AKT · Acute care/Metabolic & endocrine

Addisonian (adrenal) crisis

Acute glucocorticoid (± mineralocorticoid) deficiency

Overview

Acute, life-threatening adrenal insufficiency — shock that responds poorly to fluids, with hyponatraemia, hyperkalaemia and hypoglycaemia. Often precipitated by illness/surgery or sudden steroid withdrawal. Treat with IV hydrocortisone immediately, before confirmatory tests.

Recognise

Hypotension/shock not responding to fluids, vomiting, abdominal pain, weakness
Hyponatraemia + hyperkalaemia + hypoglycaemia
Background: known Addison’s/steroid use, pigmentation (primary), recent steroid cessation, illness/surgery

Red flags

Refractory shock with low Na+ / high K+ / low glucose → give hydrocortisone without waiting for cortisol result

Differentials & how to tell them apart

Septic shockinfective source — but may precipitate the crisis; treat both

Hyperkalaemia of other causeno hypotension/hyponatraemia/steroid history

Hypovolaemic shockresponds to fluids; normal Na+/K+ pattern

DKAketones + acidosis + hyperglycaemia

Investigations

Do NOT delay treatment for tests. Take cortisol/ACTH, U&E (low Na+, high K+), glucose; short Synacthen test once stable.

Management

IV hydrocortisone 100 mg immediately + IV saline/glucose — before confirmatory tests

1Give IV hydrocortisone 100 mg immediately and aggressive IV 0.9% saline; correct hypoglycaemia — do not wait for the cortisol result.Gate: Shock with hyponatraemia + hyperkalaemia + hypoglycaemia, especially on/just off steroids → treat as adrenal crisis empirically
2Identify/treat the precipitant; continue hydrocortisone; educate on sick-day rules and emergency hydrocortisone; steroid alert card.

IV hydrocortisone 100 mg — immediately, then 6-hourly / infusion

IV 0.9% saline + glucose — aggressive rehydration; correct hypoglycaemia

Key points

Hyperkalaemia here is part of the picture (aldosterone deficiency). Sick-day rules — double oral steroids when ill — prevent crises. Never stop long-term steroids abruptly.

Monitor & prognosis

BP, U&E, glucose, response to hydrocortisone; precipitant.

Rapid recovery with prompt steroids; fatal if missed.

Source: Society for Endocrinology emergency guidance; BNF