Adrenal Crisis

 

Adrenal Crisis 

(The 5-Minute Clinical Consult 2023)

#Definition:

Adrenal crisis is a life-threatening emergency caused by acute adrenal insufficiency, resulting in a severe deficiency of cortisol (and sometimes aldosterone). It can occur in patients with known adrenal insufficiency (primary or secondary) or as the first presentation of undiagnosed adrenal failure.

#Symptoms and Signs:

 • Sudden and severe weakness, fatigue

 • Hypotension or orthostatic hypotension (key sign) 

 • Nausea, vomiting, abdominal pain

 • Dehydration, confusion, or coma

 • May be precipitated by infection, surgery, trauma, or steroid withdrawal

 • Often associated with pituitary apoplexy causing hemorrhagic infarction and adrenal crisis, presenting with severe headache and shock 

#Diagnosis:

 • Clinical diagnosis is critical—do not delay treatment.

 • Labs:

 • Low serum cortisol

 • Hyponatremia, hyperkalemia, hypoglycemia

 • Low or normal ACTH depending on primary vs secondary cause

 • In the context of pituitary disorders, check for associated hypopituitarism and imaging (MRI).

#Differential Diagnosis:

 • Septic shock

 • Hypovolemic shock

 • Myxedema coma

 • Pituitary apoplexy

 • Severe dehydration or electrolyte imbalance 

#Treatment:

 • Immediate IV hydrocortisone 100 mg bolus, then 50–100 mg every 6–8 hours

 • Aggressive IV fluid replacement with normal saline (or dextrose-saline if hypoglycemic) 

 • Treat underlying cause (e.g., infection, surgery, trauma)

 • Monitor blood pressure, electrolytes, and urine output closely.

 • Gradually taper steroids once stable.

#Follow-Up and Ongoing Care:

 • Monitor BP, fluid balance, and serum electrolytes post-crisis 

 • Long-term glucocorticoid and mineralocorticoid replacement therapy as indicated

 • Education: Patients should carry steroid identification and emergency hydrocortisone kits.

 • Regular endocrinology follow-up to prevent recurrence.