🔥 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

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