Acute Adrenal Crisis

What is Acute Adrenal Crisis (Addisonian crisis)?

Acute adrenal crisis is a life-threatening state caused by insufficient levels of cortisol, which is a hormone produced and released by the adrenal gland. Alternative names include adrenal crisis, Addisonian crisis, and acute adrenal insufficiency.

Causes and risk factors

The two adrenal glands are located on top of the kidneys. They consist of the outer portion, called the cortex, and the inner portion, called the medulla. The cortex produces three types of hormones, all of which are called corticosteroids.

Cortisol is a glucocortoid, a corticosteroid that maintains glucose (blood sugar) regulation, suppresses the immune response, and is released as part of the body's response to stress. Cortisol production is regulated by a small gland just below the brain called the pituitary gland. Cortisol is essential for life.

Risk factors for adrenal crisis include physical stress such as infection, dehydration, trauma, or surgery, adrenal gland or pituitary gland injury, and ending treatment with steroids such as prednisone or hydrocortisone too early.

What happens in an adrenal crisis?

Acute adrenal crisis is a medical emergency caused by a lack of cortisol. Patients may experience lightheadedness or dizziness, weakness, sweating, abdominal pain, nausea and vomiting, or even loss of consciousness.

Adrenal crisis occurs if the adrenal gland is deteriorating (Addison's disease, primary adrenal insufficiency), if there is pituitary gland injury (secondary adrenal insufficiency), or if adrenal insufficiency is not adequately treated.

Symptoms

• Headache
• Profound weakness
• Fatigue
• Slow, sluggish movement
• Nausea
• Vomiting
• Low blood pressure
• Dehydration
• High fever
• Shaking chills
• Confusion or coma
• Darkening of the skin
• Rapid heart rate
• Joint pain
• Abdominal pain
• Unintentional weight loss
• Rapid respiratory rate (see tachypnea)
• Unusual and excessive sweating on face and/or palms
• Skin rash or lesions may be present
• Flank pain
• Loss of appetite

Signs and tests:

• An ACTH (cortrosyn) stimulation test shows low cortisol.
• The baseline cortisol level is low.
• Fasting blood sugar may be low.
• Serum potassium is elevated ( usually primary adrenal insufficiency).
• Serum sodium is decreased (usually primary adrenal insufficiency).

Treatment

In adrenal crisis, an intravenous or intramuscular injection of hydrocortisone (an injectable corticosteroid) must be given immediately. Supportive treatment of low blood pressure with intravenous fluids is usually necessary. Hospitalization is required for adequate treatment and monitoring. If infection is the cause of the crisis, antibiotic therapy may be needed.

Expectations (prognosis)

Death may occur due to overwhelming shock if early treatment is not provided.

Complications:

• shock
• coma
• seizures

Calling your health care provider

Call your health care provider if you have Addison's disease and are unable to retain usual medications because of vomiting. Go to the emergency room or call the local emergency number (such as 911) if symptoms of acute Addisonian crisis develop.

Prevention

People who have Addison's disease symptoms should be taught to recognize signs of potential stress that may cause an acute adrenal crisis. Most people with Addison's disease are taught to give themselves an emergency injection of hydrocortisone or increase their dose of oral prednisone in times of stress.

It is important for the individual with Addison's disease to always carry a medical identification card that states the type of medication and the proper dose needed in case of an emergency.

Never omit medication. If unable to retain medication due to vomiting, notify the health care provider.