Adrenal crisis


Adrenal crisis is a potentially life-threatening medical condition requiring immediate emergency treatment. It is a constellation of symptoms that indicate severe adrenal insufficiency caused by insufficient levels of the hormone cortisol. This may be the result of either previously undiagnosed or untreated Addison's disease, a disease process suddenly affecting adrenal function, suddenly stopping intake of glucocorticoids or an intercurrent problem in someone known to have Addison's disease, congenital adrenal hyperplasia, or other form of primary adrenal insufficiency.

Signs and symptoms

Characteristic symptoms are:
Adrenal crisis is caused by a deficiency of cortisol resulting from Addison's disease, congenital adrenal hyperplasia, corticosteroid biosynthetic enzyme defects or pituitary disorders causing failure to activate the adrenal glands.

Diagnosis

Various investigations aid the diagnosis:
Adrenal crisis is triggered by physiological stress or severe psychological stress. Activities that have an elevated risk of trauma are best avoided. Treatment must be given within two hours of trauma and consequently it is advisable to carry injectable hydrocortisone in remote areas.

Treatment

Acute adrenal insufficiency is a medical emergency and needs to be treated with injectable hydrocortisone and fluid support.
  1. 1L of 0.9% saline over 30-60 min with 100mg of i.v. Bolus hydrocortisone.
  2. Continuous infusion of saline within 24hours with 100mg I.m. hydrocortisone 6-hourly.
  3. Glucose
  4. To be shifted to oral medication based on the patient’s state. Hydrocortisone 20mg 8-hourly reduced to 20-30mg in divided doses over few days.
  5. Fludrocortisone is given later.

    Epidemiology

Hahner et al. investigated the frequency, causes and risk factors for adrenal crisis in patients with chronic adrenal insufficiency.