Immediate treatment for suspected adrenal crisis in known adrenal insufficiency?

• A. IV hydrocortisone 100 mg bolus followed by 50 mg IV every 6 hours, aggressive IV fluids, and correction of electrolytes
• B. Oral hydrocortisone and observation
• C. Diuretics and electrolyte restriction
• D. Vasopressors only

Answer: (A)

Immediate adrenal crisis is a medical emergency where there is a sudden, life-threatening deficiency of cortisol and often aldosterone. The fastest way to correct this is to replace the missing cortisol with intravenous hydrocortisone and to treat the severe volume depletion and electrolyte disturbances with aggressive IV fluids.

Hydrocortisone is given IV as a large stress-dose right away—typically a 100 mg bolus, followed by 50 mg IV every 6 hours (or an equivalent continuous infusion). This provides both glucocorticoid and some mineralocorticoid activity, which helps restore vascular tone, improve blood pressure, and correct electrolyte abnormalities. After the patient stabilizes, you taper to oral hydrocortisone for maintenance.

Simultaneously, aggressive isotonic saline is started to rapidly expand intravascular volume and correct hypotension and dehydration. Fluids and electrolytes (sodium and potassium) are monitored and corrected as needed, and glucose should be checked with treatment provided for hypoglycemia if present.

Why not other approaches? Oral hydrocortisone cannot rapidly substitute during a crisis when the patient may be unable to absorb medications or is in shock; relying on diuretics would worsen dehydration and electrolyte imbalance; vasopressors alone address blood pressure transiently but do not replace the essential cortisol deficiency that underlies the crisis.