Adrenal crisis

Adrenal crisis
Acute adrenal insufficiency is an
emergency caused by insufficient
cortisol.
Crisis may occur in the course of
treatment of chronic insufficiency, or
it may be the presenting
manifestation of adrenal
insufficiency.

Adrenal crisis
Adrenal crisis may occur in the following situations:
(1) during stress, (eg, trauma, surgery, infection, hyperthyroidism, or
prolonged fasting) in a patient with latent or treated adrenal insufficiency
(2) following sudden withdrawal of adrenocortical hormone in a patient
with chronic insufficiency or in a patient with temporary insufficiency due
to suppression by exogenous corticosteroids or megestrol
(3) following bilateral adrenalectomy or removal of a functioning adrenal
tumor that had suppressed the other adrenal
(4) following sudden destruction of the pituitary gland (pituitary necrosis),
or when thyroid hormone is given to a patient with hypoadrenalism
(5) following injury to both adrenals by trauma, hemorrhage,
anticoagulant therapy, thrombosis, infection or, rarely, metastatic
carcinoma
(6) following administration of etomidate, which is used intravenously for
rapid anesthesia induction or intubation.

Adrenal crisis
Clinical findings

Headache
Lassitude
Nausea and vomiting
Abdominal pain
Diarrhea
Confusion or coma
Fever may be 40.6 C or
more
Blood pressure is low
Cyanosis
Dehydration
Skin hyperpigmentation

Laboratory findings
The eosinophil count may be high
Hyponatremia or hyperkalemia
(or both) are usually present.
Hypoglycemia is frequent
Hypercalcemia may be present
Blood, sputum, or urine culture
may be positive if bacterial
infection is the precipitating
cause of the crisis
The diagnosis is made by a
simplified cosyntropin stimulation
test
If the patient has primary adrenal
insufficiency, the plasma ACTH is
markedly elevated, generally >
200 pg/mL (> 44 pmol/L)

Adrenal crisis
Treatment is directed primarily toward
repletion of circulating glucocorticoids and
replacement of the sodium and water deficits.
Acute: IV infusion of 5% glucose in normal
saline solution should be started with a bolus
IV infusion of 100 mg hydrocortisone followed
by a continuous infusion of hydrocortisone at
a rate of 10 mg/h. An alternative approach is
to administer a 100-mg bolus of
hydrocortisone IV every 6 h.

Adrenal crisis
Convalescent:
When the patient is able to take food by
mouth, give oral hydrocortisone, 1020
mg every 6 hours, and reduce dosage to
maintenance levels as needed.
Once the crisis has passed, the patient
must be evaluated to assess the degree
of permanent adrenal insufficiency and
to establish the cause if possible.