Addisonian Crisis: A Junior Doctor’s Guide

·     Introduction

An Addisonian crisis, also known as an acute adrenal insufficiency, is a life-threatening emergency that results from an insufficient production of cortisol and, often, aldosterone. This can occur in patients with known adrenal insufficiency or as the first presentation of Addison’s disease. The prompt recognition and management of this condition are crucial to prevent severe complications, including shock and multi-organ failure.

·     History Taking in Addisonian Crisis

When assessing a patient in potential Addisonian crisis, the history will guide you toward recognizing the underlying adrenal insufficiency and identifying precipitating factors.

·     Key Questions to Ask:

·     Symptoms of the Crisis:

·      "Have you felt extremely weak or fatigued recently?" (generalized weakness, lethargy)

·      "Are you experiencing any dizziness or fainting spells?" (hypotension)

·      "Have you been vomiting, feeling nauseous, or had diarrhea?" (gastrointestinal symptoms common in adrenal crises)

·      "Do you have any abdominal pain?" (diffuse abdominal pain is common)

·      Pre-existing Conditions:

·      "Do you have Addison’s disease or adrenal insufficiency?" (history of adrenal insufficiency)

·      "Are you taking steroid medications, such as hydrocortisone?" (steroid use and recent dose changes may indicate secondary adrenal insufficiency)

·      "Have you recently stopped taking your steroid medication?" (abrupt cessation of steroids is a common precipitant)

·     Precipitating Events:

·      "Have you had any recent infections, surgeries, or significant illnesses?" (stressors like infections can trigger a crisis in patients with adrenal insufficiency)

·      "Have you been under more stress than usual?" (physical or emotional stress can precipitate a crisis)

·     Hydration and Electrolytes:

·      "Have you noticed a reduced appetite or been unable to keep fluids down?" (this could worsen electrolyte imbalances and dehydration)

·      "Have you been urinating more or less than usual?" (aldosterone deficiency leads to dehydration and hypotension)

·     Examination Findings

Physical examination in Addisonian crisis may reveal signs of adrenal insufficiency and the resulting hypovolemia, hypotension, and electrolyte imbalance.

·      Key Examination Findings:

• General Appearance:

·      The patient may appear lethargic or confused (due to hypoglycemia or hypotension).

·      Look for signs of shock, such as cold, clammy skin.

• Vital Signs:

·      Hypotension: A hallmark of Addisonian crisis, especially postural hypotension.

·      Tachycardia: A compensatory mechanism for hypotension.

·      Fever: May indicate an underlying infection or sepsis as a trigger.

·      Dehydration:

• Dry mucous membranes and reduced skin turgor suggest dehydration secondary to aldosterone deficiency.

• Hyperpigmentation:

·      Chronic adrenal insufficiency can cause hyperpigmentation, especially in the creases of the palms, elbows, and around scars.

·      This is due to increased production of melanocyte-stimulating hormone (MSH) as part of the feedback mechanism from low cortisol levels.

·     Abdominal Examination:

·      Tenderness may be present, but typically without peritonism. Diffuse pain is often reported in Addisonian crisis.

·     Investigations

A quick and thorough workup is essential to confirm the diagnosis and guide treatment in an Addisonian crisis.

·     Key Investigations:

·     Bedside Tests:

·      Blood glucose: Hypoglycemia is common and can be severe due to cortisol deficiency.

·      ECG: Look for signs of hyperkalemia (peaked T waves, prolonged PR interval), which can result from aldosterone deficiency.

·     Blood Tests:

·      Serum electrolytes: Look for hyponatremia (low sodium) and hyperkalemia (high potassium), which are hallmark findings.

·      Cortisol levels: Low serum cortisol confirms adrenal insufficiency, but results may take time.

·      ACTH: In primary adrenal insufficiency, ACTH will be elevated.

·      Urea and creatinine: To assess dehydration and renal function.

·      FBC: May show anemia, which is often normocytic in Addison's disease.

·     Imaging:

·      Chest X-ray or CT scan: Only if infection or other precipitating causes (e.g., malignancy) are suspected.

·     Adrenal Function Tests:

·      ACTH stimulation test: If feasible, this can help confirm adrenal insufficiency, but treatment should not be delayed while waiting for results.

·     Management Plan

An Addisonian crisis is a medical emergency requiring prompt intervention to restore cortisol levels, correct electrolyte imbalances, and address underlying triggers.

·     Immediate Management:

• Hydrocortisone Replacement:

• Give 100 mg of IV hydrocortisone stat, followed by 50 mg IV every 6 hoursor continuous infusion of 200 mg/day.

• Switch to oral hydrocortisone (20 mg in the morning, 10 mg in the afternoon) once the patient is stabilized.

• Fluid Resuscitation:

• Administer 1-2 liters of IV 0.9% saline.