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Adrenal crisis in secondary adrenal insufficiency — MRCEM SBA MCQ

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HardResuscitation and critical illnessAdrenal crisis in secondary adrenal insufficiencyMRCEM SBA

A 52-year-old woman takes maintenance hydrocortisone for secondary adrenal insufficiency following pituitary surgery. Profuse watery diarrhoea and vomiting began yesterday; she has been unable to retain her hydrocortisone tablets. In the emergency department she is alert, with a blood pressure of 76/44 mmHg and pulse of 122/min despite receiving 250 mL of intravenous 0.9% sodium chloride. Her chest is clear, with no history of cardiac or renal failure. Serum sodium is 124 mmol/L, potassium 4.2 mmol/L and capillary glucose 5.6 mmol/L. Intravenous access and monitoring are established. Which immediate management plan is most appropriate?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Give hydrocortisone 100 mg IV immediately, infuse 1 litre of 0.9% sodium chloride over 30 minutes, and admit for monitoring.

This is suspected adrenal crisis in a patient who cannot absorb her replacement glucocorticoid. Gastrointestinal illness, persistent circulatory shock and hyponatraemia support that assessment. Normal potassium and glucose do not rule it out: neither abnormality is required for NICE’s recommendation to consider adrenal crisis. NICE specifies immediate IV or IM hydrocortisone; for an adult unable to absorb oral glucocorticoids during prolonged vomiting and diarrhoea, the dose is 100 mg. It also specifies 1 litre of IV 0.9% sodium chloride over 30 minutes, admission, and frequent haemodynamic, electrolyte and glucose monitoring. Continued parenteral hydrocortisone and fluids are guided by subsequent stability and oral absorption. ([nice.org.uk](https://www.nice.org.uk/guidance/NG243/chapter/recommendations)) B correctly addresses hypovolaemia but incorrectly makes hydrocortisone depend on another fluid response. C uses oral sick-day treatment when repeated vomiting makes absorption unreliable. D substitutes glucose solution for the specified isotonic resuscitation fluid despite a normal glucose. E prioritises a hypertonic-saline bolus because of the sodium result; she is alert and has no seizure or other neurological deficit attributable to hyponatraemia. Her immediate priorities remain treatment of adrenal crisis and shock, with sodium monitored during resuscitation. ([nice.org.uk](https://www.nice.org.uk/guidance/NG243/chapter/recommendations))

Reference: NICE NG243: Adrenal insufficiency—recommendations (28 August 2024) — https://www.nice.org.uk/guidance/NG243/chapter/recommendations Worcestershire Acute Hospitals NHS Trust: Management of Hyponatraemia in Adult Inpatients, WAHT-GAS-018 (Approved 10 January 2025) — https://apps.worcsacute.nhs.uk/KeyDocumentPortal/Home/DownloadFile/4442