Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets (hemodynamic, neurologic, respiratory) and reassess frequently.
- Plan definitive source control or immunomodulation when indicated; document follow‑up and patient education.
Algorithm
- Suspect adrenal crisis in hypotension/shock with GI symptoms and electrolyte abnormalities.
- Give hydrocortisone 100 mg IV immediately; draw cortisol/ACTH if feasible without delay.
- Resuscitate with isotonic fluids; correct hypoglycemia and hyperkalemia.
- Search and treat triggers (infection, missed steroids, surgery, medications).
- Taper to maintenance dosing over 24–48 h once stable; provide sick‑day rules and emergency steroid plan.
Clinical Synopsis & Reasoning
Life‑threatening cortisol deficiency with hypotension, abdominal pain, hyponatremia/hyperkalemia, and shock. Treat immediately with IV hydrocortisone and isotonic fluids; do not delay for labs. Identify precipitants (infection, missed doses, surgery) and provide sick‑day education.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced or 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 |
|---|---|---|---|
| Serum cortisol/ACTH (before steroids if feasible) | Etiology confirmation | Low cortisol; high ACTH in primary | Do not delay steroids for labs |
| BMP/glucose | Complications | Hyponatremia, hyperkalemia, hypoglycemia | Trend correction |
| Cultures/chest x‑ray | Trigger evaluation | Infection common | Guide antibiotics |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Hydrocortisone 100 mg IV bolus → 50 mg IV q6h | Glucocorticoid | Minutes | First‑line life‑saving therapy | Mineralocorticoid activity sufficient acutely |
| 0.9% Saline ± D5NS | Crystalloid | Immediate | Resuscitation and hypoglycemia prevention | Adjust for hypernatremia/osmolality |
| Empiric antibiotics (if sepsis) | Antimicrobial | Hours | Treat trigger | De‑escalate by cultures |
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.