| Emergency measures |
- Establish intravenous access with a large-gauge needle.
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- Draw blood for immediate serum electrolytes and glucose and routine measurement of plasma cortisol and ACTH. Do not wait for laboratory results.
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- Infuse 2 to 3 liters of isotonic saline or 5% dextrose in isotonic saline as quickly as possible. Frequent hemodynamic monitoring and measurement of serum electrolytes should be performed to avoid iatrogenic fluid overload.
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- Give hydrocortisone (100 mg intravenous bolus), followed by 50 mg intravenously every 6 hours (or 200 mg/24 hours as a continuous intravenous infusion for the first 24 hours). If hydrocortisone is unavailable, alternatives include methylprednisolone and dexamethasone. Saline must be administered if dexamethasone is given instead of hydrocortisone.
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- Use supportive measures as needed.*
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| Subacute measures after stabilization of the patient |
- Continue intravenous isotonic saline at a slower rate for next 24 to 48 hours.
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- Search for and treat possible infectious precipitating causes of the adrenal crisis.
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- Perform a short ACTH stimulation test to confirm the diagnosis of adrenal insufficiency, if patient does not have known adrenal insufficiency.
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- Determine the type of adrenal insufficiency and its cause if not already known.
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- Taper parenteral glucocorticoid over 1 to 3 days, if precipitating or complicating illness permits, to oral glucocorticoid maintenance dose.
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- For patients with primary adrenal insufficiency, begin mineralocorticoid replacement with fludrocortisone, 0.1 mg by mouth daily, when saline infusion is stopped.
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