What is the treatment for an adrenal crisis that has progressed to cardiac arrest?

Treatment of Adrenal Crisis Progressing to Cardiac Arrest

Immediately administer hydrocortisone 100 mg IV bolus the moment return of spontaneous circulation (ROSC) is achieved, as adrenal crisis is a recognized cause of refractory shock and cardiac arrest that responds rapidly to corticosteroid replacement. 1, 2, 3

Immediate Resuscitation During Cardiac Arrest

Standard ACLS Protocol Takes Priority

• Follow standard Advanced Cardiac Life Support (ACLS) algorithms for the specific arrest rhythm (ventricular fibrillation/pulseless ventricular tachycardia vs. asystole/pulseless electrical activity) 4
• Deliver defibrillation shocks at 200 J, 200 J, then 360 J for VF/VT without delay 4
• Administer epinephrine 1 mg IV every 3 minutes during resuscitation 4
• Establish advanced airway and secure IV/IO access while continuing CPR 4

Critical Consideration for Adrenal Crisis

• Do not delay standard ACLS interventions to give hydrocortisone during active arrest - focus on achieving ROSC first through standard resuscitation 4
• However, maintain high clinical suspicion that adrenal crisis may be the underlying precipitant, especially in patients with known adrenal insufficiency, recent etomidate use, or sepsis 3, 5

Post-ROSC Management: The Critical Window

Immediate Corticosteroid Administration

Within seconds to minutes of achieving ROSC, administer hydrocortisone 100 mg IV bolus - this is the single most important intervention for adrenal crisis and must not be delayed for diagnostic confirmation 1, 2, 6

The 100 mg dose is specifically chosen because it saturates 11β-hydroxysteroid dehydrogenase type 2, providing both glucocorticoid and mineralocorticoid effects needed in crisis 1, 2

Aggressive Fluid Resuscitation

• Initiate 0.9% isotonic saline at 1 liter over the first hour immediately after ROSC 1, 2, 6
• Continue with 3-4 liters total over the following 24-48 hours with frequent hemodynamic monitoring 4, 1
• Monitor closely to avoid fluid overload, particularly in patients with cardiac dysfunction 4, 1

Ongoing Corticosteroid Therapy

• Continue hydrocortisone 100-300 mg/day as either continuous IV infusion or divided IV/IM boluses every 6 hours 4, 1
• Do not add fludrocortisone during acute crisis - the high-dose hydrocortisone provides adequate mineralocorticoid activity 1, 2
• Only restart fludrocortisone when hydrocortisone dose tapers below 50 mg/day 1, 2

Diagnostic Workup (Without Delaying Treatment)

Pre-Treatment Blood Draw

Draw blood for cortisol, ACTH, electrolytes, creatinine, urea, and glucose before giving hydrocortisone if possible, but never delay treatment waiting for results 1, 2, 6

Expected Laboratory Findings

• Hyponatremia (present in ~90% of cases) 1, 6
• Hyperkalemia (present in ~50% of cases) 1, 6
• Hypoglycemia (more common in children) 1
• Elevated creatinine and BUN from prerenal azotemia 1, 6
• Serum cortisol <250 nmol/L with markedly elevated ACTH confirms primary adrenal insufficiency 1, 6

Evidence Supporting This Approach

Post-Cardiac Arrest Adrenal Dysfunction

Relative adrenal insufficiency is common after cardiac arrest and associated with poor survival 4, 5, 7. In one study, 86% of post-arrest patients tested met biochemical criteria for relative adrenal insufficiency, yet only 32% received appropriate evaluation or treatment 5. Patients with relative adrenal insufficiency and elevated ACTH/ADH levels had 2-fold increased risk of poor outcomes 7.

Case Evidence of Reversibility

A dramatic case report demonstrates that adrenal crisis can present as pulseless electrical activity cardiac arrest with refractory shock, responding rapidly to hydrocortisone 100 mg IV after ROSC was achieved 3. Another case showed complete recovery from cardiogenic shock and biventricular failure with corticosteroid replacement and mechanical support 8.

Critical Care Management Post-Resuscitation

Intensive Monitoring

• Admit to ICU or high-dependency unit for severe cases 4, 1, 2
• Monitor serum electrolytes frequently to guide fluid management 4, 1, 6
• Provide hemodynamic monitoring to assess response to therapy 4

Supportive Care

• Gastric stress ulcer prophylaxis 4, 1, 2
• Low-dose heparin for DVT prophylaxis 4, 1, 2
• Antibiotic treatment if infection is the precipitating cause 4, 1, 2

Transition to Maintenance Therapy

• Taper parenteral glucocorticoids over 1-3 days to oral therapy once the patient stabilizes and can tolerate oral intake 4, 1, 2
• Transition to maintenance hydrocortisone 15-25 mg daily divided into 2-3 doses 1

Common Pitfalls to Avoid

Never delay hydrocortisone administration for diagnostic confirmation - mortality increases with delayed intervention, and treatment should begin on clinical suspicion alone 1, 2, 6

Do not assume absence of hyperkalemia excludes adrenal crisis - it is present in only 50% of cases 1, 6

Avoid etomidate for intubation in patients with known or suspected adrenal insufficiency - it can precipitate or worsen adrenal crisis 3

Do not start thyroid hormone replacement before adequate glucocorticoid replacement in patients with multiple hormone deficiencies, as this can trigger crisis 1

Prevention of Future Events

Patient Education

• Teach patients to double or triple oral glucocorticoid doses during minor illness 1, 2
• Provide emergency injectable hydrocortisone for severe illness or inability to take oral medications 1, 2
• Ensure patients wear medical alert jewelry and carry emergency steroid cards 1, 2, 6

Follow-up Care

• Evaluate the precipitating cause of the crisis 4, 1, 2
• Review patient understanding of stress dosing and self-management 1, 2
• Schedule annual follow-up with assessment of health, weight, blood pressure, and electrolytes 1, 6