This document outlines the signs and symptoms of adrenal crisis including severe abdominal pain, vomiting, diarrhea, dehydration, low blood pressure, hypoglycemia and more. It then describes the diagnostic tests and findings including low cortisol levels, electrolyte abnormalities, and imaging. The treatment of adrenal crisis is also covered, focusing on intravenous hydrocortisone, saline, dextrose to address low blood pressure, blood glucose and potassium levels along with oral hydrocortisone and fludrocortisone as maintenance.

1.  Sudden penetrating pain in the legs, lower back or
abdomen
 Severe vomiting and diarrhea, resulting in dehydration
 Low blood pressure, Unexplained shock, usually refractory
to fluid and pressor resuscitation
 Syncope (loss of consciousness)
 Hypoglycemia
 Confusion, psychosis, slurred speech
 Severe lethargy
 Hypercalcemia
 Convulsions
 Fever
 Rapid withdrawal of long-term steroid therapy
 Hyperthermia or hypothermia

2.  Meningococcemia & Organisms associated with adrenal crisis e.g
Haemophilus influenzae, Staphylococcus aureus,Streptococcus
pneumonia, fungi
 Severe physiologic stress
 Azotemia
 Anticoagulants, hemorrhagic diathesis
 Adrenocorticotropin therapy, known primary or secondary
adrenocortical insufficiency
 AIDS
 Invasive or infiltrative disorders
 Tuberculosis
 Prior steroid use
 Topical steroids : large surface, long periods of use
 Inhaled steroids : > 8 mg/dl for long time, Fluticasone even at
lower dose

3.  Serum cortisol: <20 mcg/dL in severe stress
or after ACTH stimulation is indicative of
adrenal insufficiency
 ACTH test : diagnostic
 Serum chemistry, ↓Na, ↑K, metabolic
acidosis, Hypoglycemia
 CBC: Anemia, lymphocytosis, and
eosinophilia (highly suggestive)
 Cultures, Infection is a common cause of
acute adrenal crisis.

4.  Chest radiography: Assess for tuberculosis,
histoplasmosis, malignant disease, sarcoid,
and lymphoma.
 Abdominal CT scanning: Visualize adrenal
glands for hemorrhage, atrophy, infiltrative
disorders, and metastatic disease.
 Electrocardiography

5.  Primary adrenocortical failure : evidence of
infection, infiltrative disease.
 Secondary adrenocortical insufficiency:
atrophy of the adrenals or no histologic
evidence at all, especially if due to exogenous
steroid ingestion.
 Appearance of bilateral adrenal hemorrhage
may be striking, as if bags of blood are
replacing the glands.

6.  During an addisonian crisis, low blood pressure, low blood glucose,
and high levels of potassium can occur. Specific addisonian crisis
treatment for these symptoms involves intravenous (IV) injections
of:
 Hydrocortisone
 Saline
 Dextrose
 These addisonian crisis treatments usually bring rapid
improvement.
 When the patient can take fluids and medications by mouth, the
amount of hydrocortisone is decreased until a maintenance dose
is achieved. If aldosterone is deficient, maintenance therapy also
includes oral doses of fludrocortisone acetate.

7.  Dexamethasone : Used as empiric treatment of
shock in suspected adrenal crisis or insufficiency
until serum cortisol levels are drawn.
 Hydrocortisone :DOC because of
mineralocorticoid activity and glucocorticoid
effects
 Fludrocortisone (Florinef) : mineralocorticoids, .
Produces marked sodium retention and
increased urinary potassium excretion.
 Methylprednisolone : 3rd Line, of lack of
mineralocorticoid activity, in patients with fluid
overload, edema, or hypokalemia

8.  Endocrinologist
 Infectious disease specialist
 Critical care physician
 Surgeon
 Corticosteroids & IV fluids are the mainstays
of treatment. Other medications, such as
pressors (eg, dopamine, norepinephrine) or
antibiotics, are administered as clinically
indicated.