Acute Adrenal Crisis

• The role of glucocorticoids and mineralocorticoids must be understood in an effort to be knowledgeable about the effects they have on an acute adrenal crisis.
• Several factors may cause an acute adrenal crisis and are essential to discovering an accurate diagnosis.
• How to educate patients on the severity of acute adrenal crisis and how to mitigate risk.

An acute adrenal crisis is a life-threatening endocrine emergency that occurs because of the lack of glucocorticoids (primarily cortisol) or mineralocorticoids (mainly aldosterone) in the body.  The process of diagnosing it accurately can be difficult because many of its signs and symptoms are nonspecific. 

Acute adrenal crisis is a rare condition that seldom occurs if there is no injury or serious illness.  If the patient does not get treatment for acute adrenal insufficiency promptly, the prognosis for survival is low, and waiting for lab results can also threaten the patient’s life.

Role of Glucocorticoids and Mineralocorticoids

Glucocorticoids are cardiac stimulants and they help activate the release of essential vasoactive substances.  Corticosteroids are produced when the body is under stress.  Without corticosteroids, stress can cause hypotension, shock, and eventually death.

Cortisol can have serious systemic side effects such as a decrease in vascular tone and reduced effects of catecholamine such as epinephrine and norepinephrine.  Both of these effects can lead to adrenal crisis and shock.  Cortisol deficiency can result in metabolic abnormalities such as decreases in the following:

• glucose production
• protein and fat metabolism
• appetite and digestion

A type of mineralocorticoid known as aldosterone is triggered by the release of angiotensin II.  Angiotensin II triggers the adrenal glands to release aldosterone and also triggers the pituitary gland to release a hormone known as the antidiuretic hormone (ADH).  Aldosterone deficiency can result in the following:

• profound fluid and electrolyte imbalances
• a decrease in sodium and water retention and circulating blood volume
• an increase in both potassium and hydrogen ion reabsorption

Factors Associated with Acute Adrenal Crisis

The most common cause of an adrenal crisis is due to the acute withdrawal of long-term and high-dose corticosteroid therapy.  In these scenarios, it is best to taper the medication in order for one’s body to adapt to the changes gradually.

It is important to be cognizant that when the signs and symptoms of an adrenal crisis occur, typically 90% or more of the adrenal cortex is damaged.  Other factors can be due to the immune destruction of the adrenal cortex, adrenal hemorrhage, or from infiltration by metastatic carcinoma.

Other causes for an acute adrenal crisis include the following:

• Surgery
• Infection
• Burns
• Sepsis
• Anesthesia
• Fluid volume loss
• Trauma
• Asthma
• Hypothermia
• Alcohol abuse
• Myocardial infarction
• Fever
• Hypoglycemia
• Pain
• Depression

Nursing Process and Pharmacological Treatment

The nurse has a vital role to play in effectively completing an accurate history and assessment in order for proper treatment and testing to be initiated.  Patient teaching is imperative for both the patient undergoing an acute adrenal crisis and the patient’s family or caregiver(s).

Obtaining a History

It is important for the nurse to be mindful of the following while taking a history of the patient having signs and symptoms of adrenal crisis:

• Obtain a complete medication history with particular attention to medications such as corticosteroids, phenytoin, barbiturates, anticoagulants, and rifampin.
• Elicit a complete disease history including cancer, autoimmune diseases requiring treatment with corticosteroids, or any type of radiation that was performed to the head or abdomen.
• Note any family history of Addison’s disease or any other autoimmune diseases.
• Ask the patient if they has any symptoms, such as a recent decrease in appetite, abdominal pain, weight loss, or salt craving. Often in crisis, the patient has nausea, vomiting, and fever.  Rule out if the patient has experienced generalized fatigue, apathy, dizziness, weakness, headache, or changes in skin pigmentation.  Some patients complain about central nervous system effects, such as confusion, irritability, psychoses, emotional lability, or seizures.  Women may also complain of decreased libido and amenorrhea.

Physical Examination

• When a patient with an adrenal crisis presents, they may be critically ill with unexplained shock. Decreased water reabsorption can cause decreased fluid volume which can lead to hypotension and other symptoms such as tachycardia, cool and clammy skin, weak and rapid pulses, and decreased cardiac output.
• Peripheral pulses may be weak and the urine output is usually decreased.
• A decrease in catecholamine due to an adrenal crisis causes a decrease in vascular tone which makes it difficult to maintain blood pressure.
• Other presenting symptoms can be nausea, vomiting, flank pain, and hypothermia. Decreased levels of androgens can also cause a loss of pubic hair.

Pharmacological Treatment

• The pharmacological treatment for adrenal crisis aims to replace the lost fluid and electrolytes, along with hormone supplements.
• In order to correct hypovolemia and hypoglycemia, fluid replacement with dextrose and sodium-containing solutions are given.
• In an effort to replace fluid volume deficit and to maintain blood pressure, circulation, and adequate urine output, as much as 5 liters of fluid may be needed.
• Sodium, potassium, calcium, and glucose abnormalities may need to be corrected and the underlying cause that caused the adrenal crisis needs to be identified.
• The commonly used medications in adrenal crises are 4 mg IV dexamethasone and hydrocortisone sodium succinate 100 mg IV given every 6 to 8 hours.

Diagnostic Tests

The diagnostic tests ordered for a patient with an adrenal crisis include the following:

• Serum cortisol levels
• Serum electrolytes and chemistries
• ACTH stimulation test

Other less common tests include the following:

• Blood culture
• Computed tomography of the abdomen
• Complete blood count
• Skull X-Rays
• Pituitary and adrenal imaging

Patient Education

The following is important for the nurse to educate with the patient:

• The priority is maintaining the airway, breathing, and circulation.
• Patients receiving large amounts of fluids at room temperature are at risk of hypothermia; therefore, keep the room temperature warm and the bed linens dry. Also, it is important to keep the patient fully covered. If massive fluid replacement is needed, administer warmed fluids (at body temperature).
• Teach the patient about corticosteroids and the importance of tapering them before discontinuation.
• Explain the symptoms of adrenal crisis to any patient taking anticoagulants.
• Explain the effects of stress related to the disease and the need for adjustment of medications during times of stress.
• Patients with altered tissue perfusion require a skincare routine. For an immobile patient, perform active and passive range-of-motion exercises at least every 8 hours.
• Encourage coughing and deep breathing to limit complications from immobility.
• Provide the patient with small and frequent meals. Refer the patient to a dietician for a customized diet plan.

The Bottom Line

The presence of an adrenal crisis needs to be treated promptly.  If a nurse or family member suspects a patient is experiencing a crisis, it is imperative to treat the patient as soon as possible.  An acute adrenal crisis is dangerous and can become life threatening if not treated in a timely manner. 

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