Recognising adrenal crisis
Patients with an existing diagnosis of adrenal insufficiency, including Addison's disease
- check medical history: adrenal insufficiency diagnosis, and takes daily replacement glucocorticoid medication (most frequently hydrocortisone or prednisolone)
- steroid-dependent - may carry a Steroid Emergency Card (NHS or other type)
- confusion - may appear 'drunk' or 'drugged'
- nausea/vomiting/diarrhoea
- shaking, fever or feeling very cold
- weakness, drowsiness
- collapse, loss of conciousness
IMPORTANT
Patients are guided to self-administer, as soon as possible, an initial 100 mg of hydrocortisone. IF they have managed to do this, they will have temporarily increased their cortisol levels and some of their symptoms will improve.
THIS WILL NOT LAST.
They need monitoring, fluids, and the cause of their adrenal crisis must be explored, or they will have ANOTHER life-threatening ADRENAL CRISIS - and often within just a few hours after the first.
Undiagnosed patients
Due to the diverse and often gradual onset of symptoms, a significant number of patients diagnosed with adrenal insufficiency are diagnosed during their first adrenal crisis.
They will present with the same symptoms as above but:
- they won't have a steroid dependent card, they won't have adrenal insufficiency on their medical history.
- they may be underweight (gradual weight loss is a common symptom in undiagnosed patients)
- if they have Addison's disease, they may appear very tanned due to hyperpigmentation of the skin.
Adrenal crisis time-critical treatment
Adrenal crisis requires time-critical treatment with parenteral steroids and intravenous (IV) fluids. These guidelines are in line with the NICE Guidelines for Identification and Management of Adrenal Insufficiency and are provided by our Clinical Advisory Panel as an aid for A&E emergency teams receiving patients following or in a suspected adrenal crisis.
Adults:
- Administer parenteral hydrocortisone 100mg stat (IM preferable) and repeat 6 hourly until the patient is haemodynamically stable and clinical improvement (alternative 200mg/24hrs by continuous IV infusion).
- Administer 1 litre IV 0.9% saline stat and continue saline resuscitation at an appropriate rate until haemodynamic stability and correction of any electrolyte disturbance and AKI.
- Monitor U&E at least 12 hourly during initial resuscitation and continue regular monitoring until any hyponatraemia, hyperkalaemia or renal impairment are corrected.
- Identify and treat any precipitating cause for adrenal (Addisonian) crisis:
- vomiting/diarrhoeal illness
- infection
- myocardial infection
Infants and children:
As above with adjusted quantities and lower infusion rates- see below:
- initial parenteral injection of 50mg hydrocortisone/m2 (usually 25mg in infants and 50mg in children) followed by 50mg/24h in infants and 100mg/24h in children.
- adjusted volume IV 0.9% saline
