Laboratory Studies

The following should be assessed in patients with suspected adrenal crisis or adrenal insufficiency:

Complete blood count (CBC)
Electrolyte levels
BUN level
Creatinine level
Cortisol level^[7]/ACTH
Serum calcium level
Thyroid function (possibly performed in ED but unlikely to influence immediate management)

Imaging Studies

Chest radiograph

CT scan

A CT scan of the abdomen may show hemorrhage in the adrenals, calcification of the adrenals (seen with tuberculosis), or metastasis.
In cases of secondary adrenal insufficiency, a head CT scan may show destruction of the pituitary (ie, empty sella syndrome) or a pituitary mass lesion.

Other Tests

Adrenocorticotropic hormone (ACTH) stimulation test

Note: In emergent situations, do not delay treatment of presumed adrenal insufficiency during diagnostic testing. Treatment with dexamethasone allows ACTH stimulation testing without affecting or interfering with the measurement of serum cortisol levels.
Obtain baseline serum cortisol and ACTH levels.
Administer 0.25 mg (250 mcg) of cosyntropin (synthetic ACTH) intravenously (IV) or intramuscularly (IM).
Repeat cortisol levels every 30 minutes (some authors recommend 60 min) and 6 hours after ACTH administration (generally not recommended).
Normal response is indicated when the cortisol peak exceeds 18 ug/dL in response to ACTH stimulation.
In adrenal insufficiency, serum cortisol levels fail to rise after ACTH administration.

Electrocardiograph (ECG): Elevated peaked T waves may indicate hyperkalemia.

24-hour urinary cortisol: Use only in nonemergent situations.

Treatment & Management

Ishii M. Endocrine Emergencies With Neurologic Manifestations. Continuum (Minneap Minn). 2017 Jun. 23 (3, Neurology of Systemic Disease):778-801. [QxMD MEDLINE Link]. [Full Text].
Elshimy G, Chippa V, Jeong JM. Adrenal Crisis. StatPearls. 2022 Jan. [QxMD MEDLINE Link]. [Full Text].
Dineen R, Thompson CJ, Sherlock M. Adrenal crisis: prevention and management in adult patients. Ther Adv Endocrinol Metab. 2019. 10:2042018819848218. [QxMD MEDLINE Link].
Wyngaarden JB, Smith LH, Bennett JC. Adrenocortical hypofunction. Cecil Textbook of Medicine. 19th ed. WB Saunders; 1992. 1271-1288.
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
[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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
Ishii T, Adachi M, Takasawa K, et al. Incidence and Characteristics of Adrenal Crisis in Children Younger than 7 Years with 21-Hydroxylase Deficiency: A Nationwide Survey in Japan. Horm Res Paediatr. 2018. 89 (3):166-71. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Notter A, Jenni S, Christ E. Evaluation of the frequency of adrenal crises and preventive measures in patients with primary and secondary adrenal insufficiency in Switzerland. Swiss Med Wkly. 2018. 148:w14586. [QxMD MEDLINE Link]. [Full Text].
Quinkler M, Ekman B, Zhang P, Isidori AM, Murray RD, EU-AIR Investigators. Mortality data from the European Adrenal Insufficiency Registry-Patient characterization and associations. Clin Endocrinol (Oxf). 2018 Jul. 89 (1):30-5. [QxMD MEDLINE Link].
Ono Y, Ono S, Yasunaga H, Matsui H, Fushimi K, Tanaka Y. Clinical features and practice patterns of treatment for adrenal crisis: a nationwide cross-sectional study in Japan. Eur J Endocrinol. 2017 Mar. 176 (3):329-37. [QxMD MEDLINE Link].
Kawahara T, Tsuji M, Tominaga N, Toyama N, Toda M. Frequency of Adrenal Insufficiency in Patients With Hypoglycemia in an Emergency Department: A Cross-sectional Study. J Endocr Soc. 2022 Oct 1. 6 (10):bvac119. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
[Guideline] Arlt W, Society for Endocrinology Clinical Committee. SOCIETY FOR ENDOCRINOLOGY ENDOCRINE EMERGENCY GUIDANCE: Emergency management of acute adrenal insufficiency (adrenal crisis) in adult patients. Endocr Connect. 2016 Sep. 5 (5):G1-G3. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Annane D, Pastores SM, Rochwerg B, et al. Guidelines for the Diagnosis and Management of Critical Illness-Related Corticosteroid Insufficiency (CIRCI) in Critically Ill Patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. Crit Care Med. 2017 Sep 21. [QxMD MEDLINE Link].
[Guideline] Simpson H, Tomlinson J, Wass J, Dean J, Arlt W. Guidance for the prevention and emergency management of adult patients with adrenal insufficiency. Clin Med (Lond). 2020 Jul. 20 (4):371-8. [QxMD MEDLINE Link]. [Full Text].
Hahner S, Allolio B. Therapeutic management of adrenal insufficiency. Best Pract Res Clin Endocrinol Metab. 2009 Apr. 23(2):167-79. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].