Adrenal Crisis

Adrenal crisis is acute cortisol (and aldosterone) deficiency with haemodynamic collapse.

Causes: primary adrenal insufficiency (autoimmune, tuberculosis, bilateral haemorrhage), secondary adrenal insufficiency after abrupt steroid withdrawal, pituitary apoplexy, sepsis, surgery, trauma, in patients with known adrenal insufficiency during illness or missed doses.

Incidence 5 to 10 per 100 patient-years in adrenal insufficiency; mortality 0.5 per 100 patient-years.

Triggers: gastroenteritis, infection, surgery.

• Hypotension or shock unresponsive to fluids, abdominal pain, nausea, vomiting, diarrhoea, fever, confusion.
• Hyponatraemia, hyperkalaemia (primary), hypoglycaemia, eosinophilia.
• Hyperpigmentation (primary), history of steroid use.

• Do not delay treatment for testing.
• Take blood for cortisol and ACTH before hydrocortisone if feasible; random cortisol below 3 micrograms/dL (80 nmol/L) in crisis confirms deficiency.
• Sodium, potassium, glucose, creatinine, calcium, renin, aldosterone.
• Synacthen test after recovery; adrenal antibodies (21 hydroxylase), imaging for cause.
• Look for precipitant (infection, cultures).

• Hydrocortisone 100 mg IV bolus immediately, then 200 mg/24 hours by infusion or 50 mg IV/IM every 6 hours.
• Isotonic saline 1 L in the first hour, then guided by haemodynamics (3 to 4 L in 24 hours); add 5% dextrose for hypoglycaemia.
• Treat precipitant (antibiotics for sepsis).
• Taper to oral hydrocortisone 15 to 25 mg daily in divided doses over days when stable; add fludrocortisone 0.05 to 0.2 mg daily in primary disease once hydrocortisone below 50 mg/day.
• Education: sick day rules (double or triple oral dose for fever, 100 mg IM injection for vomiting), medical alert bracelet, steroid emergency card, hydrocortisone injection kit.
• Stress dosing for surgery: hydrocortisone 100 mg IV at induction, then 200 mg/24 hours.