Internal medicine: Management of Addisonian crisis

Management of Addisonian crisis

In stress situations, the organism of an (untreated) Addison patient may no longer function properly due to an insufficient production of glucocorticoids and mineralocorticoids. This can lead to sudden collapse and shock, creating at addisonian crisis – an acute, life-threatening emergency.

Frequent causes of an addisonian crisis:

• The above-mentioned stress situations are frequently triggers
• Undiagnosed hypoadrenocorticism ("the great pretender")
• Atypical hypoadrenocorticism – sudden, undetected electrolyte imbalances from onset of aldosterone deficiency
• Iatrogenesis in the course of treatment for Cushing's disease
• Failure to taper off long-term glucocorticoid treatment (abrupt discontinuation)

How is an addisonian crisis expressed?

• Generalised severe weakness to collapse of the patience (rapid onset of death possible)
• (Moderate to severe) dehydration
• Hypovolaemia and hypotension
• Bradycardia
• Hypothermia
• Vomiting
• Seizures (due to hypoglycaemia)
• Upper abdominal painOther possible diagnostic findings can be found here

Recommended treatment for acute addisonian crisis

1. First, the most important thing: Compensation for hypovolaemia/rehydration: IV Infusion: 0.9% sodium chloride solution: therapy of choice. In cases of severe hyponatraemia or acidosis, administer Ringer's lactate solution or max. 0,5mEq/l/h sodium chloride. Alternative  Ringer's lactate solution: Counteract metabolic acidosis, CAVE in case of severe hyperkalaemia, if necessary initial sodium chloride solution. Dosage: 30–80 ml/kg/24h.
2. Treatment for hyperkalaemia: A sufficient lowering of potassium level is generally achieved through IV infusion. In the event of severe cardiac arrhythmias, forced lowering of potassium levels can be achieved by administration of glucose infusions (10%, 5–10 ml/kg IV). Alternatively, 10% calcium gluconate solution 0.5 ml/kg may be given over 10-15 min: onset of action significantly faster and therefore advisable if there is a possibility of cardiac arrest. Effect, however, of relatively short duration (<1h).
3. Compensation of metabolic acidosis with sodium bicarbonate, moderate acidosis usually compensated by the administration of solutions through infusion.
4. Compensation of hypoglycaemia if applicable (glucose IV).
5. Administration of glucocorticoids (e.g. Prednisolone): Caution – carry out an ACTH stimulation test before administering glucocorticoids if Addison's disease is suspected! If, from a veterinary standpoint, the administration of glucocorticoids is essential, the medication of choice is dexamethasone (0.5–1 ml/kg IV) since little to no cross-reaction is to be expected. However, ACTH stimulation test without prior administration of dexamethasone is preferred.
6. Administration of mineralocorticoids: Administration of fludrocortisone, if applicable. Not immediately, but rather when the patient's condition is stable (normally after 2–3 days)
7. If necessary, a mucosal protective agent for gastrointestinal symptoms or bleeding.

There is often a rapid improvement in the patient's general condition, however treatment must generally be followed over several days (slow compensation for fluid loss). Electrolyte levels should be closely monitored at first.

Bibliography: Upon request

Author of the article:

Veterinarian med. vet. Julia Brüner