Adrenal Insufficiency (Addisonian Crisis)MANAGEMENT

ENDOCRINE AND METABOLIC PRESENTATIONS · 12 SECTIONS

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501 items

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

Acute Porphyria Adrenal crisis Adrenal Insufficiency (Addisonian Crisis)Dehydration Diabetes Insipidus Diabetic Ketoacidosis (DKA)Euglycemic DKA (SGLT2 inhibitor)Galactosemia GLP-1 receptor agonist complications (retained gastric contents, aspiration risk)Homocystinuria Hypercalcemia Hyperkalemia Hypermagnesemia Hypernatremia Hyperosmolar Hyperglycemic State (HHS)Hypertensive emergency Hypertensive urgency Hypocalcemia Hypoglycemia Hypogonadism (Acute Presentation)Hypokalemia Hypomagnesemia Hyponatremia Hypoparathyroidism (Tetany)Insulin pump failure Maple Syrup Urine Disease (Crisis)Medium-Chain Acyl-CoA Dehydrogenase Deficiency (MCAD)Metabolic Acidosis Metabolic Alkalosis Myasthenia gravis crisis Myxedema coma Pellagra Pheochromocytoma (Crisis)Pituitary Apoplexy Pompe Disease (GSD II)Respiratory Acidosis Respiratory Alkalosis Scurvy SIADH Starvation Ketosis Tarui Disease (GSD VII)Thyroid storm Tyrosinemia Vitamin D Deficiency (Severe-Rickets)Von Gierke Disease (GSD I)

ENT and Maxillofacial Presentations27▾

Ophthalmologic Presentations19▾

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp53

Immediate priorities

›Recognize adrenal crisis early

›Hypotension or hypovolemic shock plus one or more

›Nausea or vomiting

›Severe fatigue

›Fever without clear source

›Impaired consciousness

›Shock out of proportion to trigger severity

›Refractory to fluids alone

›Refractory to conventional vasopressors until glucocorticoid given

›Treatment must never be delayed for diagnostic workup

›Hydrocortisone 100 mg IV bolus immediately

›Draw cortisol and ACTH before treatment only if no delay

›Airway and breathing threats

›Depressed mental status

›Obtundation

›Seizure or coma

›If unable to protect airway, definitive airway control

›Rapid sequence intubation preparation

›Avoid etomidate as induction agent

›Circulation threats

›Distributive and hypovolemic shock

›SBP < 100 mmHg or >= 20 mmHg below baseline

›Tachycardia and poor perfusion

›If shock present, 1 L 0.9% saline in first hour

›Aggressive crystalloid resuscitation

›Reassess after each bolus

›Reversible cardiomyopathy from cortisol deficiency

02History/hx68

Presenting symptoms

›Core syndrome

›Fatigue (50% to 95%)

›Chronic and progressive

›Worse with stress

›Nausea and vomiting (20% to 62%)

›Impairs oral medication absorption

›Common crisis precipitant

›Anorexia and weight loss (43% to 73%)

