eMedicine Specialties > Emergency Medicine > Endocrine & Metabolic

Adrenal Insufficiency and Adrenal Crisis: Follow-up

Author: Kevin M Klauer, DO, FACEP, Assistant Clinical Professor, Michigan State University College of Osteopathic Medicine; Director, Quality and Clinical Education, Emergency Medicine Physicians, Ltd; Director, Center for Emergency Medical Education; Editor-in-Chief, Emergency Physicians Monthly
Contributor Information and Disclosures

Updated: Aug 19, 2008

Follow-up

Further Inpatient Care

Inpatient care of adrenal insufficiency should consist of the following:

  • Employ supportive measures as necessary.
  • Correct electrolyte abnormalities.
  • Perform judicious volume resuscitation.
  • Continuously monitor and administer glucose.
  • Once the patient stabilizes, usually by the second day, the corticosteroid dose may be reduced and then tapered. Oral maintenance usually can be achieved by the fourth or fifth day.
  • Mineralocorticoid administration is not needed unless a corticosteroid with low mineralocorticoid activity (eg, dexamethasone) is used, or cortisol/corticosteroid administration has been reduced to near maintenance levels. Mineralocorticoid administration usually is not necessary for treatment of secondary adrenocortical insufficiency.
  • Pursue and manage precipitating factors of adrenal crisis or insufficiency. Infectious etiologies commonly precipitate adrenal crisis. Recognition and treatment of causative factors are crucial aspects of managing adrenal hypofunction.

Further Outpatient Care

  • Maintenance of cortisol levels may be achieved by administering hydrocortisone 15-20 mg PO every morning and 5-10 mg PO between 4:00-6:00 PM every afternoon.
  • Maintenance mineralocorticoid levels may be achieved by administering 9alpha-fluorocortisol 0.05-0.1 mg every morning. (This treatment is necessary only for primary adrenocortical insufficiency.)
  • Periodically assess blood pressure, body weight, and electrolytes.
  • Advise patients to increase their cortisol dosage during times of physical stress.

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnose due to ambiguous presentations or comorbidity
  • Failure to identify missed mineralocorticoid deficiency
  • Failure to identify missed associated endocrine abnormalities
  • Failure to administer steroids before tetraiodothyronine (thyroxine T4)
  • Failure to administer glucose before steroids

Special Concerns

  • Dexamethasone
    • Administer 4 mg q6h during ACTH stimulation test.
    • This agent is 100 times more potent than cortisone but does not alter cortisol levels.
 


More on Adrenal Insufficiency and Adrenal Crisis

Overview: Adrenal Insufficiency and Adrenal Crisis
Differential Diagnoses & Workup: Adrenal Insufficiency and Adrenal Crisis
Treatment & Medication: Adrenal Insufficiency and Adrenal Crisis
Follow-up: Adrenal Insufficiency and Adrenal Crisis
References
[ CLOSE WINDOW ]

References

  1. Wyngaarden JB, Smith LH, Bennett JC. Adrenocortical hypofunction. Cecil Textbook of Medicine. 19th ed. WB Saunders; 1992:1271-1288.

  2. Lundy JB, Slane ML, Frizzi JD. Acute adrenal insufficiency after a single dose of etomidate. J Intensive Care Med. Mar-Apr 2007;22(2):111-7. [Medline].

  3. Aono J, Mamiya K, Ueda W. Abrupt onset of adrenal crisis during routine preoperative examination in a patient with unknown Addison's disease. Anesthesiology. Jan 1999;90(1):313-4. [Medline].

  4. Braunwald E, Isselbacher KJ, Fauci AS, et al. Hypofunction of adrenal cortex. In: Harrison's Principles of Internal Medicine. 11th ed. McGraw-Hill; 1987:1764-1771.

  5. Carson PP. Emergency. Adrenal crisis. Am J Nurs. Jul 2000;100(7):49-50. [Medline].

  6. Chin R. Adrenal crisis. Crit Care Clin. Jan 1991;7(1):23-42. [Medline].

  7. Cronin CC, Callaghan N, Kearney PJ, et al. Addison disease in patients treated with glucocorticoid therapy. Arch Intern Med. Feb 24 1997;157(4):456-8. [Medline].

