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Acute Addisonian crisis


Introduction


Adrenal crisis is characterized by an acute deterioration in health status due to a severe deficiency of the adrenal hormone cortisol[1]. It typically occurs in patients with known adrenal insufficiency, either primary (Addison's disease) or secondary, but can also be the first presentation of undiagnosed adrenal insufficiency[3].


Diagnosis


Diagnosing adrenal crisis can be challenging due to its nonspecific initial symptoms. Key aspects of diagnosis include:


  • Clinical Presentation: - Abdominal pain or flank pain - Confusion, loss of consciousness, or coma - Dehydration - Dizziness or lightheadedness - Severe fatigue and weakness - Hypotension (systolic blood pressure <100 mm Hg or ≥20 mm Hg lower than baseline) - Nausea and vomiting - Fever[1][2]

  • Laboratory Findings: - Hyponatremia - Hyperkalemia (in primary adrenal insufficiency) - Hypoglycemia - Metabolic acidosis[2]

  • Diagnostic Tests: - ACTH stimulation test - Cortisol level - Plasma ACTH level - Electrolyte panel[2]

  • It's crucial to note that diagnostic measures should never delay treatment if adrenal crisis is suspected[4].


Emergency Management


Prompt treatment is essential in managing adrenal crisis. The key steps include:


  1. Glucocorticoid Administration: Immediate administration of hydrocortisone is the cornerstone of treatment.

    • Adults: 100 mg intravenous (IV) or intramuscular (IM) hydrocortisone, followed by 50 mg every 6 hours or a continuous infusion of 200 mg/24 hours[1][4].

  2. Fluid Resuscitation: Rapid IV fluid administration to correct hypovolemia and hypotension.

    • Typically 1000 mL of isotonic saline in the first hour[1].

  3. Electrolyte Correction: Address any electrolyte imbalances, particularly hyponatremia and hyperkalemia[2].

  4. Glucose Administration: If hypoglycemia is present, administer IV glucose[1].

  5. Treat Underlying Cause: Identify and treat any precipitating factors, such as infections[1].

  6. Monitoring: Close monitoring of vital signs, electrolytes, and glucose levels[4].

  7. Transition to Oral Therapy: Once the patient is stable, transition to oral glucocorticoid therapy[4].


Prevention


Prevention of future adrenal crises is crucial:

  • Patient education on stress dosing and sick day rules

  • Provision of emergency hydrocortisone injection kits

  • Issuing steroid emergency cards and medical alert bracelets

  • Regular follow-up with an endocrinologist[5]


Early recognition and prompt treatment of adrenal crisis are vital to prevent potentially fatal outcomes. Healthcare providers should maintain a high index of suspicion in at-risk patients presenting with suggestive symptoms.




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