Acute Adrenal Crisis is a life-threatening, hyper-acute endocrine emergency resulting from acute absolute or relative insufficiency of glucocorticoid (and frequently mineralocorticoid) hormones in patients with primary, secondary, or tertiary adrenal insufficiency. Left untreated, acute adrenal crisis progresses rapidly to refractory vasodilatory shock, hypovolemic vascular collapse, lethal dysrhythmias from hyperkalemia, profound hypoglycemia, and death.
Adrenal crisis occurs in approximately $6 - 8\%$ of patients with diagnosed adrenal insufficiency per year, with a mortality rate between $0.5\%$ and $2.0\%$ per episode. The event is most commonly precipitated by acute physiological stress: sepsis, gastrointestinal illnesses with vomiting/diarrhea preventing oral medication absorption, major surgery, trauma, or abrupt cessation of long-term exogenous corticosteroid therapy.
Despite authoritative clinical practice guidelines published by the Endocrine Society, the European Society of Endocrinology (ESE), and the American Association of Clinical Endocrinology (AACE), severe morbidity and avoidable mortality persist due to three catastrophic clinical pitfalls:
+---------------------------------------------------------------------------------------------------------+
| ACUTE ADRENAL CRISIS DIAGNOSTIC & RESUSCITATION CASCADE |
+---------------------------------------------------------------------------------------------------------+
| 1. IMMEDIATE CLINICAL DIAGNOSTIC GATING (ENDOCRINE SOCIETY CRITERIA) |
| - Severe Absolute/Relative Hypotension: SBP < 90 mmHg OR >= 20 mmHg drop from baseline |
| REFRACTORY to aggressive crystalloid boluses and catecholamine vasopressors. |
| - PLUS at least TWO of: |
| * Severe acute abdominal symptoms (pain, vomiting, diarrhea, mimicking acute surgical abdomen) |
| * Profound unexplained fatigue, lethargy, or acute encephalopathy/delirium |
| * Hyponatremia (Na < 135 mEq/L) AND/OR Hyperkalemia (K > 5.0 mEq/L) [Primary Adrenal Insufficiency] |
| * Severe Hypoglycemia (Glucose < 70 mg/dL, especially infants, children, or secondary AI) |
| * Fever or acute hypothermia |
+---------------------------------------------------------------------------------------------------------+
|
v
+---------------------------------------------------------------------------------------------------------+
| 2. IMMEDIATE EMERGENCY PHARMACOTHERAPY (ZERO DELAY FOR LAB WORK) |
| - IF DIAGNOSIS ALREADY KNOWN: |
| * Hydrocortisone Sodium Succinate: 100 mg IV STAT bolus immediately. |
| * Followed by 200 mg / 24 hours continuous IV infusion OR 50 mg IV every 6 hours. |
| - IF ADRENAL INSUFFICIENCY SUSPECTED BUT UNCONFIRMED (DIAGNOSTIC WORKUP DESIRED): |
| * Draw baseline Cortisol & ACTH tube immediately. |
| * Administer Dexamethasone 4.0 mg IV STAT (Zero assay interference with cortisol immunoassays). |
| * Perform Cosyntropin (ACTH) Stimulation Test simultaneously without delaying corticosteroid cover.|
+---------------------------------------------------------------------------------------------------------+
|
v
+---------------------------------------------------------------------------------------------------------+
| 3. AGGRESSIVE RESUSCITATION & ELECTROLYTE / METABOLIC CORRECTION |
| - Volume Expansion: 1000 mL 0.9% Normal Saline (or 5% Dextrose in Normal Saline - D5NS) in hour 1, |
| followed by 2000 - 4000 mL over next 24 hours to restore intravascular volume. |
| - Hypoglycemia Correction: D10W or D50W push if blood glucose < 70 mg/dL. |
| - Hyperkalemia Sentinel: Hyperkalemia resolves rapidly with hydrocortisone & saline; avoid insulin |
| pushes unless ECG reveals life-threatening sine waves (insulin precipitates fatal hypoglycemia). |
+---------------------------------------------------------------------------------------------------------+
|
v
+---------------------------------------------------------------------------------------------------------+
| 4. STABILIZATION, TAPERING & ORAL FLUDROCORTISONE TRANSITION |
| - Tapering Schedule: Decrease hydrocortisone by 50% daily once patient is hemodynamically stable, |
| afebrile, and tolerating oral nutrition (Day 2: 50 mg q8h; Day 3: 25 mg q8h; Day 4: baseline). |
| - Oral Fludrocortisone Trigger: Initiate Fludrocortisone 0.05 - 0.2 mg PO daily ONLY when total daily|
