Adrenal crisis: workup and management
Adrenal crisis is life-threatening: hypotension or shock, vomiting, abdominal pain, confusion, hyponatremia or hyperkalemia in someone with known or suspected adrenal insufficiency, including chronic steroid users. Give hydrocortisone immediately; do not wait for test results.
Working diagnosis
Adult · US guidelines
Draft · awaiting physician review
01Orient
What's new in the evidence
- 2024 ESE/Endocrine Society guideline on glucocorticoid-induced adrenal insufficiency: stress coverage for current or recent glucocorticoid users whose HPA axis may be suppressed
- Minor illness: hydrocortisone 40 mg/day (e.g., 20/10/10) or prednisone 10 mg/day; surgery: hydrocortisone 100 mg at induction then 200 mg/24 h
- Adrenal crisis: hydrocortisone 100 mg IV/IM immediately, then 200 mg/24 h as infusion or 50 mg every 6 hours
Differential diagnoses
- Adrenal crisis from primary adrenal insufficiency
- Secondary or tertiary adrenal insufficiency (pituitary disease, stopped glucocorticoids, opioids, immune checkpoint inhibitors)
- Septic shock (can't miss; may coexist)
- Adrenal hemorrhage (anticoagulation, sepsis, antiphospholipid syndrome)
- Pituitary apoplexy (can't miss)
- Acute abdomen, gastroenteritis
02Assess
Risk scores and decision tools
- Morning cortisol <5 mcg/dL suggests adrenal insufficiency; >15 makes it unlikely (assay-dependent)
- ACTH stimulation test once stable
- Glucocorticoid exposure ≥20 mg/day prednisone equivalent for >3 weeks = high risk of suppression
Key history questions
- Known adrenal insufficiency, steroid doses and sick-day adherence
- Recent stop or taper of glucocorticoids (including inhaled, injected or topical)
- Vomiting, diarrhea, intercurrent illness, surgery
- Weight loss, fatigue, salt craving, hyperpigmentation
- Checkpoint inhibitors, anticoagulants, pituitary disease
Examination findings
- Hypotension, shock refractory to fluids
- Dehydration, abdominal tenderness, confusion
- Hyperpigmentation (primary), vitiligo
03Investigate
Initial investigations
- Draw cortisol and ACTH before hydrocortisone if it causes no delay
- BMP (low sodium, high potassium), glucose, CBC
- Cultures and source search
Advanced investigations
- ACTH stimulation test once stable
- Renin and aldosterone (primary)
- CT adrenals or MRI pituitary as indicated
04Treat
Immediate management
- Hydrocortisone 100 mg IV or IM immediately
- Then hydrocortisone 200 mg/24 h (50 mg IV every 6 hours or continuous infusion)
- 0.9% saline 1 L over the first hour, then as needed; dextrose if hypoglycemic
First-line treatment
- Treat the precipitant
- Taper to oral maintenance over 1–3 days once stable
- Fludrocortisone for primary adrenal insufficiency once hydrocortisone is under about 50 mg/day
Second-line treatment
- Stress-dose plans for future surgery and illness
Specialist referrals
- Endocrinology
- ICU for shock
05Disposition
Admission criteria
- All adrenal crises
Safe discharge criteria
- Stable on oral maintenance; tolerating oral intake
- Sick-day rules taught; emergency injection kit and medical alert
Follow-up timing
- Endocrinology within 1–2 weeks
Patient instructions
- Double or triple the oral dose during fever or illness (sick-day rules)
- Use the emergency hydrocortisone injection if vomiting, then seek care
Monitoring
- BP, glucose, sodium and potassium
Clinical pearls and pitfalls
- Hydrocortisone at stress doses provides enough mineralocorticoid activity; no fludrocortisone needed acutely
- Anyone on ≥20 mg/day prednisone equivalent for more than 3 weeks may have suppressed adrenals
RefGuidelines and landmark evidence
For education only. Typical adult starting points; confirm doses against renal function, allergies, interactions and your institution's protocols. Not a substitute for clinical judgment or senior review.