Emergency Department Care
Emergency department care includes the following:
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Maintain airway, breathing, and circulation in patients with adrenal crisis.
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Use coma protocol (ie, glucose, thiamine, naloxone).
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Use aggressive volume replacement therapy (dextrose 5% in normal saline solution [D5NS]).
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Correct electrolyte abnormalities as follows:
Hypoglycemia (67%)
Hyponatremia (88%)
Hyperkalemia (64%, may be offset by concurrent vomiting/diarrhea and potassium loss)
Hypercalcemia (6-33%)
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Use dextrose 50% as needed for hypoglycemia.
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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.
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Administer fludrocortisone acetate (mineralocorticoid) 0.1 mg every day as needed. Mineralocorticoid administration is usually not necessary for treatment of secondary adrenocortical insufficiency.
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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.
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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.
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.
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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Regulation of the adrenal cortex.
