone 100 mg IV bolus followed by aggressive fluid resuscitation with 0.9% saline (1 L over the first hour), without waiting for diagnostic confirmation, as treatment delay increases mortality risk. 1

Immediate Recognition and Initial Management

Do Not Delay Treatment for Diagnostics

• Treatment must begin immediately upon clinical suspicion - draw blood for cortisol, ACTH, electrolytes, glucose, and creatinine before starting therapy, but do not wait for results 1
• Recognize the clinical presentation: profound malaise, hypotension/shock, nausea/vomiting, abdominal pain (may mimic peritonitis), altered mental status ranging from confusion to coma, and muscle cramps 1
• Laboratory findings typically show hyponatremia, hyperkalemia, elevated creatinine (prerenal failure), and hypoglycemia (especially in children) 1

First-Line Emergency Treatment Protocol

Glucocorticoid Administration:

• Give hydrocortisone 100 mg IV bolus immediately 1, 2
• Follow with continuous IV infusion of 200 mg hydrocortisone per 24 hours, OR give 50 mg IV/IM every 6 hours if continuous infusion is not feasible 1, 2
• The high-dose hydrocortisone (100 mg) is critical because it saturates the 11β-hydroxysteroid dehydrogenase type 2 enzyme, providing essential mineralocorticoid effect in addition to glucocorticoid replacement 1

Fluid Resuscitation:

• Administer 1 L of 0.9% saline over the first hour 1
• Continue with 3-4 L total of isotonic saline or 5% dextrose in saline over 24-48 hours 1
• Monitor hemodynamics frequently and measure electrolytes serially to avoid fluid overload 1

Ongoing Management and Monitoring

Supportive Care

• Identify and treat precipitating causes: infections (most common), GI illness with vomiting/diarrhea, surgical procedures, myocardial infarction, or medication non-compliance 1, 3
• Consider ICU or high-dependency unit admission based on severity 1
• Implement stress ulcer prophylaxis and low-dose heparin for thromboprophylaxis 1
• Treat any identified infections with appropriate antibiotics 1

Glucocorticoid Tapering

• Continue parenteral hydrocortisone (200-300 mg/24h via continuous infusion or divided doses) for 24-48 hours 1
• Taper over 1-3 days as the precipitating illness resolves 1
• Transition to oral glucocorticoids at double the usual maintenance dose for 24-48 hours once the patient can tolerate oral intake 1, 2
• Return to normal maintenance dosing (typically hydrocortisone 15-25 mg daily or prednisone 3-5 mg daily) 1, 4

Mineralocorticoid Replacement

• Do not give fludrocortisone during acute crisis - the high-dose hydrocortisone provides adequate mineralocorticoid activity 1
• Restart fludrocortisone (0.05-0.3 mg daily) only when hydrocortisone dose decreases below 50 mg/day in patients with primary adrenal insufficiency 1, 4

Special Populations and Considerations

Pediatric Patients

• Administer hydrocortisone 2 mg/kg IV/IM immediately 2
• Children are more vulnerable to hypoglycemia - monitor blood glucose frequently 1
• Minimize fasting periods and prioritize treatment 1

Patients on Chronic Glucocorticoids

• Anyone receiving prednisolone ≥5 mg daily (or hydrocortisone equivalent ≥20 mg daily) for ≥1 month is at risk for hypothalamic-pituitary-adrenal axis suppression 1
• When in doubt, give glucocorticoids - there are no long-term adverse consequences of short-term high-dose administration in this emergency setting 1

Alternative Glucocorticoid Options

• Avoid dexamethasone in primary adrenal insufficiency - it lacks mineralocorticoid activity and will not provide the necessary aldosterone effect 1
• If IV access is unavailable, give 100 mg hydrocortisone IM 1, 2

Critical Pitfalls to Avoid

• Never delay treatment for diagnostic confirmation - adrenal crisis is a clinical diagnosis requiring immediate intervention 1, 5
• Do not use dexamethasone as first-line therapy in suspected primary adrenal insufficiency 1
• Do not add fludrocortisone during the acute phase when using high-dose hydrocortisone 1
• Do not undertaper glucocorticoids too quickly - the stress response may be prolonged depending on the precipitating illness 1
• Recognize that infections are the most common trigger (accounting for the majority of crises), requiring concurrent antimicrobial therapy 1, 3

Disposition and Patient Education

Before Discharge

• Ensure the patient understands sick-day rules: double or triple oral glucocorticoid doses during febrile illness, vomiting, or significant stress 1, 3, 6
• Provide an emergency injection kit with 100 mg hydrocortisone for IM self-administration 4, 3, 6
• Give the patient a steroid emergency card to carry at all times 1, 3, 7
• Reinforce that the patient should seek immediate medical attention if unable to tolerate oral medications 1, 3, 6