›Unintentional

›Months-long course

›Cardinal features

›Orthostatic dizziness or syncope

›Orthostatic hypotension 68% in primary AI

›Salt cravings from aldosterone deficiency

›Abdominal pain

›May mimic acute abdomen

›Peritoneal-like irritation

›Skin darkening

›Hyperpigmentation 74% in primary AI

›Buccal mucosa and palmar creases

Precipitants and triggers

›Recent stressors

›Infection especially GI illness

›Vomiting and diarrhea

›Dehydration

›Surgery, trauma, or dental procedure

›Physiologic stress demand

03Physical Exam/exam45

Vital signs and general

›Hemodynamic snapshot

›Hypotension

›SBP < 100 mmHg

›Greater than or equal to 20 mmHg below baseline

›Orthostatic changes and tachycardia

›Postural drop

›Compensatory tachycardia

›Fever

›May be from infection precipitant

›May occur without infectious source

›General appearance

›Dehydration

›Poor skin turgor

›Dry mucous membranes

›Cachexia

›Chronic weight loss

›Muscle wasting

Targeted organ exam

›Skin findings

›Hyperpigmentation in primary AI only

›Palmar creases and buccal mucosa

›Scars, areolae, and axillae

›Absence does not exclude AI

›Secondary AI lacks hyperpigmentation

›Glucocorticoid-induced AI lacks hyperpigmentation

›Abdomen

›Tenderness

04Differential Diagnosis/ddx41

Life-threatening mimics

›Shock states

›Septic shock

›Most important mimic

›May coexist with adrenal crisis

›Hypovolemic shock

›GI losses or hemorrhage

›Responds to volume alone

›Cardiogenic shock

›Acute heart failure

›Crisis itself causes reversible cardiomyopathy

›Other emergencies

›Anaphylaxis

›Hypotension with GI symptoms

›Urticaria and angioedema

›Diabetic ketoacidosis

›Nausea, vomiting, abdominal pain

›Anion-gap acidosis and ketones

Endocrine and abdominal mimics

›Endocrine

›Myxedema coma

›Hypothyroidism with hypotension

›Altered mental status

›Hypoglycemia from other causes

›Insulinoma

›Liver failure

›Abdominal

›Acute surgical abdomen

05Laboratory Tests/lt38

Core diagnostic labs

›Draw before treatment if no delay

›Serum cortisol

›Random in crisis

›Under 5 µg/dl strongly suggests AI

›Plasma ACTH

›Elevated over 2x upper limit in primary AI

›Low or low-normal in secondary or tertiary

›DHEAS

›Low in all forms of AI

›Adjunct support

Electrolytes and metabolic

›Basic metabolic panel

›Hyponatremia

›Present in 84% of undiagnosed AI

›Cortisol and aldosterone deficiency

›Hyperkalemia

›34% in primary AI only

›Mineralocorticoid deficiency

›Hypoglycemia and prerenal markers

›Low glucose

›Elevated creatinine and BUN

›Hematology

›Complete blood count

›Eosinophilia and lymphocytosis

›Mild normocytic anemia

Adjunct and etiologic labs

›Hormonal axis

06Diagnostic Tests/dt53

Scoring Systems

›Adrenal crisis clinical definition

›Hypotension or hypovolemic shock

›SBP < 100 mmHg

›Marked orthostatic drop

›Plus one or more features

›Nausea or vomiting

›Fever or impaired consciousness

›Distinguishing principle

›Shock disproportionate to trigger

›Refractory until glucocorticoid given

›Cosyntropin stimulation test

›Gold standard in stable patients

›250 µg cosyntropin IV or IM

›Cortisol at 0 and 60 minutes

›Interpretation

›Peak cortisol under 18 µg/dl confirms AI

›Newer assays use 15 to 17 µg/dl thresholds

›Performance and limits

›Sensitivity 64% and specificity 93% for secondary AI

›Normal result does not exclude recent-onset secondary AI

›Not needed when unequivocal

›Low baseline cortisol with elevated ACTH

›Primary AI already established

MRI

›Pituitary MRI

›Indications for suspected secondary AI

›Pituitary tumor or hemorrhage

07Disposition/dispo28

Level of care

›Admit all adrenal crisis patients

›ICU or high-dependency unit

›Hemodynamic monitoring

›Frequent electrolyte checks

›ICU indications

›Persistent hypotension despite treatment

›Altered mental status or severe electrolyte derangement

›Observation candidates

›Incipient crisis

›Symptomatic AI without frank hypotension

›Rapid response to stress-dose steroids

›Reassessment cadence

›Serial vitals

›Repeat electrolytes

Consults and follow-up

›Specialist involvement

›Endocrinology consultation

›All new diagnoses and recurrent crises

›HPA axis recovery not achieved within 1 year

›Persistent shock evaluation

›Investigate alternative causes

›Confirm adequate hydrocortisone and fluids

›Discharge prerequisites

›Hemodynamic stability

›Normalized blood pressure

