Adrenal Crisis

Adrenal crisis describes an acute adrenal insufficiency, often presenting as hypotension refractory to fluids and vasopressors.

Causes

• chronic adrenal insufficiency
  • most often in patients with primary adrenal insufficiency, can also occur in secondary and tertiary insufficiency
  • triggers:
    • increased demand for glucocorticoids (infection, surgery, trauma, …)
    • abrupt withdrawal of exogenous glucocorticoids
• acute adrenal insufficiency
  • pituitary infarction
  • acute adrenal gland destruction (hemorrhage, trauma)

Presentation

• volume depletion and hypotension, often refractory to fluids and vasopressors

• nausea, diarrhea, vomiting, abdominal pain

• reduced consciousness, delirium

• laboratory findings

  • hyperkalemia (in primary adrenal insufficiency)
  • hyponatremia
  • possibly hypercalcemia, hypoglycemia

Management

• primary measures:

  • establish i.v. access, measure serum electrolytes, glucose, cortisol and ACTH
    • do not wait for laboratory results, hormones values are used to confirm diagnosis later
      • normal cortisol (> 20 µg/dl) excludes adrenal insufficiency, lower values require further confirmation (i.e. ACTH test)
  • replace fluids
    • 1 to 3 liters i.v. fluid (saline or isotonic)
      • don’t give hypotonic saline (worsens hyponatremia)
    • dextrose to correct hypoglycemia
  • hydrocortisone
    • 100 mg bolus
    • followed by 50 mg every 6 hours or 200 mg/24h continuous

• secondary measures:

  • search and treat underlying trigger
  • perform ACTH-test, determine type of adrenal insufficiency
  • taper i.v. glucocorticoid to oral medication, if possible

• Patients should improve rapidly and considerably with steroid and volume replacement

• Consider prevention strategies in patients with known adrenal insufficiency, e.g. doubling or tripling of maintenance steroid dose in infection/surgery/etc.

Additional links

• EMCrit on adrenal crisis
• UpToDate article on treatment of adrenal crisis
• Adrenal insufficiency in nature disease primers

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