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Adrenal Crisis in Emergency Medicine Treatment & Management

  • Author: Kevin M Klauer, DO, EJD, FACEP; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
 
Updated: Aug 02, 2016
 

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.
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Consultations

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.

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Long-Term Monitoring

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.

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Contributor Information and Disclosures
Author

Kevin M Klauer, DO, EJD, FACEP Assistant Clinical Professor, Michigan State University College of Osteopathic Medicine; Chief Medical Officer, Emergency Medicine Physicians, Ltd; Director, Center for Emergency Medical Education; Medical Editor-in-Chief, ACEP Now; Former Editor-in-Chief, Emergency Physicians Monthly

Kevin M Klauer, DO, EJD, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Howard A Bessen, MD Professor of Medicine, Department of Emergency Medicine, University of California, Los Angeles, David Geffen 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.

Chief Editor

Romesh Khardori, MD, PhD, FACP Professor of Endocrinology, Director of Training Program, Division of Endocrinology, Diabetes and Metabolism, Strelitz Diabetes and Endocrine Disorders Institute, Department of Internal Medicine, Eastern Virginia Medical School

Romesh Khardori, MD, PhD, FACP is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, Endocrine Society

Disclosure: Nothing to disclose.

Additional Contributors

Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates

Disclosure: Nothing to disclose.

References
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  11. 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].

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  13. 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].

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Regulation of the adrenal cortex.
 
 
 
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