Adrenal Crisis: Recognize, Treat, Prevent
Definition
- Adrenal crisis is a life-threatening deterioration caused by inadequate cortisol during physiologic stress.
- Treat suspected crisis immediately. Do not delay emergency treatment for confirmatory testing.
When to Suspect Adrenal Crisis
- Consider adrenal crisis in a patient with known or possible adrenal insufficiency who has:
- Severe weakness
- Abdominal pain
- Persistent vomiting
- Hypotension
- Confusion
- Loss of consciousness
- Common listed triggers include:
- Infection
- Injury or trauma
- Surgery
- Acute illness
- Abrupt cessation of chronic glucocorticoids
Primary Versus Secondary Adrenal Insufficiency
Primary Adrenal Insufficiency
- Adrenal destruction causes low cortisol and low aldosterone.
- ACTH is elevated.
- Salt craving and hyperpigmentation support this pattern.
- Low sodium plus high potassium supports primary adrenal insufficiency.
Secondary Adrenal Insufficiency
- Pituitary ACTH deficiency lowers cortisol.
- Aldosterone is generally preserved.
- Chronic glucocorticoid exposure and withdrawal are important causes.
- Low sodium plus high potassium should not be used to support secondary adrenal insufficiency because this pattern favors primary disease.
Immediate Emergency Treatment
- Do not wait for confirmatory testing when crisis is suspected.
- Give hydrocortisone 100 mg intravenously or intramuscularly immediately.
- Continue hydrocortisone at 50 mg every six hours.
- Resuscitate with intravenous normal saline.
- Identify and treat the precipitating illness, including infection when present.
- Transfer or escalate urgently to emergency care.
Diagnostic Clarification After Stabilization
- Once stabilization is underway, use the following to clarify the diagnosis:
- Focused history and physical examination
- Morning cortisol
- ACTH
- Serum electrolytes
- Cosyntropin stimulation testing
- A low cortisol response to cosyntropin supports adrenal insufficiency.
- ACTH helps distinguish primary from secondary disease.
- Determine the underlying cause with targeted autoimmune testing or imaging.
Prevention and Sick-Day Planning
- Prevention is part of ongoing clinical care.
- Patients receiving replacement therapy need:
- Consistent medication use
- Medical identification alert
- Emergency steroid card
- A written plan for illness or surgery
- The local teaching summary advises:
- Mild illness: double the usual dose.
- Moderate illness: increase to two or three times the usual dose.
- Severe illness, trauma, or surgery: use parenteral hydrocortisone.
Clinical Pitfalls
- Never advise abrupt cessation of glucocorticoids.
- Primary and secondary adrenal insufficiency are not interchangeable.
- Do not delay emergency treatment while waiting for diagnostic confirmation.
- Follow local protocols and specialist guidance for dosing, tapering, and disposition.
Summary Takeaway
- Suspect adrenal crisis when adrenal insufficiency is possible and severe stress-related symptoms or hemodynamic instability are present.
- Treat immediately with hydrocortisone, intravenous normal saline, and management of the precipitating illness.
- Use ACTH, electrolytes, cortisol testing, and cosyntropin testing after stabilization to clarify the diagnosis.
- Prevent recurrence with adherence, identification, emergency steroid resources, and a clear sick-day plan.
