Adrenal Crisis (Addisonian Crisis)

Recognize it - Suspect adrenal crisis in shock refractory to adequate fluid resuscitation and vasopressor support. Hyponatremia, hyperkalemia, or hypoglycemia alongside hypotension is the tell, especially in an elderly patient or one with another endocrine disorder.

Treat first, test second - Hydrocortisone 100 mg IV/IM is the mainstay and goes in the moment you suspect it. If treatment isn't going to be delayed, draw cortisol, ACTH, aldosterone, renin, and a basic metabolic panel with glucose first — but never hold the steroid for labs. Don't run an ACTH stimulation test in the acute setting, even with a borderline cortisol; wait until the patient is stable.

Hydrocortisone or dexamethasone - Hydrocortisone is preferred because it carries mineralocorticoid activity. In a patient with no established diagnosis, dexamethasone 4 mg IV is the better first bolus since it doesn't interfere with cortisol assays. Dexamethasone has little to no mineralocorticoid effect and is not an appropriate maintenance drug.

Continuing steroid - Hydrocortisone 50 mg IV q6h or dexamethasone 4 mg IV q12h until vitals stabilize and the patient can take oral medication. Fludrocortisone isn't needed acutely — stress-dose hydrocortisone already carries enough mineralocorticoid activity.

Volume and glucose - Two to three liters of normal saline, or 5% dextrose in normal saline when hypoglycemic, over the first 12 to 24 hours. D5 normal saline is the typical replacement fluid after the initial bolus.

When fluid isn't enough - Patients who fail the initial fluid bolus need vasopressors for a MAP above 65, and elective intubation to protect the airway if they are comatose.

Electrolytes on the monitor - Get a 12-lead: peaked T waves point to hyperkalemia, a short QT to hypercalcemia. Seizures, arrhythmias, and coma all track the electrolyte derangement rather than the hypotension alone.

Known adrenal insufficiency coming to surgery - Correct hypovolemia, hyperkalemia, and hyponatremia before induction, give a stress dose of glucocorticoid, and continue it for 24 hours after the procedure. Current literature supports hydrocortisone 100 mg IV every 24 hours — less than the 200 to 300 mg historically taught.

Etomidate - Etomidate sits on the list of drugs that damage adrenal steroid production, alongside ketoconazole, fluconazole, and metyrapone. Pick a different induction agent in a patient who already has an adrenal problem.

Find the trigger - The crisis is almost never a standalone process. Recent surgery, a cardiac event, infection, malignancy, or a medication change usually precipitates it — culture, image, and treat the precipitant while you replace the steroid.

Disposition - These patients need ICU-level monitoring after the OR. Confirm the home hydrocortisone and any emergency IM kit before discharge planning, since a missed dose is what brings them back.

Adrenal crisis is acute, life-threatening decompensation from glucocorticoid deficiency — and in primary disease mineralocorticoid deficiency as well — in a patient with known or still-undiagnosed adrenal insufficiency. Surgery, infection, trauma, vomiting, or abrupt withdrawal of chronic steroid supplies the stress the adrenal cannot answer.

Without cortisol, cardiac function and the vascular response to catecholamines fall off, gluconeogenesis stops, and GFR drops. Without aldosterone, the kidney wastes sodium and retains potassium, so the patient arrives hypovolemic with hyponatremia, hyperkalemia, and a non-anion-gap metabolic acidosis. The result is shock that does not answer fluid or vasopressors, plus hypoglycemia and seizures. Hyperkalemia is absent in secondary (pituitary) insufficiency, where the mineralocorticoid axis stays intact.