What is the management approach for a patient with adrenal hemorrhage, potentially with underlying bleeding disorders or anticoagulation, and presenting with hypotension and impaired coagulation profile?

Management of Adrenal Hemorrhage

Immediate Hemodynamic Stabilization

For patients with adrenal hemorrhage presenting with hypotension and coagulopathy, immediately secure large-bore IV access, begin aggressive coagulopathy correction with fresh frozen plasma and cryoprecipitate, and use judicious vasopressor support with norepinephrine only if fluid resuscitation fails to maintain adequate perfusion pressure. 1

Vascular Access and Initial Laboratory Assessment

• Establish large-bore IV access, preferably 8-Fr central venous access, immediately upon presentation 1
• Draw baseline coagulation studies without delay: complete blood count, PT, aPTT, Clauss fibrinogen (not derived values), platelet count, and cross-match 1, 2
• Consider near-patient coagulation testing with thromboelastography (TEG) or thromboelastometry (ROTEM) if available to guide real-time hemostatic management 1, 2

Blood Pressure Management Strategy

• Target mean arterial pressure >65-70 mmHg to ensure adequate organ perfusion, particularly for the brain and kidneys 1
• Avoid permissive hypotension strategies used in trauma (SBP 80-90 mmHg), as adrenal hemorrhage with potential adrenal insufficiency requires adequate perfusion pressure 1, 3
• Use judicious fluid resuscitation first; if hypotension persists despite adequate volume replacement, add norepinephrine to maintain target arterial pressure 3
• Monitor with transduced invasive arterial pressure at the level of the tragus for accurate readings 1

Coagulopathy Correction

Aggressively correct any coagulopathy immediately, as this directly impacts hemorrhage expansion and mortality in adrenal hemorrhage. 1

Specific Hemostatic Targets

• Administer fresh frozen plasma 15 mL/kg if fibrinogen <1 g/L or PT/aPTT >1.5 times normal 1
• Target fibrinogen >1.5 g/L using cryoprecipitate if needed 2
• Maintain platelet count above 75 × 10^9/L 1, 2
• Consider tranexamic acid 10-15 mg/kg loading dose followed by 1-5 mg/kg/h infusion if administered within 3 hours of bleeding onset 1, 2

Anticoagulation Reversal (If Applicable)

Adrenal hemorrhage is increasingly recognized as a complication of anticoagulant therapy, particularly with direct oral anticoagulants (DOACs) 4, 5.

• For warfarin-associated hemorrhage: administer prothrombin complex concentrate (PCC) immediately at 25 units/kg for INR 2-3.9,35 units/kg for INR 4-5.9, or 50 units/kg for INR >6 2
• For DOAC-associated hemorrhage: use specific reversal agents if available (idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors) or PCC if specific agents unavailable 4
• Discontinue anticoagulation until bleeding is controlled and hemodynamic stability achieved 4, 5

Adrenal Insufficiency Management

Bilateral adrenal hemorrhage can lead to acute adrenal insufficiency and potentially fatal adrenal crisis without timely recognition and glucocorticoid replacement. 6, 7

Recognition and Treatment

• Maintain high clinical suspicion for adrenal insufficiency in patients with bilateral adrenal hemorrhage, unexplained hypotension, hyponatremia, or hyperkalemia 6, 4
• For patients with known adrenal insufficiency: continue physiological replacement steroids (<10 mg prednisone equivalent) at home dosing throughout treatment 3
• Do not administer stress-dose steroids prophylactically; however, have a low threshold to administer them if hypotension develops despite adequate fluid resuscitation in patients with bilateral hemorrhage 3
• If fluid-resistant hypotension occurs with suspected adrenal insufficiency, administer stress-dose steroids (hydrocortisone 100 mg IV bolus, then 50 mg IV every 6 hours) in consultation with endocrinology 3
• Patients with adrenal insufficiency may require 2-3 times the usual maintenance fluids during acute management 3

Endocrine Consultation

• Obtain endocrinology consultation at admission for patients with bilateral adrenal hemorrhage 3
• Perform baseline cortisol and ACTH levels before initiating steroids if clinical condition permits, but do not delay treatment for testing 6

Critical Care Management

Monitoring and Supportive Care

• Admit to intensive care unit for continuous hemodynamic monitoring 1, 2
• Monitor core temperature (bladder or esophageal probe); maintain normothermia 36-37°C 1
• Correct acid-base abnormalities and electrolyte disturbances, particularly hyponatremia and hyperkalemia 1
• Monitor blood glucose, targeting 6-10 mmol/L 1
• Perform serial coagulation monitoring (every 4-6 hours initially) to assess response to hemostatic therapy 1

Imaging Surveillance

• Obtain repeat CT imaging to assess for hematoma expansion, typically at 24-48 hours after initial presentation 1, 6
• Unilateral adrenal hemorrhage may progress to bilateral involvement, requiring vigilant monitoring 5

Post-Acute Management

Thromboprophylaxis

• Initiate venous thromboprophylaxis as soon as hemostasis is secured and bleeding has stopped, as patients remain at high risk for venous thromboembolism 1, 2
• Consider temporary inferior vena cava filtration if thromboprophylaxis is contraindicated due to ongoing bleeding risk 1

Long-Term Considerations

• For bilateral adrenal hemorrhage: assess adrenal function at 3 months post-event, as some patients develop persistent adrenal insufficiency requiring lifelong replacement 4
• For unilateral hemorrhage: monitor for potential progression to bilateral involvement or development of delayed adrenal insufficiency 5
• Carefully evaluate risk-benefit of resuming anticoagulation in patients whose hemorrhage was precipitated by anticoagulant therapy 4, 5

Critical Pitfalls to Avoid

• Do not apply trauma-based permissive hypotension protocols (SBP 80-90 mmHg) to adrenal hemorrhage, as these patients may have adrenal insufficiency requiring adequate perfusion pressure 1, 3
• Do not use derived fibrinogen values; insist on Clauss fibrinogen for accurate assessment of coagulation status 1
• Do not delay coagulopathy correction while waiting for laboratory results; begin empiric treatment based on clinical presentation and known anticoagulant use 2
• Do not overlook the possibility of adrenal insufficiency in unilateral hemorrhage, as it can progress to bilateral involvement 5
• Elderly patients on anticoagulation are at particularly high risk and require close monitoring even with seemingly minor symptoms 4