Adrenal crisis is a life-threatening condition causes due to severe cortisol deficiency requires immediate medical attention.

It affects those with adrenal insufficiency due to primary or secondary causes of dysfunction. Use of glucocorticoids in high doses are the only available therapy for adrenal crisis.

Adrenal glands damage causes decreased cortisol and aldosterone production. Inadequate adrenocorticotropic hormone production from pituitary or hypothalamic disorders.

Cortisol regulates metabolism, immune response, and vascular tone. Adrenal crisis occurs when insufficient cortisol is produced.

Primary adrenal insufficiency and aldosterone deficiency result in hypotension and dehydration.

In 1855, Thomas Addison identified symptoms of long-term adrenal insufficiency including weakness, fatigue, anorexia, weight loss, and hyperpigmentation.

Variable occurrence of primary adrenal insufficiency depends on cortisol level and testing method.

In a study of 2000 autopsies, only 22 cases show bilateral adrenal hemorrhage, but 15% who die in shock have BMAH.

Chabre et al report annual adrenal crisis incidence in Europe estimated at 6 to 8 cases per 100 patients.

Pediatric adrenal insufficiency study found high adrenal crisis rate of 4.27 per 100 persons.

Timely diagnosis and treatment of acute adrenal crisis in the absence of bilateral adrenal hemorrhage can lead to survival comparable to patients without the crisis.

Cortisol is the primary hormone in adrenal crisis. It enhances gluconeogenesis, proteolysis, protein synthesis inhibition, fatty acid mobilization, and amino acid uptake.

Cortisol reduces inflammation to stabilize lysosomes and block cytokine production.

Uncertain action possibly increased sodium, potassium activated ATPase and carbonic anhydrase activity for sodium transport.

The causes for adrenal crisis:

Autoimmune adrenalitis

Infections

Adrenal hemorrhage

Secondary Adrenal Insufficiency

Pituitary tumors

Pituitary surgery or radiation

Hypothalamic disorders

Prompt identification and IV hydrocortisone along with fluid resuscitation are essential for survival in adrenal crisis cases.

Adrenal insufficiency from hemorrhage or malignancy has worse prognosis than autoimmune causes.

Primary adrenal insufficiency causes severe hyponatremia, hyperkalemia, and worse prognosis due to heart effects.

Inadequate glucocorticoid dose adjustment during stress, illness, or surgery increases repeated crises risk and prognosis.

Collect details including presenting symptoms, episodes adrenal insufficiency, and medical history to understand clinical history of patient.

Cardiovascular Examination

Abdominal Examination

Neurological Examination

Acute symptoms are:

Hypotension and Shock

Gastrointestinal Symptoms

Mental Status Change

Electrolyte Imbalances

Hypoglycemia

Fatigue and Weakness

Administration of glucocorticoids drug in supraphysiologic doses is the only available therapy.

Dexamethasone is preferred due to no interference with serum cortisol assay and minimal mineralocorticoid activity.

ACTH stimulation test during resuscitation followed by hydrocortisone 100 mg IV every 6 hours for support.

Aggressive fluid replacement with dextrose and saline and treatment of hyperkalemia are essential.

In-depth investigation for empirical antibiotics and reversal of coagulopathy with plasma is recommended.

Dexamethasone is a preferred drug due to no interference with serum cortisol assay, fluid, and electrolyte supplementation necessary.

Endocrinology, Metabolism

Use emergency kit with hydrocortisone injection and usage instructions.

Promote relaxation exercises, mindfulness, counselling for managing psychological stress in adrenal insufficiency.

Ensure all healthcare providers aware of patient’s adrenal insufficiency and treatment plan.

Proper awareness about adrenal crisis should be provided and its related causes with management strategies.

Appointments with an endocrinologist and preventing recurrence of disorder is an ongoing life-long effort.

Endocrinology, Metabolism

Dexamethasone:

It decreases inflammation to suppress migration of polymorphonuclear leukocytes and reduce capillary permeability.

Fludrocortisone:

It enhances reabsorption of sodium to increases urinary excretion of both potassium.

Methylprednisolone:

It modulates carbohydrates, protein, and lipid metabolism of fluid and electrolyte homeostasis.

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Norepinephrine:

It increases cardiac output and heart rate to decrease renal perfusion.

Dopamine:

It stimulates both adrenergic and dopaminergic receptors.

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Adrenal crisis requires rapid and effective treatment with glucocorticoids, fluid and electrolyte management to address underlying causes and continuous monitoring.

Endocrinology, Metabolism

In the initial assessment phase, evaluate and check airway, breathing, and circulation to stabilize the patient.

Pharmacologic therapy is effective in the treatment phase as it includes use of corticosteroids and vasopressors.

In supportive care and management phase, patients should receive required attention such as lifestyle modification and intervention therapies.

The regular follow-up visits with the endocrinologist are scheduled to check the improvement of patients along with treatment response