Adrenal Crisis (Addisonian Crisis) Management

Algorithm Steps

1. ▶

   Start

   Suspected Adrenal Crisis

   Known AI patient OR high clinical suspicion

   1. ●

      Action

      Recognize Clinical Features

      Life-threatening presentation

      • Profound hypotension/shock (refractory to fluids/pressors)
      • Severe weakness, fatigue, lethargy
      • Nausea, vomiting, abdominal pain
      • Fever (may mimic sepsis)
      • Altered mental status, confusion
      • Hyperpigmentation (primary AI)
      • History of AI or chronic steroid use
      1. ●

         Action

         High-Risk Populations

         Who to suspect

         • Known adrenal insufficiency (primary or secondary)
         • Current or recent glucocorticoid use (ANY route)
         • Bilateral adrenalectomy
         • Pituitary disease/surgery
         • Autoimmune conditions (autoimmune AI)
         • Recent discontinuation of steroids
         • Sepsis with refractory hypotension
         1. ●

            Action

            1. IMMEDIATE Hydrocortisone

            DO NOT DELAY - treat empirically

            • Hydrocortisone 100 mg IV bolus STAT
            • Adults: 100 mg IV push immediately
            • Pediatrics: 50 mg/m² (max 100 mg) IV
            • If hydrocortisone unavailable: Prednisolone 25 mg IV
            • Dexamethasone 4 mg IV ONLY if testing needed (doesn't interfere with cortisol assay)
            • DO NOT wait for labs to treat if clinical suspicion high
            1. ●

               Action

               2. Aggressive IV Fluids

               Volume expansion critical

               • 0.9% Normal Saline 1L IV bolus
               • Then 0.9% NS at 200-500 mL/hr
               • Add D5NS if hypoglycemic
               • May require 2-3L in first few hours
               • Monitor for fluid overload
               1. ●

                  Action

                  4. Treat Hypoglycemia

                  Common in adrenal crisis

                  • Check glucose immediately
                  • D50W 25-50 mL IV if hypoglycemic
                  • Use dextrose-containing fluids
                  • Monitor glucose frequently
                  1. ●

                     Action

                     5. Identify & Treat Precipitant

                     Crisis usually triggered by stress

                     • Infection (most common) - cultures, empiric antibiotics if septic
                     • Surgery or trauma
                     • Missed steroid doses / non-compliance
                     • GI illness with vomiting (can't absorb PO)
                     • Emotional stress
                     • Adrenal hemorrhage (consider CT)
                     1. ●

                        Action

                        6. Monitoring

                        Close observation

                        • Blood pressure, HR (q15-30min initially)
                        • Mental status
                        • Glucose (q1-2h)
                        • Electrolytes: Na, K (hyponatremia, hyperkalemia common)
                        • Cortisol, ACTH (before treatment if possible, but DON'T delay treatment)
                        1. ◆

                           Decision

                           Clinical Response?

                           Assess within 1-2 hours

                           1. ✓

                              Outcome

                              Improving

                              Continue therapy and taper

                              • Continue hydrocortisone, gradually taper
                              • When stable: transition to PO
                              • Add fludrocortisone when IV hydrocortisone stopped (primary AI)
                              • Establish maintenance dosing
                              • Patient education on sick-day rules
                           2. ⚠

                              Warning

                              Refractory

                              No response to treatment

                              • Ensure adequate steroid dosing
                              • Aggressive fluid resuscitation
                              • Search for untreated infection/precipitant
                              • Consider alternative diagnoses
                              • ICU admission if not already
            2. ●

               Action

               3. Ongoing Steroid Replacement

               After initial bolus

               • Hydrocortisone 200 mg/24h total
               • Options: 50 mg IV q6h OR continuous infusion
               • Continuous infusion may provide more stable levels
               • No mineralocorticoid needed acutely (hydrocortisone has MC activity at high doses)
               • Taper as patient improves
            3. ⚠

               Warning

               ⚠️ Vasopressor Warning

               Pressors less effective without steroids

               • Adrenal crisis causes catecholamine resistance
               • Vasopressors may be ineffective until steroids given
               • Always give hydrocortisone with pressors
               • Response to pressors improves after steroids