What is the emergency management of an Addison (adrenal) crisis in a patient with known primary or secondary adrenal insufficiency presenting with severe hypotension, vomiting, abdominal pain, fever, confusion, or shock?

Emergency Management of Addison Crisis

Immediately administer IV hydrocortisone 100 mg bolus and begin rapid infusion of 0.9% isotonic saline at 1 L/hour—treatment must never be delayed for diagnostic procedures in suspected adrenal crisis. 1

Immediate Actions (First Hour)

• Give IV hydrocortisone 100 mg as an immediate bolus to saturate mineralocorticoid receptors and provide life-saving glucocorticoid replacement 1
• Infuse 0.9% isotonic saline at 1 L/hour initially, with 3-4 L total planned over the first 24 hours to correct severe hypovolemia and electrolyte abnormalities 1
• Draw blood for serum cortisol, ACTH, sodium, potassium, creatinine, urea, and glucose before giving hydrocortisone if possible, but do not delay treatment to obtain these samples 1
• Obtain cultures and initiate empiric antibiotics if infection is the suspected precipitating cause 1

Continuing Management (First 24-48 Hours)

• Continue hydrocortisone 100 mg IV every 6 hours (total 400 mg/day) or as continuous infusion of 100-300 mg/24 hours until the patient is hemodynamically stable 1
• Maintain IV isotonic saline infusion at a slower rate after the initial liter, with frequent hemodynamic monitoring and serum electrolyte measurements to avoid fluid overload 1
• Do not give fludrocortisone during acute crisis—high-dose hydrocortisone provides sufficient mineralocorticoid effect by saturating mineralocorticoid receptors 1
• Consider ICU or high-dependency unit admission depending on severity, with prophylaxis for stress ulcers and DVT 1
• Treat the precipitating cause aggressively (infection, trauma, myocardial infarction, etc.) 1

Tapering and Transition (Days 2-4)

• Taper parenteral glucocorticoids over 1-3 days to oral replacement only when the precipitating illness is controlled and the patient can tolerate oral intake 1
• Restart fludrocortisone 0.05-0.1 mg daily when hydrocortisone dose falls below 50 mg/day, as lower doses no longer provide adequate mineralocorticoid effect 1
• Transition to maintenance oral 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) 1, 2

Recognition of Adrenal Crisis

The diagnosis should be suspected immediately in any patient with known adrenal insufficiency presenting with:

• Severe hypotension or shock that is refractory to initial fluid resuscitation 1, 3
• Vomiting and/or diarrhea (the most common precipitating events) with inability to take oral medications 1, 3
• Abdominal pain that may mimic an acute surgical abdomen with peritoneal irritation 1
• Altered mental status ranging from confusion to loss of consciousness or coma 1
• Fever from infection or as a direct manifestation of the crisis 1

Laboratory findings typically include hyponatremia (present in 90% of cases), hyperkalaemia (only ~50% of cases), prerenal renal failure with elevated creatinine, and sometimes hypoglycemia in children 1, 4

Critical Pitfalls to Avoid

• Never delay treatment to perform diagnostic testing—mortality is high if treatment is delayed, and the clinical presentation is sufficient to initiate therapy 1, 3, 2
• Do not rely on the absence of hyperkalemia to rule out adrenal crisis, as it occurs in only approximately 50% of cases and is typically absent in secondary adrenal insufficiency 1, 4
• Do not use dexamethasone for acute crisis management in confirmed adrenal insufficiency—it lacks mineralocorticoid activity and is inadequate for primary adrenal insufficiency 4
• Recognize that common precipitants include gastrointestinal illness, infections, surgical procedures, trauma, myocardial infarction, and treatment failures in poorly educated or non-compliant patients 1

Prevention of Future Crises

• Reinforce patient education on stress-dosing: double or triple usual daily dose during fever, illness, vomiting, or physical stress 1, 2
• Prescribe emergency injectable hydrocortisone 100 mg IM kit with self-injection training for use when oral intake is impossible 1, 2
• Ensure patients wear medical alert identification (bracelet or necklace) indicating adrenal insufficiency to trigger immediate stress-dose administration by emergency personnel 1, 2
• Provide a steroid emergency card with clear instructions for healthcare providers 1
• Address any precipitating causes and ensure adequate maintenance replacement therapy to prevent recurrence 1