Addisonian crisis

Objectives

Guide the safe management of acute adrenal insufficiency ('Addisonian crisis') on operations

Scope

Management of adrenal insufficiency/ Addisonian crisis

Audience

Clinical decision makers at Roles 1 - 3

Initial Assessment & Management

Presentation and history

Adrenal crisis represents acute adrenal insufficiency, typically precipitated by infection, injury, surgery, or cessation of long-term steroid therapy. In Role 1 environments, it is likely to be indistinguishable from septic shock.  Identification in a role 1 environment will be a consequence of known adrenal insufficiency, or a medical history including long term steroid use; Look for Steroid alert card, medical alert bracelet or necklace with the words 'adrenal insufficiency' or similar.  In a patient with such a history, there should be a very high index of suspicion for adrenal insufficiency, and 100mg hydrocortisone should be administered alongside initial resuscitation. 

Features of a crisis:

IN role 1, treatment will be as for sepsis: 

Advanced Assessment & Management

Features of chronic adrenal insufficiency (Addison’s):

• Fatigue
• Hyperpigmentation of gums, scars, hands
• Gastrointestinal symptoms: N+V, weight loss
• Muscular weakness and cramps
• Postural hypotension
• Headache
• Loss of axillary or pubic hair in women
• Anxiety or depression

Investigation:

• Low Sodium in 75% of patients
• High potassium in 35% of patients
• Hypoglycaemia
• Metabolic acidosis

Management

Immediate fluid replacement with IV 0/9% saline

Immediate IV Hydrocortisone: 100mg 'stat'. 50 - 100 mg 6 hourly until eating and drinking.

At R2/R3 Check initial morning cortisol. Cut-offs vary depending on assay.

• Over 300 nmol/l normal
• <100 nmol/l likely adrenal insufficiency
• 100-300 nmol/l Arrange ACTH stimulation test (SynACTHen 250mcg IM, measure cortisol after 30min)

Prolonged Casualty Care

Maintain adequate hydration

IV or IM hydrocortisone dosing can be continued until oral hydrocortisone becomes available; tablets are not available at the time of writing in the 300, 500, or 370 modules.  If locally available, the patient can be converted to oral hydrocortisone as soon as eating and drinking: 'doubled dose' normally 20mg on waking, 10mg at 2pm. Adjust depending on clinical picture. Maintenance dose normally 10mg on waking and 5mg at 2 pm.

There is scant evidence for continuing IV/IM hydrocortisone beyond 5 days rather than switching to oral tablets.  If situation mandates ongoing intermittent parenteral hydrocortisone dosing, then when stable, eating and drinking, the dose can be reduced to 25mg QDS IM/IV, with ongoing liaison with the physician cadre via Pando and expedited evacuation. 

Paediatric Considerations

Up to date guidance for adrenal insufficiency in children can be found at the following link: https://www.bsped.org.uk/clinical-resources/bsped-adrenal-insufficiency-consensus-guidelines/.

Adrenal crisis in children may present with an acutely unwell child with tachycardia, hypotension, hypoglycaemia, hyponatraemia, hyperkalaemia, or altered consciousness not attributable to another illness.  They should be treated immediately with glucocorticoids and IV fluids as follows: