Adrenal Crisis
100 mg
IV Hydrocortisone
Bolus dose for crisis
<18 mcg/dL
Random Cortisol
Suggestive of adrenal insufficiency
3
Classic Findings
Hypotension hypoglycemia hyperkalemia
Presentation and Triggers
the patient who crashes despite everything you throw at themRefractory hypotension unresponsive to fluids and vasopressors
Hypoglycemia (cortisol mobilizes glucose during stress)
Hyperkalemia and hyponatremia (aldosterone is also deficient)
Altered mental status, weakness, abdominal pain
Triggers include surgery, infection, or trauma in chronic steroid users
Abrupt discontinuation of chronic corticosteroid therapy
Pituitary apoplexy or adrenal hemorrhage (Waterhouse-Friderichsen)
If hypotension won't respond to fluids and vasopressors, think adrenal crisis
Treatment Protocol
Hydrocortisone 100 mg IV bolus immediately
Followed by 50 mg IV every 8 hours
Aggressive IV fluid resuscitation with D5NS for hypoglycemia
Treat hyperkalemia per standard protocol
Identify and treat the precipitating cause
Do NOT wait for lab confirmation if clinical picture fits
Key Values to Memorize
Hydrocortisone 100 mg bolus
50 mg q8h maintenance
Cortisol <18 = suspicious
Hypotension + hypoglycemia
Hyperkalemia + hyponatremia
Steroid withdrawal = trigger
adrenal crisis is the diagnosis you cannot afford to miss
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Refractory hypotension is the clue
When blood pressure will not respond to adequate fluid resuscitation and vasopressors, adrenal crisis should be on your differential. The adrenals are not producing enough cortisol to maintain vascular tone. Hydrocortisone is the missing piece.
Abrupt steroid withdrawal as trigger
Patients on chronic steroids who suddenly stop have suppressed adrenal glands that cannot mount a stress response. Surgery, infection, or trauma in these patients can precipitate full adrenal crisis. Always ask about recent steroid use.
Random cortisol below 18 is suggestive
A random cortisol level below 18 mcg/dL in an acutely ill patient suggests adrenal insufficiency. Do not wait for the cosyntropin stimulation test to treat if the patient is crashing. Give hydrocortisone empirically.
Refractory Hypotension
Fluids not working. Vasopressors not working. Think adrenal crisis. Give hydrocortisone 100 mg IV now.
The Triad
Hypotension + hypoglycemia + hyperkalemia = classic adrenal crisis presentation. Hyponatremia is common too.
Your adrenal glands are like the battery that powers your body during stress. Cortisol is the charge. Every time you face illness, trauma, or surgery, your body draws heavily on that battery to keep blood pressure up and glucose available.
In adrenal crisis, the battery is completely dead. No cortisol output. Blood pressure drops because vessels lose their tone. Blood sugar drops because cortisol is not mobilizing glucose. Potassium rises because aldosterone is also gone.
Hydrocortisone 100 mg IV is the jump start. It replaces what the adrenals cannot produce. Blood pressure responds, glucose stabilizes, and potassium starts to normalize. Then you maintain with 50 mg every 8 hours.
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