Treat suspected adrenal crisis secondary to AI
STEP 1 — Gather Information
Collect history of adrenal insufficiency (especially secondary/pituitary origin), recent stressors (illness, surgery, trauma), current medications (glucocorticoid use), and assess for hypotension, hypoglycemia, fatigue, nausea, or abdominal pain. Measure vital signs and point-of-care glucose if available.
If hypotension, hypoglycemia, or acute illness is present in a patient with known adrenal insufficiency, proceed to Step 2; otherwise, consider alternative diagnoses.
STEP 2 — Rule In / Rule Out
Is adrenal crisis suspected based on the triad of hypotension, hypoglycemia, or acute illness in a patient with adrenal insufficiency?
- Yes → Proceed to Step 3
- No → Seek other causes; adrenal crisis unlikely; stop algorithm
STEP 3 — Classify or Stratify
Stratify by hemodynamic severity: systolic BP <90 mmHg, altered mental status, or ongoing shock vs stable vitals.
- If systolic BP <90 mmHg, altered mental status, or signs of shock → administer 100 mg hydrocortisone
- If vitals stable but criteria met → administer 50 mg hydrocortisone
STEP 4 — Decide
Give the selected dose of hydrocortisone via immediate intravenous or intramuscular injection; repeat dose if no clinical improvement within 15–20 minutes and consider continuous infusion if refractory.
Clinical Guardrails / Mimics / Pitfalls
Do not delay treatment for confirmatory testing; avoid oral hydrocortisone if vomiting or impaired consciousness; do not use fludrocortisone in secondary AI; ensure fluid resuscitation with isotonic crystalloids; monitor for hypoglycemia and hyperglycemia after steroid administration; consider sepsis or myocardial infarction as mimics that also require urgent hydrocortisone.
Concrete Clinical Example
A 45-year-old woman with known hypopituitarism presents with fever, systolic BP 85/50 mmHg, and glucose 45 mg/dL. She receives 100 mg hydrocortisone IV immediately, followed by fluid resuscitation; blood pressure improves to 110/70 mmHg within 30 minutes.
Source: Hormonal Replacement in Hypopituitarism in Adults: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, DOI:10.1210/jc.2016-2118