| Emergency measures |
- Establish intravenous access with a large-gauge needle.
- Draw blood for immediate serum creatinine, BUN, electrolytes, glucose, and routine measurement of plasma cortisol and ACTH. Do not wait for laboratory results.
- Infuse 1 liter of isotonic saline or 5% dextrose in isotonic saline as quickly as possible. Repeat fluid bolus as needed for volume resuscitation, followed by maintenance fluids. Frequent hemodynamic monitoring and measurement of serum electrolytes should be performed to avoid iatrogenic fluid overload.
- Give hydrocortisone (100 mg intravenous bolus), followed by 50 mg intravenously every 6 hours (or 200 mg/24 hours as a continuous intravenous infusion for the first 24 hours). If hydrocortisone is unavailable, alternatives include methylprednisolone and dexamethasone. Saline must be administered if dexamethasone is given instead of hydrocortisone.
- Use supportive measures as needed.*
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| Subacute measures after stabilization of the patient |
- Continue intravenous isotonic saline at a slower rate for next 24 to 48 hours.
- Search for and treat possible infectious precipitating causes of the adrenal crisis.
- Taper parenteral glucocorticoid over 1 to 3 days, if precipitating or complicating illness permits, to oral glucocorticoid maintenance dose.
- For patients with primary adrenal insufficiency, begin mineralocorticoid replacement with fludrocortisone, 0.1 mg by mouth daily, when saline infusion is stopped or hydrocortisone dose is tapered to <40 mg daily.
- If the patient does not have known adrenal insufficiency, confirm the diagnosis and determine the underlying cause. Refer to UpToDate topics on the diagnostic and etiologic evaluation of adrenal insufficiency in adults.
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