Adrenal Crisis

Adrenal crisis (acute adrenal insufficiency) is a life-threatening emergency requiring immediate recognition and treatment by the NP. It occurs when cortisol demand exceeds supply -- most commonly in patients with known primary adrenal insufficiency (Addison disease) or chronic secondary insufficiency (from exogenous glucocorticoid suppression of the hypothalamic-pituitary-adrenal axis) who experience physiological stress (infection, surgery, trauma) without adequate stress-dose glucocorticoid coverage. Pathophysiology: cortisol deficiency causes loss of vascular tone (cortisol permissive effect on catecholamine sensitivity), impaired gluconeogenesis causing hypoglycemia, reduced cardiac contractility, and sodium wasting with potassium retention (in primary AI -- aldosterone is also deficient). In secondary AI, aldosterone production is preserved (RAAS-mediated, not ACTH-dependent). Clinical presentation: severe hypotension refractory to fluid resuscitation (hallmark), altered mental status, nausea/vomiting/abdominal pain mimicking acute abdomen, fever, hypoglycemia, and hyponatremia. In primary AI, hyperpigmentation (ACTH-driven melanocyte stimulation) and hyperkalemia may be present. The clinician initiates immediate treatment: IV hydrocortisone 100 mg bolus (provides both glucocorticoid and mineralocorticoid activity at stress doses), then 50 mg IV every 6-8 hours; aggressive IV normal saline resuscitation (2-3 L in first hours); dextrose for hypoglycemia; identification and treatment...