Adrenal Crisis

Overview

An adrenal crisis, also called acute adrenal insufficiency, is a medical emergency that happens when the body suddenly lacks enough cortisol. Cortisol is a hormone made by the adrenal glands that helps the body manage stress, maintain blood pressure, and regulate blood sugar and salt balance. Without enough of it, the body cannot cope with the demands of illness or injury.

An adrenal crisis is life-threatening and needs emergency treatment with steroid medication. It usually occurs in people who already have adrenal insufficiency, such as Addison's disease, or who take long-term steroid medication. Recognizing the warning signs and acting fast can save a life.

Symptoms

An adrenal crisis can develop quickly. Warning signs include:

• Severe weakness and extreme fatigue
• Severe vomiting and diarrhea, leading to dehydration
• Severe abdominal, lower back, or leg pain
• Very low blood pressure, causing dizziness or fainting
• Confusion or reduced alertness
• Rapid heart rate
• Loss of consciousness

These symptoms may follow a period of worsening tiredness, nausea, and loss of appetite. If someone with known adrenal insufficiency becomes very unwell, collapses, or cannot keep down their steroid medication, treat it as an emergency and call for help immediately.

Causes

An adrenal crisis occurs when the demand for cortisol outstrips the body's supply. Common triggers include:

• Physical stress: Infection, fever, injury, surgery, or another illness in someone with adrenal insufficiency, whose body cannot raise cortisol as needed.
• Missed or insufficient steroid doses: Stopping or skipping steroid replacement medication, or not increasing the dose during illness.
• Stopping long-term steroids suddenly: The adrenal glands may be unable to restart cortisol production quickly.
• Sudden adrenal damage: Rarely, bleeding into the adrenal glands or severe infection.

Risk Factors

• Known adrenal insufficiency, such as Addison's disease
• Long-term use of steroid (corticosteroid) medication
• Recently stopping steroids suddenly
• An infection, illness, injury, or surgery
• Severe vomiting or diarrhea that prevents keeping medication down
• Not increasing steroid doses during illness as advised

Diagnosis

Because an adrenal crisis is life-threatening, treatment is started immediately when it is suspected, often before tests are complete. Evaluation includes:

• Clinical assessment: Recognizing the combination of low blood pressure, vomiting, weakness, and a history of adrenal insufficiency or steroid use.
• Blood tests: Checking cortisol, sodium, potassium, blood sugar, and other levels.
• Identifying the trigger: Looking for an infection or other illness that set off the crisis.

Anyone with adrenal insufficiency should carry medical identification so emergency staff know to treat for adrenal crisis quickly.

Treatment

An adrenal crisis is treated as an emergency with rapid replacement of cortisol and fluids.

• Emergency steroids: An injection of hydrocortisone (a steroid) is given right away to replace the missing cortisol.
• Intravenous fluids: Fluids, often with salt and sugar, restore blood pressure and correct dehydration and chemical imbalances.
• Treating the trigger: Any infection or underlying illness is treated.
• Monitoring: Close observation in hospital until the person is stable.

People at risk are often prescribed an emergency hydrocortisone injection kit and taught, along with their family, how and when to use it before help arrives.

Prevention

For people with adrenal insufficiency, an adrenal crisis can often be prevented:

• Never stop steroid replacement medication suddenly
• Increase the steroid dose during illness, fever, injury, or surgery as your doctor has advised (so-called sick-day rules)
• Carry an emergency injection kit and know how to use it
• Wear medical identification stating you have adrenal insufficiency
• Seek medical care early when ill, especially with vomiting that prevents keeping medication down

When to Get Emergency Help

Call emergency services immediately if you or someone with adrenal insufficiency develops:

• Severe vomiting or diarrhea and cannot keep medication down
• Extreme weakness, confusion, or collapse
• Dizziness or fainting from very low blood pressure
• Loss of consciousness

If an emergency hydrocortisone injection kit is available, use it as instructed while waiting for help. Tell responders the person has adrenal insufficiency so they can treat the crisis without delay.

Related Topics

Frequently Asked Questions

References

1. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Adrenal Insufficiency & Addison's Disease.
2. Mayo Clinic. Addison's disease — Symptoms and causes.
3. MedlinePlus, U.S. National Library of Medicine. Acute adrenal crisis.
4. Endocrine Society. Adrenal Insufficiency.