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: Dec 16, 2009

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 can usually 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 is usually 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 orally (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 every 6 hours during adrenocorticotropic hormone (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
Multimedia: Adrenal Insufficiency and Adrenal Crisis
References
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References

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Further Reading

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Keywords

adrenal insufficiency, adrenal crisis, adrenocortical insufficiency, severe acute adrenocortical insufficiency, primary adrenocortical insufficiency, primary adrenal insufficiency, secondary adrenocortical insufficiency, secondary adrenal insufficiency, treatment, diagnosis, symptoms

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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.

 
 
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