What is the treatment for an Addison's crisis, specifically when a Corte (corticosteroid) injection is administered to a patient with known adrenal insufficiency?

Treatment of Addison's Crisis with Corticosteroid Injection

Adrenal crisis requires immediate administration of 100 mg hydrocortisone IV bolus without any delay for diagnostic procedures, followed by aggressive fluid resuscitation with 1 liter of 0.9% saline over the first hour. 1, 2, 3

Immediate Emergency Management (First Hour)

Hydrocortisone Administration:

• Give 100 mg hydrocortisone IV bolus immediately upon clinical suspicion—this dose saturates 11β-hydroxysteroid dehydrogenase type 2 to provide the necessary mineralocorticoid effect 1, 2, 3
• If IV access is unavailable, give 100 mg IM 4, 1
• Administer over 30 seconds to 10 minutes depending on dose 5
• Critical pitfall: Never delay treatment waiting for diagnostic confirmation—mortality increases with delayed intervention 2, 3

Fluid Resuscitation:

• Infuse 0.9% isotonic saline at 1 liter over the first hour 1, 2, 3
• This addresses the severe dehydration and volume depletion that are key pathophysiologic features 3

Diagnostic Blood Draw:

• Draw blood for serum cortisol, ACTH, electrolytes (Na, K), creatinine, urea, and glucose before starting treatment, but do not wait for results 4, 1, 2
• Test for precipitating causes such as bacterial or viral infections 4

Ongoing Management (First 24-48 Hours)

Continued Glucocorticoid Therapy:

• Continue hydrocortisone 100-300 mg per day, either as:
  • Continuous IV infusion of 200 mg per 24 hours 3, OR
  • 100 mg IV/IM every 6 hours (divided boluses) 4, 1, 2
• Both approaches are acceptable; the continuous infusion provides more stable levels 3

Continued Fluid Management:

• Administer total of 3-4 liters of isotonic saline over 24-48 hours 1, 2, 3
• Maintain slower infusion rate after the initial liter with frequent hemodynamic monitoring 2, 3
• Monitor serum electrolytes frequently to guide fluid management and avoid complications 3

Do NOT Add Separate Mineralocorticoid:

• High-dose hydrocortisone (≥50 mg per day) provides adequate mineralocorticoid activity during acute crisis 3
• Fludrocortisone is unnecessary and should not be given during the acute phase 3

Special Considerations

Pediatric Dosing:

• Initial fluid bolus: 10-20 mL/kg (maximum 1,000 mL) normal saline 3
• Monitor blood glucose more frequently—children are more vulnerable to hypoglycemia 3

Supportive Care:

• Consider ICU or high-dependency unit admission for severe cases with persistent hypotension 1, 2
• Provide gastric stress ulcer prophylaxis 2
• Consider low-dose heparin depending on severity 2
• Treat precipitating conditions (especially infections) with appropriate antimicrobial therapy 1, 2

Common Pitfalls to Avoid

Clinical Recognition Errors:

• Even mild gastrointestinal upset may precipitate crisis—patients cannot absorb oral medication when they need it most 4, 3
• The absence of hyperkalemia does NOT exclude adrenal crisis—it is present in only 50% of cases 3
• Hyponatremia is present in 90% of cases, but its absence should not prevent treatment if clinical suspicion is high 3

Treatment Errors:

• Never use dexamethasone alone—it lacks mineralocorticoid activity and is inadequate for primary adrenal insufficiency 3
• Do not attribute persistent fever solely to infection—it may be due to adrenal insufficiency itself 3
• 8.6% of adrenal crises occur due to insufficient glucocorticoid medication during hospital stays 3

Transition to Maintenance Therapy

Tapering Protocol:

• Taper parenteral glucocorticoids over 1-3 days once the patient stabilizes and can tolerate oral medications 1, 2
• Double the usual oral hydrocortisone dose for 48 hours after resuming oral intake 3
• Restart fludrocortisone 50-200 μg once daily when hydrocortisone dose falls below 50 mg per day 1, 3

Long-term Maintenance:

• Transition to hydrocortisone 15-25 mg daily in 2-3 divided doses 1
• Add fludrocortisone 50-200 μg once daily 1

Prevention of Future Crises

Patient Education (Essential):

• Teach patients to double or triple oral glucocorticoid doses during minor illness 1, 2, 3
• Instruct on use of parenteral hydrocortisone during severe illness or inability to take oral medications 1, 3
• Provide emergency injectable hydrocortisone kit 1, 2

Medical Identification:

• Patients must wear medical alert jewelry (bracelet/necklace) 1, 2
• Carry emergency steroid card at all times 1, 2

Common Precipitating Factors to Educate About:

• Gastrointestinal illness with vomiting/diarrhea (most common trigger) 4, 2, 3
• Any infection 2, 3
• Surgical procedures without adequate steroid coverage 2, 3
• Physical trauma 2, 3
• Severe allergic reactions 4, 2