An Overview of Adrenal Crisis

An adrenal crisis occurs when there is not enough cortisol in the body, and in the case of primary adrenal insufficiency, also not enough aldosterone. It is a life-threatening situation that requires immediate medical attention.

The adrenal glands are located right on top of the kidneys and are responsible for the production of the hormone called cortisol. Cortisol helps to control blood pressure levels and blood sugar levels and is released as part of the body’s stress response.

Symptoms

Some of the symptoms of adrenal crisis are:

• Hypotension (low blood pressure)
• Hypovolemic shock (insufficient blood volume)
• Nausea
• Vomiting
• Hypoglycemia (low blood sugar)
• Abdominal pain
• Weakness
• Confusion
• Coma
• Light-headedness

Causes

In most cases, there is an event to trigger the adrenal crisis. Gastrointestinal illness can trigger an adrenal crisis, and so can—although less commonly—infections, physical stress, surgical stress, emotional stress, dehydration, and accidents.

Primary Adrenal Insufficiency

Also known as Addison’s disease, this is a condition where there is an insufficiency of cortisol in the body caused by problems with the adrenal glands themselves. There is also often an insufficiency of aldosterone- a mineralocorticoid hormone that helps balance sodium and potassium in the body to control blood pressure. As a result, the absence of aldosterone can lead to hypotension, hyponatremia, and hyperkalemia seen in primary adrenal crisis. There are many conditions that can cause primary adrenal insufficiency, including:

• Autoimmune adrenalitis: the most common cause of primary adrenal insufficiency. In it, the immune system attacks and gradually destroys the adrenal glands.
• Infections like tuberculosis, AIDS, and fungal infections
• Cancer that has spread from other parts of the body to the adrenal glands
• Bilateral adrenalectomy: a surgery where both adrenal glands are removed
• Congenital adrenal hyperplasia: a condition a person has from birth where the adrenal glands’ ability to make hormones is limited
• Adrenomyeloneuropathy: An inherited neurological disorder that has adrenal insufficiency as one of its common symptoms.

Secondary Adrenal Insufficiency

In this condition, there is inadequate cortisol in the body, too, but it is caused by a problem with the pituitary gland instead. The pituitary gland normally produces the adrenocorticotropic hormone (ACTH), which then triggers the adrenal glands to release cortisol. Aldosterone levels are typically not affected. Secondary adrenal insufficiency can be caused by a number of conditions:

• Pituitary tumor: an abnormal growth of cells in the pituitary gland
• Sheehan’s syndrome: a condition where the pituitary gland is damaged due to severe blood loss during childbirth
• Traumatic head injury: can damage the pituitary gland, which is located in the brain
• Drugs: including high-dose progestins and opioids
• Autoimmune diseases: such as thyroid disease or diabetes 
  

However, with both kinds of adrenal insufficiency, the chances of adrenal crisis are higher if the condition has gone undiagnosed or is not managed/treated properly.

Discontinuation of Glucocorticoid Medicines

If you’ve been using glucocorticoid medication for a long period of time and you suddenly discontinue using it, you are at risk of having an adrenal crisis as well.

Adrenal Hemorrhage

This is a rare occurrence in which one or both of the adrenal glands hemorrhage (bleed out). How exactly it happens is currently unknown, but the medical hypothesis links it to the adrenal glands reacting to stress caused by conditions and situations like sepsis, burns, trauma, and the use of anticoagulants.

There are two types of adrenal hemorrhage: unilateral adrenal hemorrhage (affecting just one adrenal gland) and bilateral adrenal hemorrhage (affecting both glands). Only bilateral adrenal hemorrhage leads to an adrenal crisis.

Diagnosis

Diagnosing adrenal crisis is usually very difficult as it shares symptoms with many other conditions like sepsis and cardiogenic shock. This difficulty is also worsened by the fact that this is a life-threatening state, and any delay in treatment could be fatal. When an adrenal crisis is suspected, treatment is often given before confirming the diagnosis with testing.

Some of the tests used to diagnose adrenal crisis are:

• ACTH stimulation test: This test measures the adrenal glands’ response to stimulation by ACTH. It checks to see if the adrenal glands will respond appropriately to ACTH by releasing cortisol. It first measures the cortisol levels in the blood, then it gives an injection of ACTH and re-checks the blood cortisol levels.
• Other blood tests to check the blood sugar levels, cortisol levels, potassium levels, and sodium levels may also be performed.

Diagnosing adrenal crisis during pregnancy is complicated because of the many changes—hormonal and otherwise—that occur. Usually, a healthcare provider will diagnose a pregnant woman with an adrenal crisis when their symptoms are extreme or are accompanied by low blood sugar, salt cravings, or low blood sodium levels.

Treatment

High doses of hydrocortisone (a corticosteroid) are the main treatment for adrenal crisis. The administration of hydrocortisone can either be intravenous (through a vein) or intramuscular (through a muscle).

Intravenous fluids (IVF) are also given to help with dehydration and low blood pressure.

After the crisis is under control, treatment for the underlying infection or condition that triggered the adrenal crisis (if any) will be started.

Coping

If you have been diagnosed with adrenal insufficiency or have had an adrenal crisis in the past, you should always wear or carry a medical card or tag that says you have adrenal insufficiency. It is especially useful in ensuring that you get the right treatment if you experience an adrenal crisis.

For example, if you are unconscious during an emergency in which you are brought to the hospital without a card or tag, valuable time will be wasted trying to diagnose you or even trying to treat you for another condition with similar symptoms.

As instructed by your healthcare provider, you may need to be prepared to increase your intake of glucocorticoids or receive an emergency shot when you’re in situations of high stress—whether it’s physical or emotional.

More Tips

It’s a good idea to keep in mind the following tips if you are at risk of adrenal crises:

• Always have your glucocorticoid (usually hydrocortisone) on you at all times.
• Ask your healthcare provider to show you the proper technique for intramuscular injection of your glucocorticoids.
• If it is your child who has adrenal insufficiency or has previously suffered an adrenal crisis, ensure that their teachers, as well as the school administrator, are aware of this in case of emergencies.
• If possible, confirm that the school nurse is able to properly administer shots of glucocorticoids should it become necessary.

A Word From Verywell

Adrenal crisis is a life-threatening and potential occurrence. If you have any form of adrenal insufficiency, you should make sure that you and the people around you are adequately prepared for its possible occurrence. Preparedness during these situations is key in managing any emergencies that may arise. In addition, your readiness can help you rest assured that you are maintaining your health in the best way possible.