Adrenal crisis
Adrenal crisis (also known as acute adrenal insufficiency or Addisonian crisis) is a medical emergency caused by a severe cortisol deficiency.
The primary manifestations are gastrointestinal symptoms and symptoms of acute circulatory failure (eg hypotension, confusion). Laboratory findings can include:
- hypoglycaemia
- hyponatraemia
- hyperkalaemia
- hypercalcaemia
- increased urea and creatinine concentrations.
Adrenal crisis usually occurs in patients with primary adrenal insufficiency, precipitated by acute stress (such as illness or surgery) or abrupt cessation of glucocorticoid therapy. Patients with adrenal insufficiency secondary to hypopituitarism can also experience acute cortisol deficiency, but circulatory collapse is less likely because their renin–angiotensin–aldosterone axis is intact.
If possible, collect blood samples to measure plasma glucose and electrolyte concentrations before starting treatment. In a patient with suspected adrenal crisis but no previous diagnosis of primary adrenal insufficiency, also collect samples to measure plasma cortisol, adrenocorticotrophic hormone (ACTH) and renin concentrations. However, it is essential that treatment with intravenous glucocorticoid therapy begins quickly; do not delay treatment to wait for laboratory results, or if phlebotomy is delayed or not available.
For an adult, start treatment with:
hydrocortisone 100 mg intravenously, initially, then 50 mg intravenously, every 6 hours until stable and tolerating oral intake. adrenal crisis (adult) hydrocortisone
If intravenous access is not established or if parenteral glucocorticoid therapy is not immediately available, an oral glucocorticoid can be used:
prednisolone (or prednisone) 40 mg orally. adrenal crisis (adult) prednis ol one
For a neonate or child within the normal weight range for their age1, use:
hydrocortisone adrenal crisis (child) hydrocortisone
neonate or child up to 6 weeks: 25 mg intravenously or intramuscularly, initially, then 5 to 10 mg intravenously or intramuscularly, 6-hourly until stable and tolerating oral intake
child 6 weeks to 3 years: 25 mg intravenously or intramuscularly, initially, then 10 mg intravenously or intramuscularly, 6-hourly until stable and tolerating oral intake
child 3 to 7 years: 50 mg intravenously or intramuscularly, initially, then 12.5 mg intravenously or intramuscularly, 6-hourly until stable and tolerating oral intake
child 7 to 12 years: 50 mg intravenously or intramuscularly, initially, then 25 mg intravenously or intramuscularly, 6-hourly until stable and tolerating oral intake.
For children outside the normal weight range for their age1, use:
hydrocortisone 50 to 75 mg/m2 intravenously or intramuscularly, initially, then 12.5 to 18.75 mg/m2 intravenously or intramuscularly, 6-hourly until stable and tolerating oral intake2. hydrocortisone
Higher doses may be needed in very sick children.
Intravenous sodium chloride 0.9% is required to correct hypovolaemia. If present, prompt correction of hypoglycaemia and severe hyperkalaemia are also important. Hyperkalaemia usually responds to intravenous fluids and hydrocortisone therapy—do not use intravenous insulin and glucose.
Once the patient is stable and tolerating oral intake, patients with pre-existing adrenal insufficiency can resume their usual oral glucocorticoid at the dose used for intercurrent illness. If the patient is recovering well, reduce the dose to the usual maintenance dose over 2 to 3 days.
After an episode of adrenal crisis, patients who were not already known to have adrenal insufficiency should be assessed to establish the cause and guide further management.