Addisonian crisis

Patients may present in shock, often (but not always) in a patient with known Addison’s, or someone on long-term steroids who has forgotten their tablets. Remember bilateral adrenal hemorrhage (e.g. meningococcemia) as a cause. An alternative presentation is with hypoglycemia.

Investigations

• Cortisol and ACTH (this needs to go straight to laboratory, call ahead!)
• Urea & Creatinine
• Electrolytes—can have ↑ K+ (check ECG and give calcium gluconate if needed) and ↓ Na+ (salt depletion, should resolve with rehydration and steroids).

Management

If suspected, treat before biochemical results.

1. Hydrocortisone 100mg IV stat.
2. IV fluid bolus e.g. 500mL 0.9% saline to support BP, repeated as necessary.
3. Monitor blood glucose: the danger is hypoglycemia.
4. Blood, urine, sputum for culture, then antibiotics if concern about infection.

Continuing treatment

1. Glucose IV may be needed if hypoglycemic.
2. Give IV fluids as guided by clinical state and to correct Urea, creatinine, & Electrolytes imbalance.
3. Continue hydrocortisone, e.g. 100mg/8h IV or IM.
4. Change to oral steroids after 72h if patient’s condition good.
5. Fludrocortisone may well be needed if the cause is adrenal disease: ask an expert.
6. Search for (and vigorously treat) the underlying cause. Get endocrinological help.