What Are the Signs of an Adrenal Crisis?

The adrenal glands are located just above the kidneys and are divided into two sections:

• The cortex or outer section produces cortisol
• The medulla or inner part produces the hormone adrenaline or epinephrine

In reaction to stress, both cortisol and adrenaline are released. The pituitary gland regulates cortisol production. Adrenocorticotropic hormone is produced by the pituitary gland (ACTH). This hormone stimulates the adrenal glands to produce cortisol.

An adrenal crisis occurs when the following happens:

• Damage to or disease of the adrenal gland (can occur as a result of Addison's disease or another adrenal gland disease, as well as surgery)
• Inability to produce ACTH due to pituitary gland conditions
• Untreated adrenal insufficiency

Adrenal crisis can be caused by either chronic adrenal insufficiency plus a trigger or acute adrenal insufficiency alone.

Adrenal crisis is almost always precipitated by some form of stress, physical, traumatic, anesthetic, or emotional stress. However, an infection can trigger an adrenal crisis even if it appears to be a simple viral infection. Medications can also act as triggers.

Causes of adrenal crisis may include:

• Stopping long-term use of corticosteroid medicine too quickly
• Sepsis (infection in the blood)
• Stress from surgery
• Major illnesses, such as a heart attack
• Trauma to the adrenal glands
• Surgery to remove adrenal glands
• Damage to the pituitary gland
• Therapy to replace the thyroid hormone (especially in people with preexisting adrenal insufficiency)

Risk factors of adrenal crisis may include:

• Septic shock
• Addison disease
• Taking steroids for a long time
• Taking blood thinners
• Tuberculosis or related diseases
• Immune system diseases
• HIV

An adrenal crisis is a life-threatening medical emergency with a high mortality rate unless treated promptly. In an adrenal crisis, the drug hydrocortisone must be administered immediately intravenously (IV). If low blood pressure is diagnosed, IV fluids are administered as well. If the crisis was caused by an infection or another medical problem, additional treatment may be necessary.

Common treatment options for adrenal crisis may include:

• Treatment of triggers
  • Obtaining cultures to identify the microorganism before beginning empiric antibiotics in people with a possible infection
  • IV fluids
• Steroids
  • IV hydrocortisone
  • IV dexamethasone
• Resuscitation
  • Volume resuscitation may be provided based on the hemodynamic assessment
  • Vasopressors may be used early with subsequent weaning based on clinical parameters
  • If needed, hypoglycemia is treated with IV glucose

Adrenaline crisis should typically improve quickly with aggressive resuscitation and steroid administration.

Being proactive and well-informed is the best way to prevent adrenal crisis:

• Do not suddenly stop taking steroids 
  • Although steroid side effects can be substantial, you should not discontinue taking steroids abruptly without consulting your doctor if adverse symptoms arise.
  • Several approaches can help you manage the adverse effects of steroids, including adjusting type, dose, and schedule.
  • During the corticosteroid withdrawal and for one year after the taper, keep an eye out for signs of adrenal crisis.
• Do not miss daily steroid doses for more than 24 hours
  • Missing daily steroid dosages for more than 24 hours might potentially result in an adrenal crisis.
  • Consult your doctor if you missed your steroid dose for over 24 hours.
• Be aware of when stress doses should be administered
  • Be aware of the appropriate amount of steroid dose to take on “sick days.”
  • To avoid a life-threatening adrenal crisis, you must communicate this critical information with your doctor during times of severe sickness, surgery, or trauma.

If left untreated, adrenal fatigue can cause hormones produced by your adrenal glands to gradually decline. Symptoms progressively worsen and eventually, results in an adrenal crisis, which can result in a coma, long-term disability, and death. 

Even though it has been treatable for almost 70 years, inadequate preventative measures or postponed treatment frequently result in deaths. 

Early glucocorticoid administration can save lives, with the positive effects getting apparent 24 hours after starting therapy. Dehydration, electrolyte imbalances, and cortisol deficiency of an adrenal crisis can be quickly treated with vigorous saline infusions and stress doses of hydrocortisone.