🔥 Adrenal Crisis: When Cortisol Can't Keep Up
Adrenal crisis—also called acute adrenal insufficiency—is a life-threatening emergency caused by a sudden drop in cortisol levels. It's a must-know for Step 1 and Step 2, especially in patients with Addison’s disease or chronic steroid use.
USMLE Buzzwords: Hypotension + hyponatremia + hyperkalemia + history of steroids = Adrenal crisis
🧬 Pathophysiology
Abrupt drop in cortisol due to:
Primary adrenal failure (Addison’s)
Abrupt steroid withdrawal
Stress (infection, trauma, surgery) in someone with chronic adrenal insufficiency
Cortisol deficiency → ↓ vascular tone, hypoglycemia, electrolyte imbalance
Aldosterone deficiency (in primary AI) → Na⁺ loss, K⁺ retention, hypotension
🩺 Key Signs and Symptoms
| Feature | Description |
|---|---|
| Hypotension | Often refractory to fluids/pressors |
| Abdominal pain | May mimic peritonitis |
| Nausea/Vomiting | Common and early finding |
| Weakness, fatigue | Severe in chronic cases |
| Confusion or coma | Late stage presentation |
| Fever | If infectious trigger present |
| Hyperpigmentation | Suggests chronic Addison’s disease |
🧪 Lab Findings
| Test | Expected Result |
|---|---|
| Sodium | ↓ Hyponatremia |
| Potassium | ↑ Hyperkalemia |
| Glucose | ↓ Hypoglycemia |
| Cortisol | ↓↓↓ |
| ACTH | ↑↑ in primary adrenal insufficiency |
| BUN/Creatinine | Elevated if volume depleted |
🧪 Diagnostic Confirmation
Cosyntropin stimulation test (ACTH stimulation test)
Give synthetic ACTH → measure cortisol at 30 and 60 minutes
No rise in cortisol = adrenal insufficiency
Don't delay treatment if crisis is suspected—treat first!
💊 Emergency Treatment
| Step | Treatment |
|---|---|
| 1 | IV hydrocortisone 100 mg stat, then q6–8h |
| 2 | IV normal saline with 5% dextrose |
| 3 | Correct Na⁺, K⁺, and glucose levels |
| 4 | Treat underlying cause (e.g., infection) |
| 5 | Long-term steroid tapering and stress dosing education |
📚 Sample USMLE Vignette
A 28-year-old with Addison’s disease presents with hypotension, abdominal pain, and vomiting after a flu-like illness. Labs show Na⁺ 127, K⁺ 5.8, glucose 55, and cortisol 2. What’s the next step?
✅ Answer: Administer IV hydrocortisone and fluids immediately
📲 Call to Action
⚡ Cortisol saves lives—don’t forget it on exam day.
📲 Download the King of the Curve App for:
Daily USMLE-style emergencies
Endocrine disorders flashcards
Visual summaries of high-yield conditions
Curve Coins and leaderboard challenges
Frequently Asked Questions (FAQs)
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Aim for 4-6 focused hours, ensuring you incorporate breaks to avoid burnout.
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Practice mindfulness techniques, take practice exams under realistic conditions, and maintain a balanced lifestyle.
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