Medical Care
See the list below:
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Administration of glucocorticoids in supraphysiologic or stress doses is the only definitive therapy. [3, 4]
Dexamethasone does not interfere with serum cortisol assay and, thus, may be the initial drug of choice. However, because dexamethasone has little mineralocorticoid activity, fluid and electrolyte replacement are essential.
A short ACTH stimulation test may be performed during resuscitation. Once complete, hydrocortisone 100 mg IV every 6 hours is the preferred treatment to provide mineralocorticoid support.
Delaying glucocorticoid replacement therapy while awaiting the results of the ACTH stimulation test is inappropriate and dangerous.
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In addition to corticosteroid replacement, aggressive fluid replacement with 5% or 10% intravenous dextrose and saline solutions and treatment of hyperkalemia is mandatory. Fludrocortisone, a mineralocorticoid, may also be given.
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A thorough search for a precipitating cause and administration of empiric antibiotics are indicated. Reversal of coagulopathy should be attempted with fresh frozen plasma.
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Pressors (eg, dopamine, norepinephrine) may be necessary to combat hypotension.
Consultations
See the list below:
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Endocrinologist
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Infectious disease specialist
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Critical care physician
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Cardiologist
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Surgeon
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Other consultations as clinically indicated
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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.
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Enlarged, dense, suprarenal masses
