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    Addisonian – Adrenal Crisis – Diagnosis & Treatment

    Cardiovascular, Critical Care / Resuscitation, Hematological / Oncological

    Last Updated Feb 21, 2024
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    Addisonian crisis (also called adrenal crisis or acute adrenal insufficiency) is the result of an acute deficiency of cortisol production by the body and requires immediate recognition and treatment to avoid death.

    • A deficiency of aldosterone may lead to decreased intravascular volume, vascular tone, cardiac output, and renal perfusion.
    • Most cases occur in patients with known adrenal insufficiency (primary or secondary) who experience an acute stress event, resulting in rapid depletion of their cortisol stores if they do not adjust their usual dose of glucocorticoid therapy.

    Stresses or events that can precipitate Addisonian crisis include:

      • Infection (e.g. gastroenteritis, upper respiratory tract infections).
      • Recent surgeries or traumatic injuries.
      • Abrupt cessation of chronic steroid therapy.
      • Fasting.
      • Use of levothyroxine in patients with untreated adrenal insufficiency.

    Diagnostic Process

    Initial diagnosis of Addisonian crisis should be based on clinical judgment and treatment must not be delayed for diagnostic testing.

    • If untreated, rapid progression to an altered level of consciousness, metabolic encephalopathy, shock, coma, and death.
    • Table 1 below, provides a summary of typical symptoms, physical exam findings, and laboratory findings for patients in Addisonian crisis.
    Table 1. Typical symptoms, physical exam findings, and laboratory findings during Addisonian crisis




    ·          Malaise.

    ·         Fatigue.

    ·         Weakness.

    ·         Presyncope or syncopal episodes.

    ·         Confusion.

    ·         Salt craving.

    ·         Abdominal and/or back pain.


     Physical Exam Findings



    ·         Hypotension.

    ·         Fever if infectious stressor.

    ·         Hyperpigmentation (palmar creases, buccal mucosa, old scars).


     Laboratory Findings



    ·         Hyponatremia.

    ·         Hyperkalemia.

    ·         Acute kidney injury from renal hypoperfusion.

    ·         Non-anion gap metabolic acidosis.

    ·         Normochromic anemia.

    ·         Hypoglycemia (more common in children).


    Diagnostic Tests


    • After initial treatment, diagnose and treat the precipitating cause of the crisis.
    • Laboratory testing for serum chemistry (sodium, potassium, glucose, calcium), CBC with differential, cortisol, adrenocorticotropic hormone (ACTH), aldosterone, renin, and thyroid function.
      • Major features of Addisonian crisis in patients with primary adrenal insufficiency include volume depletion, hypotension, hyponatremia, and hyperkalemia (due to mineralocorticoid deficiency and inappropriate secretion of antidiuretic hormone.
      • Volume depletion and hyperkalemia are less prominent in patients with secondary adrenal insufficiency since mineralocorticoid production is preserved.
    • In patients not known to have adrenal insufficiency, ACTH stimulation testing can be performed immediately after starting glucocorticoid treatment.
      • Standard high-dose testing uses 250 mcg IV of cosyntropin (synthetic ACTH) and measures the rise in serum cortisol at 30 and 60 minutes.
      • If serum cortisol does not rise to a peak of ≥ 500 to 550 nmol/L, adrenal insufficiency is likely.
    • ECG may show peaked T waves (hyperkalemia) or short QT interval (hypercalcemia).
    • Abdominal CT can assess for hemorrhage or calcification of the adrenal glands if needed.

    Recommended Treatment

    Immediate treatment with IV fluids and parenteral glucocorticoids and maximal supportive care and monitoring in the ICU.


    • 2-3 liters of normal saline infused in the first few hours as needed to volume resuscitate.
    • 5% dextrose in normal saline if hypoglycemic.

    Glucocorticoid Replacement

    • Administer a bolus of glucocorticoids such as hydrocortisone (100mg IV bolus) or an equivalent such as dexamethasone (4mg IV bolus).
      • In patients without known adrenal insufficiency, dexamethasone is preferred because it does not interfere with diagnostic testing like hydrocortisone.
    • Maintenance therapy is required until vital signs have stabilized:
      • Dexamethasone 4mg IV every 12 hours.
      • Hydrocortisone 50mg IV every 6 hours.
    • Critically ill patients that do not respond to initial IV fluids and glucocorticoids should be started on vasopressors to maintain a MAP above 65.


    • If a new diagnosis of adrenal insufficiency is confirmed, refer to Internal Medicine for further endocrine specialist investigations to determine if primary or secondary adrenal insufficiency.

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