  8. Dluhy RG. Assessment of systemic corticosteroid activity. Respir Med. Nov 1997;91 Suppl A:32-3. [Medline].

  9. Duclos M, Guinot M, Colsy M, Merle F, Baudot C, Corcuff JB, et al. High risk of adrenal insufficiency after a single articular steroid injection in athletes. Med Sci Sports Exerc. Jul 2007;39(7):1036-43. [Medline].

  10. Gilliland PF. Endocrine emergencies. Adrenal crisis, myxedema coma, and thyroid storm. Postgrad Med. Nov 1983;74(5):215-20, 225-7. [Medline].

  11. Guyton AC, et al. The adrenocortical hormones. In: Textbook of Medical Physiology. 7th ed. WB Saunders; 1986:909-919.

  12. Lelubre C, Lheureux PE. Epigastric pain as presentation of an addisonian crisis in a patient with Schmidt syndrome. Am J Emerg Med. Feb 2008;26(2):251.e3-4. [Medline].

  13. Omori K, Nomura K, Shimizu S. Risk factors for adrenal crisis in patients with adrenal insufficiency. Endocr J. Dec 2003;50(6):745-52. [Medline].

  14. Reincke M. Subclinical Cushing's syndrome. Endocrinol Metab Clin North Am. Mar 2000;29(1):43-56. [Medline].

  15. Rosen P. Endocrine disorders. In: Emergency Medicine: Concepts and Clinical Practice. 3rd ed. Mosby-Year Book; 1992:2252-2259.

  16. Rusnak RA. Adrenal and pituitary emergencies. Emerg Med Clin North Am. Nov 1989;7(4):903-25. [Medline].

  17. Simm PJ, McDonnell CM, Zacharin MR. Primary adrenal insufficiency in childhood and adolescence: advances in diagnosis and management. J Paediatr Child Health. Nov 2004;40(11):596-9. [Medline].

  18. Tuchelt H, Dekker K, Bahr V, Oelkers W. Dose-response relationship between plasma ACTH and serum cortisol in the insulin-hypoglycaemia test in 25 healthy subjects and 109 patients with pituitary disease. Clin Endocrinol (Oxf). Sep 2000;53(3):301-7. [Medline].

  19. Vesely DL. Hypoglycemic coma: don't overlook acute adrenal crisis. Geriatrics. May 1982;37(5):71-3, 76-7. [Medline].

  20. Wiltshire EJ, Wilson R, Pringle KC. Addison's disease presenting with an acute abdomen and complicated by cardiomyopathy. J Paediatr Child Health. Nov 2004;40(11):644-5. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

adrenal insufficiency, adrenal crisis, adrenocortical insufficiency, severe acute adrenocortical insufficiency, primary adrenocortical insufficiency, primary adrenal insufficiency, secondary adrenocortical insufficiency, secondary adrenal insufficiency, suppression of the hypothalamic-pituitary axis, mineralocorticoid function, glucocorticoid, hypopituitarism, cortisol, aldosterone, pan-hypopituitarism, panhypopituitarism, Sheehan syndrome, endocrinedisorders, adrenocorticotropic hormone, ACTH,adrenocorticotropic hormone deficiency

ACTH deficiency, postpartum pituitary infarction, hypothalamic-pituitary disease, hypothyroidism, physiologic effects of glucocorticoids, physiologic effects of aldosterone, tuberculosis of adrenal gland, fungal infection of adrenal gland, idiopathic atrophy of adrenal gland, congenital adrenal hyperplasia, adrenal hemorrhage, septicemia-induced Waterhouse-Friderichsen syndrome, fulminant meningococcemia, steroid withdrawal, autoimmune adrenaldestruction,polyglandular autoimmune disorders, PGAs, Schmidt syndrome, idiopathic autoimmune adrenal insufficiency, myocardial infarction, psychoses, depression, hypoglycemia, alcohol abuse, hypothermia, asthma

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Kevin M Klauer, DO, FACEP, Assistant Clinical Professor, Michigan State University College of Osteopathic Medicine; Director, Quality and Clinical Education, Emergency Medicine Physicians, Ltd; Director, Center for Emergency Medical Education; Editor-in-Chief, Emergency Physicians Monthly
Kevin M Klauer, DO, FACEP is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Howard A Bessen, MD, Professor of Medicine, Department of Emergency Medicine, UCLA School of Medicine; Program Director, Harbor-UCLA Medical Center
Howard A Bessen, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.