A 33-year-old woman presents to the emergency department with rapid onset confusion, severe abdominal pain and vomiting over the last 1 hour. A collateral history from her partner reveals that she has been having unusual salt cravings and light-headedness upon standing over the past 2 months, but had put this down to her recent increased stress from work. Past medical history is significant for Graves’ disease, which is well-controlled on carbimazole. Vital signs are temperature 38.0° C (100.4° F), blood pressure 80/59 mmHg, pulse 92 beats/min, and respirations 18/min. On physical examination, the patient has a capillary refill time of 4 seconds and dry mucous membranes. A generalized bronze skin tan is also noted. Pertinent laboratory studies include the following:
- Sodium - 128 mmol/L
- Potassium - 6.0 mmol/L
- Glucose - 3.1 mmol/L
Intravenous access is obtained, and the patient is transferred to intensive care unit (ICU).
Which of the following is the definitive therapy for this patient?
- A) Intravenous 0.9% sodium chloride
- B) Intravenous 5% dextrose
- C) Intravenous hydrocortisone
- D) Intravenous insulin
- E) Intravenous norepinephrine
C) Intravenous hydrocortisone
This patient is experiencing an acute adrenal crisis on a background of previously undiagnosed Addison disease. As it is a life-threatening medical emergency caused by severe glucocorticoid deficiency, the definitive therapy is rapid administration of glucocorticoids. Hydrocortisone has both mineralocorticoid and glucocorticoid activity, making it the preferred glucocorticoid for treating adrenal insufficiency. If hydrocortisone is unavailable, alternatives include prednisolone, prednisone, or dexamethasone.
Fluid resuscitation with IV sodium chloride 0.9% is also essential in the management of an acute adrenal crisis as patients present hyponatremic and dehydrated but will not reverse the underlying cause of their hyponatremia. Hypotonic saline should not be used because used because it can worsen hyponatremia.
IV 5% dextrose will help with the patient’s hypoglycemia but will not reverse the underlying cause of their hypoglycemia.
Hyperkalemia can be reversed with insulin, but this will not treat the underlying cause of the hyperkalemia.
Vasopressors such as norepinephrine are not a typical part of the management of acute adrenal crisis.
Key Learning Point
Fluids and glucocorticoid replacement are the mainstays of treatment for an acute adrenal crisis. Glucocorticoid administration is the only definitive therapy for this condition as it targets its underlying pathophysiology.
Dr. Ted O'Connell