A patient presents with fever, hypotension, abdominal pain, and hyponatremia; suspected adrenal crisis. What is the initial management?

• A. Immediate IV hydrocortisone, aggressive IV fluids, and endocrine evaluation
• B. IV antibiotics only
• C. Surgery
• D. Oral steroids

Answer: (B)

When a patient with suspected adrenal crisis presents with fever, low blood pressure, abdominal pain, and hyponatremia, the priority is to stabilize circulation and replace deficient cortisol as quickly as possible. This crisis stems from acute glucocorticoid (and often mineralocorticoid) deficiency, which impairs vascular tone and salt and water balance, leading to refractory shock if not treated immediately.

The best initial management is to start aggressive IV isotonic fluid resuscitation to restore perfusion, and give immediate IV hydrocortisone. Hydrocortisone is used because it provides both glucocorticoid and mineralocorticoid activity, helping with vascular responsiveness and electrolyte abnormalities. A typical approach is 100 mg of hydrocortisone IV now, followed by another 50 mg IV every 6 hours or a continuous infusion, while fluids are continued. Do not delay this treatment for laboratory tests; draw relevant labs (cortisol, ACTH, electrolytes, glucose) but treat first. If the patient is hypoglycemic, give dextrose; monitor closely and adjust fluids based on vitals and labs.

Endocrine evaluation should occur in parallel, but it should not hold up initial therapy. If there’s a possibility of infection or septic shock contributing to the picture, broad-spectrum antibiotics are appropriate, but they are adjuncts to the urgent steroid and fluid resuscitation, not substitutes for them. Oral steroids would be inappropriate in this shock state due to impaired absorption and rapid need for high-dose systemic glucocorticoids. Surgery is not indicated unless a separate surgical emergency is identified.

So, the essence is: immediately start IV fluids and IV hydrocortisone, with endocrine assessment started right away.