What is the best course of treatment for a patient with suspected adrenal hemorrhage, potentially complicated by adrenal insufficiency and hemodynamic instability?

Management of Adrenal Hemorrhage

Immediate Resuscitation and Stabilization

For any patient with suspected adrenal hemorrhage presenting with hemodynamic instability, immediately administer IV hydrocortisone 100 mg bolus plus 0.9% saline infusion at 1 L/hour—do not delay treatment for diagnostic testing. 1, 2

Critical First Steps (Within Minutes)

• Secure large-bore IV access (8-Fr central line preferred in adults; consider intra-osseous if peripheral access fails) 1
• Administer high-flow oxygen and monitor pulse oximetry continuously 1
• Begin aggressive fluid resuscitation with warmed 0.9% saline at 1 L/hour (minimum 2L total) 1, 2
• Give stress-dose corticosteroids immediately: hydrocortisone 100 mg IV bolus, then 50-100 mg IV every 6-8 hours 1, 3
• Actively warm the patient and all transfused fluids to prevent coagulopathy 1

Hemodynamic Monitoring

• Continuous ECG, blood pressure, respiratory rate, and urine output monitoring are essential 1
• Assess for signs of internal bleeding: abdominal distension, flank pain, falling hemoglobin, hemodynamic deterioration 4, 5, 6
• If hypotension persists despite fluids and hydrocortisone, consider angiographic embolization rather than emergency surgery (which carries high mortality) 6

Diagnostic Workup (Performed in Parallel with Treatment)

Immediate Laboratory Testing

• Baseline labs before steroid administration (if patient stable enough): morning cortisol, ACTH, complete metabolic panel (sodium, potassium, glucose), complete blood count 1, 2
• Coagulation studies: PT, aPTT, fibrinogen (Clauss method, not derived) 1
• Cross-match blood for potential transfusion 1

Key Laboratory Findings Suggesting Adrenal Insufficiency

• Hyponatremia (present in 90% of newly diagnosed adrenal insufficiency cases) 2
• Hyperkalemia (present in only ~50% of cases, so absence does not exclude diagnosis) 2
• Morning cortisol <250 nmol/L (<9 μg/dL) with elevated ACTH is diagnostic of primary adrenal insufficiency 1, 2
• Hypoglycemia may be present 2

Imaging

• CT abdomen/pelvis with IV contrast is the diagnostic modality of choice 4, 5, 6, 7
• CT findings: rounded or oval mass altering adrenal anatomy, attenuation 45-70 HU, no contrast enhancement, maximum diameter often >10 cm 7
• Look for preceding adrenal congestion: adrenal gland thickening and peri-adrenal fat stranding may precede frank hemorrhage 5
• Assess for bilateral involvement (critical, as bilateral hemorrhage causes primary adrenal insufficiency and adrenal crisis) 1, 4, 5

Assessment for Adrenal Insufficiency

When to Suspect Adrenal Insufficiency

Bilateral adrenal hemorrhage or infiltrative disease mandates assessment for adrenal insufficiency. 1

• Clinical features: unexplained hypotension, abdominal pain, nausea/vomiting, weakness, altered mental status, fever 4, 5, 6, 8
• Precipitating factors: sepsis, anticoagulation therapy, post-surgical stress, trauma, COVID-19 infection 4, 8
• Hypotensive episode often precedes overt signs of adrenal insufficiency 8

Diagnostic Testing for Adrenal Insufficiency

• Do not delay treatment for diagnostic testing if patient is unstable 1, 2
• If diagnosis uncertain and you need to preserve diagnostic accuracy, use dexamethasone 4 mg IV instead of hydrocortisone (does not interfere with cortisol assays) 2
• ACTH stimulation test (250 μg cosyntropin IV/IM with cortisol at 0,30, and 60 minutes): peak cortisol <500 nmol/L (<18 μg/dL) confirms adrenal insufficiency 1, 2

Definitive Management Based on Hemodynamic Status

Hemodynamically Unstable Patients

• Continue stress-dose hydrocortisone 50-100 mg IV every 6-8 hours 1, 3
• Aggressive volume resuscitation with 0.9% saline 1, 2
• Consider angiographic embolization if bleeding continues (preferred over emergency surgery) 6
• Transfuse blood products as needed to maintain hemoglobin and correct coagulopathy 1
• Avoid vasopressors initially—restore volume and give steroids first 1

Hemodynamically Stable Patients

• Continue hydrocortisone 50-100 mg IV every 6-8 hours initially, then taper to maintenance dosing over 5-7 days 1
• Maintenance glucocorticoid replacement: hydrocortisone 15-25 mg daily in divided doses (typically 10 mg at 7 AM, 5 mg at noon, 2.5-5 mg at 4 PM) 2
• For primary adrenal insufficiency (bilateral hemorrhage), add fludrocortisone 0.05-0.1 mg daily for mineralocorticoid replacement 1, 2

Exclusion of Underlying Adrenal Tumor

All patients with adrenal hemorrhage require workup to exclude a hormonal-active or malignant adrenal tumor. 6

• Measure 24-hour urine metanephrines or plasma metanephrines to exclude pheochromocytoma (hemorrhage into pheochromocytoma can trigger fatal crisis) 1
• Measure serum aldosterone and renin if hypertension or hypokalemia present 2
• Measure DHEA-S and testosterone if virilization signs present 1
• Follow-up CT imaging at 3-6 months to document resolution and exclude underlying mass 1, 6

Long-Term Management and Patient Education

For Confirmed Adrenal Insufficiency

• Lifelong glucocorticoid replacement is required for bilateral adrenal hemorrhage 2
• All patients need education on stress dosing: double or triple dose during illness, fever, or physical stress 1, 2
• Prescribe emergency injectable hydrocortisone 100 mg IM kit with self-injection training 1, 2
• Medical alert bracelet or necklace indicating adrenal insufficiency is mandatory 1, 2
• Endocrinology consultation should be obtained for all patients with confirmed adrenal insufficiency 1, 2

Follow-Up Imaging

• Repeat CT at 3-6 months to document resolution of hemorrhage and exclude underlying tumor 1, 6
• If hemorrhage does not resolve or grows, surgical resection should be considered 1, 6

Critical Pitfalls to Avoid

• Never delay steroid administration for diagnostic testing in unstable patients—mortality is high if untreated 1, 2
• Do not rely on electrolyte abnormalities alone—hyperkalemia is absent in 50% of adrenal insufficiency cases 2
• Do not assume unilateral hemorrhage excludes adrenal insufficiency—assess both glands on imaging 1, 4
• Avoid emergency laparotomy unless absolutely necessary—angiographic embolization has better outcomes 6
• Do not miss underlying pheochromocytoma—hemorrhage into pheochromocytoma can be fatal without appropriate management 1
• Remember anticoagulation therapy is a major risk factor—adrenal hemorrhage can occur even with therapeutic anticoagulation levels 8