Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Suspect crisis in hypotension/electrolyte derangements; give hydrocortisone immediately.
- Aggressive fluids and dextrose; treat precipitants.
- Taper to maintenance; provide education and emergency steroid card/injector.
Clinical Synopsis & Reasoning
Life-threatening cortisol deficiency with hypotension, hyponatremia, hyperkalemia, and hypoglycemia. Treat immediately with hydrocortisone 100 mg IV, aggressive isotonic fluids, and dextrose as needed; do not delay for labs. Identify precipitating illness or medication nonadherence.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|
| Random cortisol, ACTH (do not delay therapy) | Support | Confirm after stabilization | — |
| Electrolytes, glucose, and renal function | Complications | Correct metabolic derangements | — |
| Infection workup and medication history | Precipitant | Common triggers | — |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| Shock unresponsive to fluids/pressors | Cortisol deficiency | Immediate hydrocortisone; ICU |
| Refractory hypoglycemia or hyponatremia/hyperkalemia | Metabolic instability | Aggressive correction |
| Known adrenal insufficiency without access to meds | High relapse risk | Education; emergency steroid plan |
| Pregnancy or intercurrent infection | Higher demand | Early stress dosing |
| Anticoagulation with suspected adrenal hemorrhage | Bleeding risk | Imaging; heme consult |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Hydrocortisone 100 mg IV bolus then 50 mg IV q6h (or 200 mg/day infusion) | Glucocorticoid | Minutes | Life-saving replacement | Covers mineralocorticoid needs acutely |
| 0.9% saline ± D5 for hypoglycemia | Resuscitation | Minutes | Restore perfusion and glucose | — |
| Resume/adjust chronic steroid and fludrocortisone after stabilization | Maintenance | Days | Prevent recurrence | Education on sick-day rules |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- Endocrine Society adrenal insufficiency statements — Link