What is an appropriate initial treatment for suspected adrenal crisis?

• A. Oral prednisone
• B. Intravenous hydrocortisone
• C. Intravenous epinephrine
• D. Oral hydrocortisone

Answer: (B)

In adrenal crisis, the priority is rapid replacement of deficient cortisol to restore vascular tone and prevent shock. Intravenous hydrocortisone is best because it acts quickly and provides both glucocorticoid and mineralocorticoid effects, which help stabilize blood pressure and support fluid and electrolyte balance during the crisis.

Give a 100 mg IV hydrocortisone bolus right away, then continue with 50 mg IV every 6 hours or switch to a continuous infusion totaling about 200 mg in 24 hours. This rapid steroid replacement should occur alongside aggressive IV fluid resuscitation (typically normal saline) and close monitoring of blood glucose and electrolytes. Do not delay treatment to obtain labs.

Oral steroids or non-IV options aren’t suitable for the initial management in this setting. Oral prednisone wouldn’t act quickly enough, and the patient’s absorption may be unreliable during shock. Oral hydrocortisone also wouldn’t provide the rapid systemic effects needed in a crisis. Epinephrine is not a substitute for cortisol replacement and is used for anaphylaxis or severe hypotension from other causes when indicated, not as the primary treatment for adrenal crisis.