Adrenal Crisis in Emergency Medicine Treatment & Management
- Author: Kevin M Klauer, DO, EJD, FACEP; Chief Editor: Romesh Khardori, MD, PhD, FACP more...
Emergency Department Care
Emergency department care includes the following:
- Maintain airway, breathing, and circulation in patients with adrenal crisis.
- Use coma protocol (ie, glucose, thiamine, naloxone).
- Use aggressive volume replacement therapy (dextrose 5% in normal saline solution [D5NS]).
- Correct electrolyte abnormalities as follows:
- Hypoglycemia (67%)
- Hyponatremia (88%)
- Hyperkalemia (64%, may be offset by concurrent vomiting/diarrhea and potassium loss)
- Hypercalcemia (6-33%)
- Use dextrose 50% as needed for hypoglycemia.
- Administer hydrocortisone 100 mg intravenously (IV) every 6 hours. During adrenocorticotropic hormone (ACTH) stimulation testing, dexamethasone (4 mg IV) can be used instead of hydrocortisone to avoid interference with testing of cortisol levels.
- Administer fludrocortisone acetate (mineralocorticoid) 0.1 mg every day as needed. Mineralocorticoid administration is usually not necessary for treatment of secondary adrenocortical insufficiency.
- 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.
- Always treat the underlying problem that precipitated the crisis. Infectious etiologies commonly precipitate adrenal crisis. Recognition and treatment of causative factors are crucial aspects of managing adrenal hypofunction.
Endocrine consultation following admission is beneficial. If no endocrinologist is available, a general internist can manage the process. Emergency management should be implemented in the ED prior to consultation when sufficient clinical suspicion for this diagnosis is present.
ICU admission is necessary for most patients with acute adrenal insufficiency and adrenal crisis.
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. A morning dose of 10-15 mg of hydrocortisone is believed to be potentially sufficient. Avoid giving hydrocortisone dose in the evening or at bedtime since it may cause insomnia. Mid to late afternoon is best suited for second dose.
Maintenance mineralocorticoid levels may be achieved by administering 9 alpha-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.
Wyngaarden JB, Smith LH, Bennett JC. Adrenocortical hypofunction. Cecil Textbook of Medicine. 19th ed. WB Saunders; 1992. 1271-1288.
Rushworth RL, Falhammar H, Munns CF, Maguire AM, Torpy DJ. Hospital Admission Patterns in Children with CAH: Admission Rates and Adrenal Crises Decline with Age. Int J Endocrinol. 2016. 2016:5748264. [Medline]. [Full Text].
Hahner S, Loeffler M, Bleicken B, et al. Epidemiology of adrenal crisis in chronic adrenal insufficiency - the need for new prevention strategies. Eur J Endocrinol. 2009 Dec 2. [Medline].
Smans LC, Van der Valk ES, Hermus AR, Zelissen PM. Incidence of adrenal crisis in patients with adrenal insufficiency. Clin Endocrinol (Oxf). 2016 Jan. 84 (1):17-22. [Medline].
Hahner S, Loeffler M, Bleicken B, Drechsler C, Milovanovic D, Fassnacht M, et al. Epidemiology of adrenal crisis in chronic adrenal insufficiency: the need for new prevention strategies. Eur J Endocrinol. 2010 Mar. 162(3):597-602. [Medline].
Ahi S, Esmaeilzadeh M, Kayvanpour E, Sedaghat-Hamedani F, Samadanifard SH. A bulking agent may lead to adrenal insufficiency crisis: a case report. Acta Med Iran. 2011. 49(10):688-9. [Medline].
Lundy JB, Slane ML, Frizzi JD. Acute adrenal insufficiency after a single dose of etomidate. J Intensive Care Med. 2007 Mar-Apr. 22(2):111-7. [Medline].
[Guideline] Marik PE, Pastores SM, Annane D, et al. Recommendations for the diagnosis and management of corticosteroid insufficiency in critically ill adult patients: consensus statements from an international task force by the American College of Critical Care Medicine. Crit Care Med. 2008 Jun. 36(6):1937-49. [Medline].
Hahner S, Allolio B. Therapeutic management of adrenal insufficiency. Best Pract Res Clin Endocrinol Metab. 2009 Apr. 23(2):167-79. [Medline].
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. 2007 Jul. 39(7):1036-43. [Medline].
Lelubre C, Lheureux PE. Epigastric pain as presentation of an addisonian crisis in a patient with Schmidt syndrome. Am J Emerg Med. 2008 Feb. 26(2):251.e3-4. [Medline].
Puar TH, Stikkelbroeck NM, Smans LC, Zelissen PM, Hermus AR. Adrenal crisis: still a deadly event in the 21st century. Am J Med. 2015 Sep 9. [Medline].
Hahner S, Hemmelmann N, Quinkler M, Beuschlein F, Spinnler C, Allolio B. Timelines in the management of adrenal crisis - targets, limits and reality. Clin Endocrinol (Oxf). 2015 Apr. 82 (4):497-502. [Medline].