Adrenal Hemorrhage

Adrenal Hemorrhage – Treatment Options

Introduction
Adrenal hemorrhage is a rare but potentially life-threatening condition characterized by bleeding into one or both adrenal glands. It may occur due to trauma, sepsis (especially meningococcal sepsis leading to Waterhouse–Friderichsen syndrome), coagulopathy, anticoagulant therapy, surgery, or severe physiological stress. Clinical presentation ranges from asymptomatic incidental findings to acute adrenal crisis with hypotension, abdominal or flank pain, fever, and shock. Prompt recognition and tailored management are crucial to prevent mortality.

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1. Hemodynamic Stabilization

• Intravenous fluid resuscitation with isotonic saline is initiated to correct hypovolemia and maintain blood pressure.

• Vasopressors may be required in patients with refractory hypotension, especially when adrenal insufficiency contributes to shock.

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2. Glucocorticoid Therapy

• If adrenal insufficiency or crisis is suspected, empiric hydrocortisone is administered immediately.

  • Dose: 100 mg IV bolus followed by 200 mg/24 h continuous infusion or 50 mg IV every 6 hours.

• Hydrocortisone is preferred for its combined glucocorticoid and mineralocorticoid effects.

• Transition to oral replacement therapy is made once the patient stabilizes.

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3. Correction of Coagulopathy

• Discontinuation of anticoagulants (e.g., heparin, warfarin, DOACs) if implicated.

• Reversal agents such as vitamin K, protamine sulfate, or specific antidotes are used when indicated.

• Platelet transfusions or fresh frozen plasma (FFP) may be necessary in patients with coagulopathy or thrombocytopenia.

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4. Management of Underlying Cause

• Sepsis: Broad-spectrum IV antibiotics and supportive therapy are started promptly.

• Trauma: Management may involve surgical or interventional radiology approaches if bleeding persists or hemodynamic instability continues.

• Anticoagulant-related hemorrhage: Requires close monitoring, drug discontinuation, and supportive care.

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5. Surgical or Interventional Management

• Most cases are managed conservatively with supportive care and steroids.

• Surgical exploration or embolization may be required in cases of ongoing hemorrhage, hemodynamic instability, or suspicion of malignancy.

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6. Long-Term Management

• Patients with bilateral adrenal hemorrhage often develop chronic adrenal insufficiency, requiring lifelong glucocorticoid ± mineralocorticoid replacement.

• Hydrocortisone 15–25 mg/day (divided doses) and fludrocortisone 0.05–0.2 mg/day may be prescribed for maintenance.

• Regular follow-up includes monitoring electrolytes, blood pressure, and adrenal imaging to assess recovery or detect complications.