Adrenal crisis is shock refractory to volume resuscitation and pressors. It can result from acute destruction of the hypothalamic-pituitary axis or the adrenal glands or from acute stressors in the setting of underlying primary or secondary adrenal insufficiency. Reported stressors include acute infection, especially gastrointestinal infection; surgery; extreme physical activity; acute severe injury or burns; and cessation of chronic glucocorticoid replacement CLINICAL FEATURES : Acute adrenal crisis is characterized by severe hypotension refractory to vasopressors. Other symptoms include severe abdominal pain, nausea, and vomiting, mimicking an acute abdomen. CNS symptoms of confusion, disorientation, and lethargy may be present. There may be associated sepsis, even without fever. Consider adrenal crisis in situations of unexplained hypotension, especially in patients with a history of glucocorticoid therapy; those with acquired immunodeficiency syndrome, tuberculosis, autoimmune disease, or severe head trauma; those with a history of chronic fatigue and hyperpigmentation; and those with disorders known to cause acute adrenal crisis TREATMENT : The recommended treatment is outlined in Table 230-4. Begin therapy immediately in any suspected case of adrenal crisis, because prognosis is related to the rapidity of treatment onset. Give IV fluids early to treat hypotension. If hypoglycemia is present, give dextrose-containing solutions. Administer IV Fluids for Hypotension Use dextrose-containing saline if hypoglycemic. ↓ Give Steroids Hydrocortisone (100-milligram bolus) is the drug of choice for cases of adrenal crisis or insufficiency, especially for underlying primary insufficiency (provides both glucocorticoid and mineralocorticoid effects). or Dexamethasone, 4-milligram bolus (preferred if rapid adrenocorticotropic hormone stimulation test is contemplated). ↓ Consider Vasopressors Administer only after steroid therapy in patients unresponsive to aggressive fluid resuscitation (choice of norepinephrine, dopamine, or phenylephrine [Neo-Synephrine®]). ↓ Consider Steroid Supplementation Patients may require lifelong glucocorticoids ± mineralocorticoid ± androgen supplementation. ↓ Determine Underlying Cause Investigate as appropriate—sepsis, adrenal hemorrhage, CNS abnormality. ↓ Optimize Maintenance Dosage of Steroids During periods of stress, increase maintenance doss of chronic steroids to three times the daily dose, to satisfy increased physiologic need for cortisol. convert it into point-wise separate them