Addisonian crisis

Addisonian crisis

• sepsis or surgery causing an acute exacerbation of chronic insufficiency (e.g. Addison's, hypopituitarism)
• adrenal haemorrhage e.g. Waterhouse-Friderichsen syndrome (fulminant meningococcaemia)
• steroid withdrawal (most common precipitant)
• inadequate 'sick day rule' management or intercurrent illness (commonly gastroenteritis) in patients with underlying Addison's disease

• confusion, syncope, lethargy, convulsions
• hypotension, tachycardia, hypothermia
• hyponatraemia, hyperkalaemia, hypoglycaemia
• abdominal pain or cramps

• hydrocortisone 100 mg IM or IV followed by 200 mg per 24 hours as a continuous infusion or 50 mg IV or IM every 6 hours (taper according to response as the patient becomes stable)
• 1 litre of normal saline infused over 30–60 minutes, then a further 4–6 litres over the first 24 hours if required; include dextrose if hypoglycaemic
• no fludrocortisone is required acutely as high-dose cortisol exerts a weak mineralocorticoid effect
• once stable, convert to oral replacement after approximately 24 hours, reducing to maintenance dosing over 3–4 days
• identify and treat the precipitating cause (e.g. infection)
• educate patients (and carers) about 'sick day rules' and encourage use of steroid alert cards or bracelets to prevent future crises