Emergency Management of Adrenal Crisis
Immediately administer hydrocortisone 100 mg IV bolus and begin 0.9% isotonic saline 1 L over the first hour without waiting for diagnostic confirmation—treatment delay increases mortality. 1
Immediate Recognition and Action (First Hour)
Give hydrocortisone 100 mg IV bolus as soon as adrenal crisis is suspected—this dose saturates 11β-hydroxysteroid dehydrogenase type 2 to provide both glucocorticoid and mineralocorticoid activity, eliminating the need for separate fludrocortisone during acute management. 1
Start aggressive fluid resuscitation with 0.9% isotonic saline at 1 L over the first hour—volume depletion and circulatory collapse are key pathophysiologic features requiring rapid correction. 1
If IV access cannot be rapidly established, give hydrocortisone 100 mg IM immediately—intramuscular administration is an acceptable backup route when venous access is delayed. 1
Draw blood for serum cortisol, ACTH, electrolytes (sodium, potassium), creatinine, BUN, and glucose before starting treatment, but never delay therapy waiting for results—early laboratory workup aids diagnosis without postponing life-saving intervention. 1
Clinical Recognition Triggers
Suspect adrenal crisis in any patient presenting with hypotension (often <90/60 mmHg), severe dehydration, marked nausea/vomiting, abdominal pain, altered mental status (confusion, obtundation, coma), or unexplained collapse—these nonspecific symptoms often lead to misdiagnosis and delayed treatment. 1, 2
Orthostatic hypotension occurs before supine hypotension develops—monitor both sitting/standing and supine blood pressure for early detection. 1
Hyponatremia is present in approximately 90% of cases, hyperkalemia in 50%, and hypoglycemia is more common in children than adults—however, absence of these findings should not prevent treatment if clinical suspicion is high. 1
Ongoing Management (First 24–48 Hours)
Hydrocortisone Dosing
Continue hydrocortisone 200 mg per 24 hours as continuous IV infusion (preferred method)—this is the only administration mode that persistently achieves median cortisol concentrations in the range observed during major stress. 1, 3
Alternative regimen: hydrocortisone 50 mg IV or IM every 6 hours (total 200 mg/day)—use this when continuous infusion is not feasible. 1
Do not add separate mineralocorticoid (fludrocortisone) during acute crisis—high-dose hydrocortisone (≥50 mg per day) provides adequate mineralocorticoid activity. 1
Fluid Resuscitation and Electrolyte Correction
Continue isotonic saline infusion at a slower rate after the initial liter, delivering a total of 3–4 L over 24–48 hours—adjust based on hemodynamic response and avoid fluid overload. 1
Consider 5% dextrose in isotonic saline if hypoglycemia is present—particularly important in pediatric patients who are more vulnerable to hypoglycemia. 1
Monitor serum electrolytes frequently to guide fluid management—hyponatremia and hyperkalemia typically correct with hydrocortisone and volume replacement without requiring specific electrolyte therapy. 1
Perform frequent blood glucose monitoring, especially in children—hypoglycemia is a common finding in pediatric adrenal crisis. 1
Supportive Care
Admit patients with persistent hypotension or severe presentation to an ICU or high-dependency unit—close monitoring ensures rapid escalation of support if needed. 1
Provide gastric stress-ulcer prophylaxis—reduces risk of stress-related gastrointestinal bleeding. 1
Administer low-dose heparin for DVT prophylaxis—helps prevent venous thromboembolism during immobilization. 1
Treat precipitating infections promptly with appropriate antimicrobial therapy—infections (especially gastrointestinal illness with vomiting/diarrhea) are the most common trigger of adrenal crisis. 1, 4
Transition to Maintenance Therapy
Taper parenteral glucocorticoids over 1–3 days once the precipitating illness permits and oral intake is tolerated—gradual reduction prevents rebound crisis. 1, 5
Reduce to double the usual oral maintenance dose for 24–48 hours, then return to standard physiologic replacement of 15–25 mg hydrocortisone daily divided into 2–3 doses—the largest dose should be given upon awakening. 1, 6
Re-introduce fludrocortisone only after the hydrocortisone dose falls below 50 mg per day—lower glucocorticoid doses no longer provide sufficient mineralocorticoid activity. 1, 5
Special Populations
Pediatric Patients
Give initial normal saline fluid bolus of 10–20 mL/kg (maximum 1,000 mL) in children with hypotension—adjust hydrocortisone dosing based on age and body weight. 1
Monitor blood glucose more frequently in children—they are more vulnerable to hypoglycemia than adults. 1, 7
Obstetric Patients
- Administer hydrocortisone 100 mg IM at the onset of labor, then continue 200 mg per 24 hours IV infusion (or 50 mg IM every 6 hours) until after delivery—taper rapidly over 1–3 days postpartum. 1
Critical Pitfalls to Avoid
Never postpone treatment to obtain diagnostic confirmation—mortality increases with delayed intervention, and treatment should begin based on clinical suspicion alone. 1, 4
Never use dexamethasone as the primary glucocorticoid in primary adrenal insufficiency—it lacks mineralocorticoid activity and is inadequate for crisis management. 1
Do not attribute persistent fever solely to infection—pyrexia may be due to adrenal insufficiency itself, and steroid supplementation should not be reduced while the patient is febrile. 1
Never start thyroid hormone replacement before adequate glucocorticoid replacement in patients with multiple hormone deficiencies—this can trigger adrenal crisis. 1
Prevention of Future Crises
Educate all patients to double or triple oral glucocorticoid doses during minor illness with fever, and to use parenteral hydrocortisone during severe illness with vomiting or inability to take oral medications—patient education is paramount to preventing recurrent crises and unnecessary deaths. 1, 5, 2
Provide every patient with an emergency glucocorticoid injection kit and train them (and a companion) in parenteral self-administration—this reduces barriers to early treatment. 1, 4
Ensure all patients wear medical alert identification jewelry and carry an emergency steroid card—this triggers stress-dose corticosteroids by emergency medical personnel. 1, 5, 7
Investigate recurrent crises for chronic under-replacement with fludrocortisone, low salt consumption, poor medication adherence, or underlying psychiatric disorders—identifying modifiable factors helps prevent future episodes. 1, 5