Management of Children with an Adrenal Crisis

The following guidelines are generally applicable. Individual situations may require deviation from these guidelines.

DIAGNOSIS

1. Signs and symptoms of Adrenal Crisis:

   • weakness

   • fever

   • abdominal pain

   • hypotension

   • dehydration

   • hypoglycemia

   • seizure

   • shock
      

2. Patient may have a history of adrenal insufficiency or exogenous glucocorticoid use
   
   Note: MEGACE® suppresses hypothalamic-pituitary-adrenal axis and adrenal crisis can occur shortly after discontinuation of MEGACE®.
    

3. Undiagnosed primary adrenal insufficiency causes chronic fatigue, weakness, abdominal pain, anorexia, weight loss, vomiting, diarrhea, salt craving, skin pigmentation
    

4. Other autoimmune conditions may be a clue to the presence of Addison disease
    

5. Undiagnosed ACTH deficiency may be associated with headache, visual changes, seizures, focal neurological signs
    

6. Laboratory Evaluation drawn BEFORE administering exogenous steroids
    

7. DO NOT wait for results to come back to start treatment if you suspect Adrenal Crisis

• STAT labs for diagnosis-serum electrolytes and glucose, urine
  electrolytes
• Check creatinine, BUN, Urinalysis, CBC with diff to assist with management
• Draw 5-10 mL extra clotted blood in case you want to measure steroid concentrations
• ACTH levels require pre-chilled purple top tube sent immediately to lab

Table 1. STAT Lab Results Supporting Diagnosis of Adrenal Insufficiency

Consult attending physician/endocrinologist for appropriate diagnostic tests if patient not known to have a condition that causes adrenal insufficiency (See Table 2 below)

Table 2 – Endocrine Lab Assessment of Adrenal Insufficiency

8. Further specific diagnostic testing is required to establish exact cause of adrenal insufficiency

TREATMENT OF ADRENAL CRISIS

1. Assure airway and breathing are adequate
    
2. Patient will virtually always have significant volume contraction

• Cardiac monitor
• Replace fluid loss
  • Isotonic crystalloid with added dextrose
  • 20 mL/kg rapid infusion
• May need to repeat bolus

3. Give IV glucocorticoid – if possible, AFTER diagnostic blood tests drawn (Table 1 above)

Table 3.  IV Steroid Treatment for Adrenal Crisis

4. Ongoing Care

   • Admit to PICU

   • Close monitoring of hydration and blood glucose

   • Check electrolytes q2-4 h depending on degree of illness

   • Replace 50% of fluid deficit in first 8 hours, using 0.9% saline with 5% glucose

   • Replace remaining fluid deficit over 8-24 hours

   • Add potassium to IV as allowed by serum K+ level

   • Diagnose cause of adrenal insufficiency (See Table 4)

   • Taper glucocorticoid to physiological dose over 1-3 days as patient condition allows

   • Begin oral fludrocortisone (0.1 mg once daily) if mineralocorticoid deficiency present

   • Prescribe injectable (IM) steroid for home emergency use (e.g. Hydrocortisone)

   • Advise patient to wear medical ID indicating “adrenal insufficiency.”

Table 4. Features of Adrenocortical Failure Caused by Adrenal or CNS Disease

Copyright 2002
Medical College of Georgia
All rights reserved.

Pediatric Endocrinology
Department of Pediatrics | Medical College of Georgia
Please email comments, suggestions or questions to:
Andrew Muir, M.D., amuir@mcg.edu

February 27, 2004