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Adrenal crisis is a life-threatening emergency caused by acute adrenal insufficiency, characterized by severe hemodynamic instability, electrolyte abnormalities, and altered mental status. It carries high mortality if not recognized and treated promptly with glucocorticoid replacement.
The adrenal cortex produces glucocorticoids (cortisol), mineralocorticoids (aldosterone), and adrenal androgens. In adrenal crisis, deficiency of cortisol impairs vascular tone, gluconeogenesis, and stress response. Mineralocorticoid deficiency (in primary adrenal insufficiency) causes sodium wasting, volume depletion, and hyperkalemia. The most common precipitants are physiologic stress (infection, surgery, trauma) superimposed on pre-existing adrenal insufficiency or sudden glucocorticoid withdrawal.
Clinical reasoning focuses on recognizing the triad of hemodynamic instability (refractory hypotension), hyponatremia with or without hyperkalemia, and an appropriate precipitating stressor. In known adrenal insufficiency, any acute illness is a potential crisis. Treatment must not be delayed for diagnostic confirmation — empiric IV hydrocortisone 100mg is given immediately. Differentials include septic shock, hypovolemic shock, and other causes of electrolyte disturbance. The cosyntropin stimulation test confirms diagnosis in non-emergency settings.