Adrenal Crisis Workup
- Author: Lisa Kirkland, MD, FACP, CNSP, MSHA; Chief Editor: George T Griffing, MD more...
Laboratory Studies
- Serum chemistry: Abnormalities are present in as many as 56% of patients. Hyponatremia is common (although not diagnostic); hyperkalemia, metabolic acidosis, and hypoglycemia also may be present.
- Serum cortisol: Less than 20 mcg/dL in severe stress or after ACTH stimulation is indicative of adrenal insufficiency.
- ACTH test (diagnostic): Determine baseline serum cortisol, then administer ACTH 250 mcg intravenous push (IVP), and then draw serum cortisol 30 and 60 minutes after ACTH administration. An increase of less than 9 mcg/dL is considered diagnostic of adrenal insufficiency.
- CBC: Anemia (mild and nonspecific), lymphocytosis, and eosinophilia (highly suggestive) may be present.
- Serum thyroid levels: Assess for autoimmune, infiltrative, or multiple endocrine disorders.
- Cultures: Perform blood and other cultures as clinically indicated. Infection is a common cause of acute adrenal crisis.
Imaging Studies
- Chest radiography: Assess for tuberculosis, histoplasmosis, malignant disease, sarcoid, and lymphoma.
- Abdominal CT scanning: Visualize adrenal glands for hemorrhage (as in the image below), atrophy, infiltrative disorders, and metastatic disease. Adrenal hemorrhage appears as hyperdense, bilaterally enlarged adrenal glands.
Computed tomographic (CT) scans of the abdomen show normal adrenal glands several months before the onset of hemorrhage (upper panel) and enlarged adrenals 2 weeks after an acute episode of bilateral adrenal hemorrhage (lower panel). The attenuation of the adrenal glands, indicated by arrows, is increased after the acute event. Reproduced from Rao RH, Vagnucci AH, Amico JA: Bilateral massive adrenal hemorrhage: early recognition and treatment. Ann Intern Med. Feb 1 1989;110(3):227-35 with permission from the journal.
Other Tests
- Electrocardiography
- Prolongation of the QT interval can induce ventricular arrhythmias.
- Deep negative T waves have been described in acute adrenal crisis.
Histologic Findings
Histology depends on the cause of the adrenal failure. In primary adrenocortical failure, histologic evidence of infection, infiltrative disease, or other condition may be demonstrated. Secondary adrenocortical insufficiency may cause atrophy of the adrenals or no histologic evidence at all, especially if due to exogenous steroid ingestion. Appearance of bilateral adrenal hemorrhage may be striking, as if bags of blood are replacing the glands.
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| Timing | Hydrocortisone | Hydrocortisone | Fludrocortisone |
| Routine daily | … | 20 mg PO at 8 am 10 mg PO at 4 pm | 0.1 mg PO at 8 am |
| Day of operation | 10 mg/h continuous infusion | … | … |
| Postoperative day 1 | 5-7.5 mg/h continuous infusion | … | … |
| Postoperative day 2 | 2.5-5 mg/h continuous infusion | … | … |
| Postoperative day 3 | 2.5-5 mg/h continuous infusion or | 40 mg PO at 8 am 20 mg PO at 4 pm | 0.1 mg PO at 8 am |
| Postoperative day 4 | 2.5-5 mg/h continuous infusion or | 40 mg PO at 8 am 20 mg PO at 4 pm | 0.1 mg PO at 8 am |
| Postoperative day 5 | … | 40 mg PO at 8 am 20 mg PO at 4 pm | 0.1 mg PO at 8 am |
| Postoperative day 6 | … | 20 mg PO at 8 am 20 mg PO at 4 pm | 0.1 mg PO at 8 am |
| Postoperative day 7 | … | 20 mg PO at 8 am 10 mg PO at 4 pm | 0.1 mg PO at 8 am |
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