emDocs - May 15, 2015 - By Brit Long / Author Phipps A - Editors: Koyfman A & Long B.
"Management
As soon as adrenal crisis is suspected, steroids should be given. Hydrocortisone is the steroid of choice, as it has both glucocorticoid and mineralocorticoid effects. Patients 12 years and older should receive 100 mg IV initially and then 100 mg IV every 8 hours after that until the acute crisis resolves. For children ages 3-12 years old, dosing should be reduced to 50 mg IV and for infants <3 years old reduced further to 25 mg IV. Dexamethasone 4 mg IV is also an option and preferred by some physicians as it will interfere less with a rapid ACTH simulation test.
Fluid hydration in the form of IV fluid boluses should be given, with up to 2-3 L often required in the initial resuscitation stages to treat any concurrent dehydration. Afterwards, IV hydration with D5 NS can be beneficial, as it will help correct the hypoglycemia and hyponatremia often seen in these patients. Vasopressors can be started as needed, although these patients’ hypotension can be refractory to both fluids and vasopressors. Steroids are ultimately needed for vascular tone. The precipitating cause should be treated as indicated.
Most patients will need admission to the ICU for close monitoring and blood pressure management.
Summary
Adrenal crisis is a life-threatening emergency that needs to be recognized and treated quickly in the ED to prevent subsequent morbidity and mortality. Approximately half of patients will have no past medical history of adrenal insufficiency. The hallmark of the disease is hypotension refractory to IV fluids and vasopressors. Treat empirically with hydrocortisone and treat any precipitating causes."
http://www.emdocs.net/adrenal-crisis-in-the-ed/