Adrenal Crisis in Emergency Medicine Guidelines

Updated: Sep 01, 2020
  • Author: Kevin M Klauer, DO, EJD, FACEP; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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Guidelines

Guidelines Summary

Guidelines from Britain’s Society for Endocrinology on the emergency management of adrenal crisis, published in 2016, include the following diagnostic recommendations [16] :

  • Adrenal insufficiency should be ruled out in any acutely ill patient with signs or symptoms potentially suggestive of acute adrenal insufficiency
  • Assess blood pressure and fluid balance status; if clinically feasible, measure blood pressure from supine to standing to check for postural drop
  • Assess patient drug history; determine whether there has been glucocorticoid use
  • Perform appropriate blood tests: Sodium, potassium, urea, and creatinine; full blood counts; thyroid-stimulating hormone and free thyroxine; paired serum cortisol and plasma ACTH
  • If the patient is hemodynamically stable, consider performing a short Synacthen test (serum cortisol at baseline and 30 min after intravenous injection of 250 μg ACTH 1–24)
  • Serum/plasma aldosterone and plasma renin
  • Diagnostic measures should never delay prompt treatment of a suspected adrenal crisis

The guidelines include the following recommendations for emergency treatment [16] :

  • Administer hydrocortisone: Immediate bolus injection of 100 mg hydrocortisone intravenously or intramuscularly followed by continuous intravenous infusion of 200 mg hydrocortisone per 24 hours (alternatively, 50 mg hydrocortisone per intravenous or intramuscular injection every 6 h)
  • Rehydrate with rapid intravenous infusion of 1000 mL of isotonic saline infusion within the first hour, followed by further intravenous rehydration as required (usually 4-6 L in 24 h; monitor for fluid overload in case of renal impairment and in elderly patients)
  • Contact an endocrinologist for urgent review of the patient, advice on further tapering of hydrocortisone, and investigation of the underlying cause of the disease, including the diagnosis of primary versus secondary adrenal insufficiency
  • Tapering of hydrocortisone can be started after clinical recovery guided by an endocrinologist; in patients with primary adrenal insufficiency, mineralocorticoid replacement must be initiated (starting dose 100 μg fludrocortisone once daily) as soon as the daily glucocorticoid dose is below 50 mg of hydrocortisone every 24 hours

Guidelines on critical illness–related corticosteroid insufficiency (CIRCI) were published in 2017 by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. [17]

The task force was unable to reach agreement on a single test that can reliably diagnose CIRCI, although delta cortisol (change in baseline cortisol of < 9 μg/dL at 60 min) after cosyntropin (250 μg) administration and a random plasma cortisol of >10 μg/dL may be used by clinicians. The guidelines also state the following [17] :

  • Suggest against using plasma-free cortisol or salivary cortisol level over plasma total cortisol
  • For treatment of specific conditions, suggest using IV hydrocortisone < 400 mg/day for ≥3 days at full dose in patients with septic shock that is not responsive to fluid and moderate- to high-dose vasopressor therapy
  • Suggest not using corticosteroids in adult patients with sepsis without shock
  • Suggest the use of IV methylprednisolone 1 mg/kg/day in patients with early moderate to severe acute respiratory distress syndrome (PaO 2/FiO 2< 200 and within 14 days of onset)

A 2020 guidance by Simpson et al on the prevention and emergency management of adult adrenal insufficiency indicated that patients at risk for adrenal crisis include the following [18] :

  • Patients in whom the presence of primary adrenal insufficiency has been established or is suspected; eg, those with Addison disease, congenital adrenal hyperplasia (CAH), bilateral adrenalectomy, or adrenal hemorrhage
  • Patients with an established or suspected diagnosis of adrenal insufficiency arising from hypopituitarism that has itself resulted from hypothalamo-pituitary disease, who are either undergoing permanent glucocorticoid replacement or in whom glucocorticoid replacement is required owing to illness or stress (such as a surgical procedure)
  • Patients undergoing exogenous glucocorticoid treatment—through an oral, a topical, an inhaled, an intranasal, or an intra-articular route—that equals or exceeds a dose of prednisolone 5 mg/day for 4 weeks or longer; this is because such patients are likely to have suppressed hypothalamic-pituitary-adrenal axis (HPA) function (ie, tertiary adrenal insufficiency)
  • Patients undergoing a course of oral glucocorticoid within 12 months of long-term therapy cessation