Treatment of Adrenal Crisis

Emergency Management Algorithm

The American College of Internal Medicine recommends immediate intervention with hydrocortisone 100 mg IV bolus, without delaying treatment for diagnostic procedures, in patients with adrenal crisis 1, 3
The American College of Internal Medicine suggests fluid resuscitation with 0.9% saline 1 L over the first hour, followed by 3-4 L over 24-48 hours, with frequent hemodynamic monitoring in patients with adrenal crisis 2, 3, 4
The American College of Internal Medicine recommends ongoing glucocorticoid administration with hydrocortisone 100-300 mg/day, either as continuous IV infusion or divided IV/IM boluses every 6 hours, in patients with adrenal crisis 1, 2, 3
Laboratory assessment, including serum cortisol, ACTH, electrolytes, creatinine, urea, glucose, and tests for precipitating causes, is recommended in patients with adrenal crisis 3
Additional supportive care, such as ICU/high-dependency unit admission, gastric stress ulcer prophylaxis, low-dose heparin, and antibiotic treatment, may be considered in patients with adrenal crisis 2, 3, 5
Tapering of parenteral glucocorticoids over 1-3 days to oral maintenance therapy is recommended once the patient is stabilized 3, 4

Common symptoms of adrenal crisis include malaise, fatigue, nausea, vomiting, abdominal pain, muscle pain/cramps, dehydration, hypotension, and shock 1, 2
Neurological manifestations, such as impaired cognitive function, confusion, loss of consciousness, and coma, may occur in patients with adrenal crisis 3
Laboratory findings, including hyponatremia, hyperkalemia, increased creatinine, hypoglycemia, and mild hypercalcemia, are common in patients with adrenal crisis 3

Gastrointestinal illness with vomiting/diarrhea is a common trigger for adrenal crisis 3
Infections, surgical procedures without adequate steroid coverage, physical injuries or trauma, myocardial infarction, severe allergic reactions, and severe hypoglycemia in diabetic patients are also common precipitating factors for adrenal crisis 3

Patient education on managing their condition during illness or stress is essential to prevent adrenal crisis 4
Medical identification, such as wearing medical alert jewelry and carrying a steroid/emergency card, is recommended for patients with adrenal insufficiency 4, 6
Stress dosing guidelines, including doubling oral glucocorticoid dose during minor illness and using parenteral hydrocortisone during severe illness or surgery, are recommended to prevent adrenal crisis 1, 2, 4

Evaluating the precipitating cause and reviewing the patient's understanding of stress dosing and self-management are recommended after an adrenal crisis 3, 4, 5
Ensuring the patient has emergency supplies, such as injectable hydrocortisone, and considering annual follow-up with assessment of health, well-being, weight, blood pressure, and electrolytes are also recommended 4