What is the acute management of adrenal crisis, including glucocorticoid dosing and fluid resuscitation?

Acute Management of Adrenal Crisis

Immediately administer hydrocortisone 100 mg IV bolus and begin 0.9% isotonic saline 1 L over the first hour without awaiting diagnostic confirmation—treatment delay increases mortality. 1

Immediate Emergency Management (First Hour)

• Give hydrocortisone 100 mg IV bolus the moment you suspect adrenal crisis—this single intervention is the most critical and must never be delayed for laboratory results or diagnostic confirmation. 1, 2 The 100 mg dose saturates 11β-hydroxysteroid dehydrogenase type 2, providing both glucocorticoid and essential mineralocorticoid activity. 1

• Simultaneously infuse 0.9% isotonic saline 1 L over the first hour—aggressive volume expansion is mandatory because profound dehydration and circulatory collapse are core pathophysiologic features. 1, 2 Fluid resuscitation and hydrocortisone must occur together; neither alone is sufficient to reverse shock. 2

• If IV access cannot be rapidly established, give hydrocortisone 100 mg IM immediately—intramuscular administration provides adequate glucocorticoid effect when venous access is unavailable. 1

• Draw blood for serum cortisol, ACTH, electrolytes (sodium, potassium), creatinine, urea, and glucose before starting treatment, but do not wait for results—early laboratory workup aids diagnosis without delaying therapy. 1, 2 Even a few minutes' delay to obtain labs can worsen outcomes. 1

Clinical Recognition Triggers

Suspect adrenal crisis in any patient presenting with:

• Severe hypotension (often <90/60 mmHg) or shock, especially if unresponsive to standard vasopressors 1, 2
• Profound dehydration with tachycardia 1
• Severe nausea, vomiting, or abdominal pain mimicking an acute abdomen 1
• Altered mental status—ranging from confusion and lethargy to obtundation or coma 1
• Unexplained collapse with electrolyte abnormalities (hyponatremia in ~90%, hyperkalemia in ~50%) 1, 2

Critical pitfall: Absence of hyperkalemia does not exclude adrenal crisis—it is present in only half of cases. 1 Similarly, normal or even elevated plasma cortisol does not exclude relative adrenal insufficiency in physiologically stressed patients. 1

Ongoing Management (First 24–48 Hours)

• Continue hydrocortisone 200 mg per 24 hours as continuous IV infusion (preferred method) or alternatively give 50 mg IV/IM every 6 hours. 1, 2 Both regimens deliver equivalent daily glucocorticoid load. 1

• Infuse a total of 3–4 L of 0.9% isotonic saline (or 5% dextrose-in-saline) over 24–48 hours—continue slower fluid resuscitation after the initial liter, with frequent hemodynamic monitoring to prevent fluid overload. 1, 2

• Monitor serum electrolytes every 4–6 hours initially—hypernatremia may develop with prolonged high-dose hydrocortisone beyond 48–72 hours. 2 If hypernatremia occurs, consider switching to methylprednisolone sodium succinate. 2

• Check blood glucose frequently, especially in children—pediatric patients are more vulnerable to hypoglycemia. 1

• Do not add separate mineralocorticoid (fludrocortisone) during acute crisis—hydrocortisone doses ≥50 mg per day provide adequate mineralocorticoid activity. 1 Restart fludrocortisone only after hydrocortisone dose falls below 50 mg/day. 1, 3

Supportive Care

• Admit patients with persistent hypotension or severe presentation to ICU or high-dependency unit for close monitoring and rapid escalation of support. 1

• Provide gastric stress-ulcer prophylaxis to reduce risk of stress-related gastrointestinal bleeding. 1

• Administer low-dose heparin prophylaxis to 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, 5

Clinical pearl: Persistent fever may be due to adrenal insufficiency itself, not just infection—do not reduce steroid supplementation while the patient remains febrile. 1

Transition to Maintenance Therapy

• Taper parenteral glucocorticoids over 1–3 days once the precipitating illness permits oral intake—gradual reduction prevents rebound crisis. 1, 3 After uncomplicated recovery, 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. 1, 3

• Avoid abrupt cessation of high-dose therapy—always taper gradually to prevent rebound crisis. 2, 3 Tapering too rapidly can precipitate life-threatening adrenal crisis. 3

• Restart fludrocortisone when hydrocortisone dose falls below 50 mg per day—lower glucocorticoid doses no longer provide sufficient mineralocorticoid activity. 1, 3

Special Populations

Pediatric Patients

• Give initial normal saline fluid bolus of 10–20 mL/kg (maximum 1,000 mL) in children with hypotension. 1

• Dose hydrocortisone based on age and body weight—children require more frequent blood glucose monitoring due to higher hypoglycemia risk. 1

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. 1

• Perform rapid tapering over 1–3 days after uncomplicated vaginal delivery or cesarean section back to regular replacement dose. 3

Prevention of Future Crises

• Educate patients to double or triple oral glucocorticoid doses during minor illness and to use parenteral hydrocortisone during severe illness or inability to take oral medications. 1 However, recognize that patient education alone does not prevent many adrenal crisis events—the incidence remains 5–10 crises per 100 patient-years despite education efforts. 6, 4, 5

• Provide emergency injectable hydrocortisone kit and train a companion in its use—every patient should carry this kit. 1, 4, 7

• Ensure patients wear medical-alert identification jewelry and carry a steroid-emergency card—these tools facilitate rapid recognition and treatment by healthcare providers or bystanders. 1, 5, 7

• Investigate recurrent crises for chronic under-replacement (inadequate fludrocortisone, low salt intake), poor medication adherence, or underlying psychiatric disorders affecting compliance. 1

Critical pitfall: Never start thyroid hormone replacement before adequate glucocorticoid replacement in patients with multiple hormone deficiencies—this can trigger adrenal crisis. 1