In suspected primary adrenal crisis, what is the initial emergency management?

• A. Administer urgent IV hydrocortisone and isotonic fluids
• B. Start oral prednisone and diuretics
• C. Administer diuretics alone
• D. Observe without steroids

Answer: (A)

In suspected primary adrenal crisis, the priority is rapid stabilization with fluids and immediate steroid replacement. The body's needing cortisol and volume quickly; giving intravenous hydrocortisone addresses both the severe cortisol deficiency and the accompanying mineralocorticoid deficit that drives hypotension and shock in Addisonian crisis. Start with a bolus of hydrocortisone 100 mg IV, then continue with 50 mg IV every 6 hours (or use a continuous infusion). At the same time, begin isotonic saline, typically with rapid initial fluids to restore perfusion (often 1–2 liters in the first hour), and adjust based on blood pressure and perfusion.

This approach is essential even before lab confirmation, because delaying steroids in adrenal crisis markedly increases mortality risk. After stabilization, continue glucocorticoid replacement and add mineralocorticoid replacement (such as fludrocortisone) as the patient improves, with a plan for transitioning to oral therapy. Monitor glucose and electrolytes, addressing hypoglycemia or electrolyte disturbances as needed.

Choices that rely on oral prednisone, diuretics, or observation without steroids do not address the acute deficient cortisol (and aldosterone) in shock and can worsen the patient’s condition.