Adrenal crisis in ICU — FFICM MCQ

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ModerateRenal and MetabolicAdrenal crisis in ICUFFICM

A 55-year-old woman with known Addison's disease is admitted with pneumonia. She is confused, hypotensive and hyponatraemic with potassium 5.9 mmol/L and glucose 3.1 mmol/L. She has vomited for 2 days and missed her steroid tablets. Blood cultures have been taken. What is the most appropriate management?

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Correct answer: C — Give intravenous hydrocortisone and isotonic fluid immediately

Option C (Give intravenous hydrocortisone and isotonic fluid immediately) is correct. This woman has classic adrenal crisis: known Addison's disease, an intercurrent infective stressor (pneumonia), vomiting causing missed oral steroids, and the biochemical triad of hyponatraemia, hyperkalaemia and hypoglycaemia with hypotension and confusion. UK Society for Endocrinology guidance mandates immediate empirical treatment without waiting for confirmatory tests: 100 mg hydrocortisone IV or IM stat, followed by continuous infusion or 50 mg six hourly, plus rapid rehydration with 0.9% sodium chloride. Steroid replacement here is simultaneously the specific endocrine treatment and the resuscitative measure that corrects the hypotension, hyponatraemia and hyperkalaemia; blood cultures were already taken so antibiotics for pneumonia should follow promptly but do not precede steroids. Why the other options are wrong: B. Wait for cortisol level before steroids: This delays life-saving treatment; a random cortisol or short synacthen test should never postpone hydrocortisone in a suspected crisis, as the patient can deteriorate to cardiovascular collapse or death while awaiting results. E. Give furosemide for hyponatraemia: The hyponatraemia here is due to cortisol and mineralocorticoid deficiency causing sodium loss and volume depletion; furosemide worsens hypovolaemia and hyperkalaemia and is dangerously wrong. A. Restrict fluids and give demeclocycline: This regimen is for SIADH-related euvolaemic hyponatraemia, not the hypovolaemic, hyperkalaemic hyponatraemia of adrenal crisis; fluid restriction would worsen her hypotension. D. Treat with insulin-glucose as sole therapy: This is hyperkalaemia treatment for cardiac stabilisation, not definitive therapy, and it ignores the underlying cortisol deficiency and risks worsening her hypoglycaemia (glucose 3.1 mmol/L). Key point: In suspected adrenal crisis, give hydrocortisone and isotonic fluid immediately and empirically, never delaying treatment to await confirmatory cortisol results.

Reference: Society for Endocrinology, Guidance for the prevention and emergency management of adult patients with adrenal insufficiency (Emergency management of acute adrenal insufficiency), Endocrine Connections 2020; summarised at pmc.ncbi.nlm.nih.gov/articles/PMC7385786/