Addisonian Crisis Management

Clinical Presentation and Diagnosis

Addisonian crisis presents with hypotension, dehydration, malaise, fatigue, nausea, vomiting, abdominal pain, muscle pain/cramps, and potentially shock, with laboratory findings typically including hyponatremia, hyperkalemia, increased creatinine, hypoglycemia, and mild hypercalcemia 1, 2
Neurological manifestations may include impaired cognitive function, confusion, loss of consciousness, and coma 1, 2
Hyperpigmentation of skin is a classic sign of primary adrenal insufficiency due to elevated ACTH levels 2, 3

Administer hydrocortisone 100 mg IV bolus immediately, without waiting for diagnostic confirmation, and begin fluid resuscitation with 0.9% saline 1L over the first hour, followed by 3-4L over 24-48 hours 1, 3
Continue glucocorticoid administration with hydrocortisone 100-300 mg/day, either as continuous IV infusion or divided IV/IM boluses every 6 hours 1, 3
Monitor hemodynamic parameters frequently and evaluate and treat precipitating causes (infection, trauma, surgery) 1, 3

Patient education on managing their condition during illness or stress is essential, including specific stress dosing guidelines: double or triple oral glucocorticoid dose during minor illness and use parenteral hydrocortisone during severe illness 1, 3
Ensure patients have emergency supplies, including injectable hydrocortisone, and recommend medical identification (medical alert jewelry and emergency steroid card) 1, 3

During surgery, follow stress dosing protocols based on procedure severity, with major surgery requiring 100 mg hydrocortisone IM before anesthesia, and continue 100 mg every 6 hours until able to take oral medication 4
During pregnancy, increased requirements during third trimester; during delivery, administer 100 mg hydrocortisone IM at onset of labor 6, 7
Unaccustomed intense or prolonged exercise may require increased hydrocortisone and salt intake 4, 5, 6