Adrenal crisis is rare, but when it hits, it kills fast. Cortisol is vital for maintaining blood pressure, glucose, and stress response. Without it, patients collapse into refractory shock that won’t respond to fluids or pressors unless you replace steroids. For rookies, the challenge is thinking of adrenal crisis early in undifferentiated shock.
What Is Adrenal Crisis?
- Acute, life-threatening cortisol deficiency.
- Can occur in:
- Primary adrenal insufficiency (Addison’s disease).
- Secondary adrenal insufficiency (pituitary disease, chronic steroid use with abrupt withdrawal).
- Congenital adrenal hyperplasia (children).
- Acute illness in steroid-dependent patients.
Triggers
- Infection (sepsis is the most common).
- Surgery, trauma, or other acute illness.
- Sudden withdrawal of long-term steroids.
- Physiological stress without adequate steroid “coverage.”
Clinical Features (Red Flags)
- Shock refractory to fluids and vasopressors.
- Hypotension + tachycardia.
- Electrolyte changes: hyponatremia, hyperkalemia, hypoglycemia.
- Nausea, vomiting, abdominal pain (mimics gastroenteritis).
- Weakness, confusion, coma.
- Skin hyperpigmentation (in chronic Addison’s).
Rookie pearl: Shock + low sodium + high potassium = adrenal crisis until proven otherwise.
ED Workup
- Bedside glucose (often low).
- Electrolytes, renal function.
- Cortisol level (draw before giving steroids if possible).
- CBC, cultures if infection suspected.
- Don’t delay treatment for labs — crisis is clinical.
ED Management
Step 1: Steroid Replacement (Life-Saving!)
- Hydrocortisone 100 mg IV bolus, then 50 mg IV q6h OR continuous infusion.
- If hydrocortisone unavailable → dexamethasone 4–6 mg IV (doesn’t interfere with cortisol assay).
Step 2: Fluids
- Isotonic saline (NS or LR): large boluses (20 mL/kg in kids, 1–2 L in adults).
- Dextrose-containing fluids if hypoglycemic.
Step 3: Correct Metabolic Issues
- Treat hypoglycemia with IV dextrose.
- Monitor potassium (often falls after steroids/fluids).
Step 4: Treat Trigger
- Sepsis → early antibiotics.
- Trauma, surgery, illness → supportive management.
Disposition
- Admit all patients.
- ICU if hypotension, shock, altered mental status, or persistent electrolyte abnormalities.
- Consult endocrinology.
Common Rookie Mistakes
- Treating refractory shock with only fluids/pressors, forgetting steroids.
- Missing the diagnosis in patients with GI symptoms (abdominal pain, vomiting).
- Not checking bedside glucose early.
- Stopping steroids after initial dose instead of continuing.
- Forgetting stress-dose steroids in known Addison’s patients who present sick.
Rookie Pearls
- Refractory shock? Think adrenal crisis.
- Always give steroids before waiting on cortisol labs.
- Hydrocortisone is best, but dexamethasone works in a pinch.
- In kids with known congenital adrenal hyperplasia, this is a common ED emergency.
- Early recognition = dramatic turnaround once steroids given.
Take-Home Message
Adrenal crisis is a can’t-miss ED diagnosis. For rookies:
- Shock that won’t respond to fluids/pressors = give steroids.
- Look for low sodium, high potassium, hypoglycemia as clues.
- Treat with hydrocortisone + fluids + glucose while managing the trigger.
Remember: In undifferentiated shock, the safest move is to ask yourself: “Could this be adrenal crisis?” and treat early.
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