›Tolerating oral intake and medication

›Education and equipment

08Treatment/t55

Immediate stabilization

›Glucocorticoid first

›Hydrocortisone 100 mg IV bolus immediately

›IM if no IV access

›Do not delay for labs

›Rationale

›Restores vascular tone

›Reverses vasopressor refractoriness

›Fluid resuscitation

›0.9% normal saline

›1 L in the first hour

›Titrate to hemodynamics and electrolytes

›Hypoglycemia correction

›Dextrose 0.5 to 1 g/kg

›D50 or D10 infusion

Ongoing glucocorticoid

›Hydrocortisone maintenance dosing

›200 mg per 24 hours

›Continuous IV infusion preferred

›Or 50 mg IV every 6 hours

›Day 2 onward

›Reduce to 100 mg per day after 24 hours

›Guided by clinical response

›Oral transition once stable

›Start at 2 to 3x usual dose when tolerating PO

›Taper to maintenance over 2 to 3 days

›Alternatives if hydrocortisone unavailable

›Prednisolone

09Special Populations/sp39

Pregnancy

›Pregnancy considerations

›Increased glucocorticoid requirement

›Higher demand in third trimester

›Stress-dose at labor and delivery

›Preferred agents

›Hydrocortisone preferred

›Avoid dexamethasone which crosses placenta

›Crisis management unchanged

›Hydrocortisone 100 mg IV bolus

›Aggressive saline resuscitation

›Fludrocortisone in primary AI

›Continue maintenance

›Monitor blood pressure and potassium

Geriatric

›Older adult features

›Atypical presentation

›Confusion or delirium predominant

›Falls and functional decline

›Higher crisis risk

›Age over 65 years a risk factor

›Polypharmacy and CYP3A4 interactions

›Comorbidity caution

›Cardiac tolerance of fluid resuscitation

›Monitor for fluid overload

›Disposition bias

›Lower threshold for admission

›Limited home supports

10Background/b48

Epidemiology

›Burden and presentation

›Crisis as first manifestation

›Up to 50% of primary AI present in crisis

›Frequently undiagnosed at presentation

›Causes of primary AI

›Autoimmune adrenalitis most common in developed countries

›Tuberculosis leading cause in developing countries

›Glucocorticoid-induced AI

›Most common form overall

›Crisis may be first manifestation

Pathophysiology

›Mechanisms of cortisol deficiency

›Primary AI

›Cortisol, aldosterone, and androgen deficiency

›Hyperpigmentation, hyperkalemia, salt wasting

›Secondary AI

›Cortisol deficiency only with preserved aldosterone

›No hyperpigmentation or hyperkalemia

›Hemodynamic consequences

›Loss of vascular tone and catecholamine sensitivity

›Reduced myocardial contractility

›Etiologic categories

›Autoimmune and infiltrative

›Autoimmune polyendocrine syndromes

›Adrenal metastases and infiltration

›Vascular and pituitary

›Adrenal hemorrhage in Waterhouse-Friderichsen syndrome

11Patient Discharge Instructions/pdi21

copy discharge instructions

›Adrenal insufficiency home care

›Take steroid medication exactly as prescribed every day

›Never stop steroids suddenly

›Carry your emergency hydrocortisone injection kit at all times

›Wear medical alert identification

›Sick-day rules

›Double your dose if you have a fever of 38°C

›Triple your dose if you have a fever of 39°C

›Use the emergency injection and come to the ER if you cannot keep pills down

›Drink electrolyte-containing fluids when ill

›Return to ER immediately for

›Persistent vomiting or diarrhea stopping your medication

›Fever not responding to stress dosing

›Dizziness, fainting, or near-fainting

›Confusion or severe drowsiness

›Any symptoms resembling a prior crisis

›Follow-up

›See endocrinology within 1 to 2 weeks

›Annual influenza vaccine

›Pneumococcal vaccine if over 60 years

›Ensure a caregiver can also give your injection

12References/r12

Guidelines and key sources

›Society guidelines

›Endocrine Society primary adrenal insufficiency guideline

›ESE and Endocrine Society glucocorticoid-induced AI joint guideline 2024

›Bornstein primary adrenal insufficiency clinical practice guideline 2016

›Landmark reviews

›Rushworth Adrenal Crisis NEJM 2019

›Vaidya Adrenal Insufficiency in Adults JAMA 2025

›Husebye Adrenal Insufficiency Lancet 2021

›Coding standards

›ICD-10 E27.1 primary adrenocortical insufficiency

›ICD-10 E27.2 Addisonian crisis

›ICD-10 E27.3 drug-induced adrenocortical insufficiency

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Reviewed by SymptomDx Medical Team · Last reviewed August 18, 2026

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