EM · Endocrine emergencies

Adrenal crisis (Addisonian crisis)

Also known as Addisonian crisis · Acute adrenal insufficiency · Adrenal emergency · Glucocorticoid crisis

Adrenal crisis (Addisonian crisis) is the acute, life-threatening state of cortisol deficiency producing vasodilatory shock refractory to fluid, abdominal pain, vomiting and the classic biochemistry of hyponatraemia, hyperkalaemia and hypoglycaemia. The triggers are an infection, surgery, trauma, sepsis and the abrupt withdrawal of chronic steroids. The Fellowship-critical management is an initial intravenous bolus of hydrocortisone 100 mg followed by 200 mg over the first 24 hours, 0.9 per cent saline 1 L within the first hour, and glucose if hypoglycaemic — fludrocortisone is not needed acutely because hydrocortisone has mineralocorticoid activity at the high doses. Hydrocortisone is never delayed for the cortisol result: the blood is drawn but treatment is immediate. The differential is septic shock, the upper gastrointestinal bleed and diabetic ketoacidosis. ACEM-primary, globally tagged.