🚨 Adrenal Crisis
Overview
Adrenal crisis (acute adrenal insufficiency) is a life-threatening endocrine emergency caused by an acute deficiency of adrenal hormones, primarily cortisol. It can occur in patients with known adrenal insufficiency or as the first presentation. Prompt recognition and aggressive treatment are vital to prevent shock and death.
Recognition
Patients present with non-specific symptoms including severe fatigue, weakness, nausea, vomiting, abdominal pain, and confusion. Hypotension (often refractory to fluids), hypoglycaemia, and hyperkalaemia are common. In primary adrenal insufficiency, hyperpigmentation may be present. A precipitating stressor (e.g., infection, surgery) is often identified.
Initial Assessment (ABCDE)
A: Assess airway patency; protect if GCS is low. B: Assess breathing for rate and oxygen saturation. C: Assess circulation for heart rate, blood pressure (often hypotensive), capillary refill, and signs of shock. D: Assess disability using GCS, and check blood glucose. E: Expose fully to check for hyperpigmentation, signs of infection, and temperature.
Red Flags
Refractory hypotension despite fluid resuscitation, rapidly decreasing GCS, severe hypoglycaemia, hyperkalaemia with ECG changes, and signs of cardiovascular collapse are critical red flags. Any patient with known adrenal insufficiency presenting with acute illness and hypotension should be treated for adrenal crisis immediately.
Investigations
Bedside: Capillary blood glucose, ECG. Bloods: Urgent urea and electrolytes (for hyperkalaemia, hyponatraemia), creatinine, full blood count, blood gas (for acidosis), cortisol level (taken before steroids if possible), ACTH level (if primary adrenal insufficiency suspected), blood cultures if infection suspected. Imaging: Chest X-ray if respiratory symptoms.
Immediate Management
Administer high-flow oxygen if hypoxic. Establish intravenous access and administer rapid intravenous fluid resuscitation with isotonic saline or 5% glucose in saline for hypoglycaemia. Administer intravenous glucocorticoids immediately, ideally after taking a blood sample for cortisol. Treat any underlying precipitating factors, such as infection. Monitor vital signs closely.
Escalation Triggers
Any suspicion of adrenal crisis warrants immediate senior medical review. Patients with refractory shock, severe electrolyte abnormalities, or rapidly deteriorating GCS require urgent critical care involvement. Failure to respond to initial glucocorticoid and fluid therapy also necessitates escalation.
MLA High-Yield Notes
Adrenal crisis is a 'don't miss' diagnosis. Always give stress-dose steroids immediately if suspected, even before diagnostic tests, as delay is fatal. Hydrocortisone is the steroid of choice. Remember to look for a medical alert bracelet or steroid card. Hyponatraemia and hyperkalaemia are classic electrolyte derangements.
References
- Society for Endocrinology Clinical Guidance: Diagnosis and management of adrenal insufficiency
- NICE Guideline NG18: Diabetes (type 1 and type 2) in children and young people: diagnosis and management (relevant for hypoglycaemia management)
- Resuscitation Council UK: Advanced Life Support Guidelines