1.  Sudden penetrating pain in the legs, lower back or
abdomen
 Severe vomiting and diarrhea, resulting in dehydration
 Low blood pressure, Unexplained shock, usually refractory
to fluid and pressor resuscitation
 Syncope (loss of consciousness)
 Hypoglycemia
 Confusion, psychosis, slurred speech
 Severe lethargy
 Hypercalcemia
 Convulsions
 Fever
 Rapid withdrawal of long-term steroid therapy
 Hyperthermia or hypothermia

2.  Meningococcemia & Organisms associated with adrenal crisis e.g
Haemophilus influenzae, Staphylococcus aureus,Streptococcus
pneumonia, fungi
 Severe physiologic stress
 Azotemia
 Anticoagulants, hemorrhagic diathesis
 Adrenocorticotropin therapy, known primary or secondary
adrenocortical insufficiency
 AIDS
 Invasive or infiltrative disorders
 Tuberculosis
 Prior steroid use
 Topical steroids : large surface, long periods of use
 Inhaled steroids : > 8 mg/dl for long time, Fluticasone even at
lower dose

3.  Serum cortisol: <20 mcg/dL in severe stress
or after ACTH stimulation is indicative of
adrenal insufficiency
 ACTH test : diagnostic
 Serum chemistry, ↓Na, ↑K, metabolic
acidosis, Hypoglycemia
 CBC: Anemia, lymphocytosis, and
eosinophilia (highly suggestive)
 Cultures, Infection is a common cause of
acute adrenal crisis.

4.  Chest radiography: Assess for tuberculosis,
histoplasmosis, malignant disease, sarcoid,
and lymphoma.
 Abdominal CT scanning: Visualize adrenal
glands for hemorrhage, atrophy, infiltrative
disorders, and metastatic disease.
 Electrocardiography

5.  Primary adrenocortical failure : evidence of
infection, infiltrative disease.
 Secondary adrenocortical insufficiency:
atrophy of the adrenals or no histologic
evidence at all, especially if due to exogenous
steroid ingestion.
 Appearance of bilateral adrenal hemorrhage
may be striking, as if bags of blood are
replacing the glands.

6.  During an addisonian crisis, low blood pressure, low blood glucose,
and high levels of potassium can occur. Specific addisonian crisis
treatment for these symptoms involves intravenous (IV) injections
of:
 Hydrocortisone
 Saline
 Dextrose
 These addisonian crisis treatments usually bring rapid
improvement.
 When the patient can take fluids and medications by mouth, the
amount of hydrocortisone is decreased until a maintenance dose
is achieved. If aldosterone is deficient, maintenance therapy also
includes oral doses of fludrocortisone acetate.

7.  Dexamethasone : Used as empiric treatment of
shock in suspected adrenal crisis or insufficiency
until serum cortisol levels are drawn.
 Hydrocortisone :DOC because of
mineralocorticoid activity and glucocorticoid
effects
 Fludrocortisone (Florinef) : mineralocorticoids, .
Produces marked sodium retention and
increased urinary potassium excretion.
 Methylprednisolone : 3rd Line, of lack of
mineralocorticoid activity, in patients with fluid
overload, edema, or hypokalemia

8.  Endocrinologist
 Infectious disease specialist
 Critical care physician
 Surgeon
 Corticosteroids & IV fluids are the mainstays
of treatment. Other medications, such as
pressors (eg, dopamine, norepinephrine) or
antibiotics, are administered as clinically
indicated.