| hydrocortisone dose drops below 50 mg/day (in primary adrenal insufficiency only). |
+---------------------------------------------------------------------------------------------------------+
The Cosyntropin stimulation test evaluates adrenal functional reserve by administering synthetic $\alpha^{1-24}\text{-corticotropin}$:
| Modality | Dose & Delivery | Indication & Kinetics | Cutoff for Normal Adrenal Reserve |
|---|---|---|---|
| Standard High-Dose | $250\ \mu\text{g}$ IV / IM | Gold standard for Primary Adrenal Insufficiency; maximal adrenocortical stimulation. | Peak Cortisol $\ge 18.0\ \mu\text{g/dL}$ ($500\text{ nmol/L}$) at $30$ or $60\text{ min}$. |
| Low-Dose / Physiological | $1.0\ \mu\text{g}$ IV | Highly sensitive for Secondary/Tertiary (Central) Adrenal Insufficiency; avoids supraphysiologic stimulation. | Peak Cortisol $\ge 18.0\ \mu\text{g/dL}$ at $30\text{ min}$. |
Understanding corticosteroid potency ratios is critical to prevent under-dosing or inadvertent assay interference:
\[\begin{array}{lcccc} \hline \textbf{Steroid Compound} & \textbf{Equivalent Dose (mg)} & \textbf{Anti-Inflammatory Potency} & \textbf{Mineralocorticoid Potency} & \textbf{Cortisol Assay Interference} \\ \hline \text{Hydrocortisone (Cortisol)} & 20.0 & 1.0 & 1.0 & \textbf{YES (100\% Cross-Reaction)} \\ \text{Cortisone Acetate} & 25.0 & 0.8 & 0.8 & \textbf{YES} \\ \text{Prednisone / Prednisolone} & 5.0 & 4.0 & 0.8 & \textbf{YES (Partial 10-25\%)} \\ \text{Methylprednisolone} & 4.0 & 5.0 & 0.5 & \textbf{Minimal (< 5\%)} \\ \textbf{Dexamethasone} & \mathbf{0.75} & \mathbf{25.0} & \mathbf{0.0} & \textbf{ZERO (0\% Cross-Reaction)} \\ \text{Fludrocortisone} & 2.0 & 10.0 & 125.0 & \text{None} \\ \hline \end{array}\]The following complete, zero-dependency Python clinical decision-support engine provides automated diagnostic criteria evaluation, cosyntropin stimulation kinetics interpretation, weight-tiered pediatric and adult stress-dose titrators, and oral fludrocortisone transition schedules.
#!/usr/bin/env python3
"""
OpenPHR Cookbook 380: Offline Clinical Endocrinology & Critical Care Engine
Acute Adrenal Crisis Staging, Cosyntropin Stimulation Test Interpreter,
Stress-Dose Hydrocortisone Titrator & Fludrocortisone Transition Protocol.
Dependencies: Python 3.8+ (Standard Library Only).
"""
from dataclasses import dataclass, field
from enum import Enum
from typing import Dict, List, Optional, Tuple, Union
class AdrenalInsufficiencyType(Enum):
PRIMARY_ADDISONS = "Primary Adrenal Insufficiency (Addison's Disease - Adrenocortical Destruction)"
SECONDARY_TERTIARY_CENTRAL = "Secondary or Tertiary Adrenal Insufficiency (Hypothalamic-Pituitary Axis Failure / Exogenous Steroid Suppression)"
CIRCI_CRITICAL_ILLNESS = "Critical Illness-Related Corticosteroid Insufficiency (CIRCI / Septic Shock Relative AI)"
NORMAL_ADRENAL_RESERVE = "Intact Adrenocortical Reserve (Excludes Primary Adrenal Insufficiency)"
INDETERMINATE = "Indeterminate / Requires Complete Cosyntropin Dynamic Stimulation Testing"
class ClinicalCrisisSeverity(Enum):
REFRACTORY_SHOCK = "Life-Threatening Refractory Shock / Impending Cardiovascular Collapse"
SEVERE_ACUTE_CRISIS = "Severe Acute Adrenal Crisis"
INCIPIENT_IMPENDING_CRISIS = "Incipient / Impending Adrenal Crisis (Pre-Shock Phase)"
STABLE_OUTPATIENT = "Stable Outpatient / Non-Crisis Presentation"
@dataclass
class AdrenalCrisisPatientPresentation:
# Patient demographics
age_years: float
weight_kg: float
is_adult: bool
is_pregnant: bool = False
# Vital signs
heart_rate_bpm: int = 110
systolic_bp_mmhg: int = 80
diastolic_bp_mmhg: int = 48
baseline_typical_sbp: int = 120
temperature_celsius: float = 38.5
# Clinical manifestations
refractory_to_fluids_and_pressors: bool = True
acute_abdominal_pain_vomiting_diarrhea: bool = True
profound_weakness_lethargy_delirium: bool = True
hypoglycemia_symptoms: bool = True
hyperkalemic_ecg_changes: bool = False
known_prior_adrenal_insufficiency: bool = False
chronic_exogenous_steroid_use: bool = False
precipitating_illness: str = "Severe Sepsis / Gastroenteritis"
# Laboratory parameters
serum_sodium_meq_l: float = 126.0
serum_potassium_meq_l: float = 5.8
serum_glucose_mg_dl: float = 58.0
baseline_cortisol_ug_dl: Optional[float] = None
baseline_acth_pg_ml: Optional[float] = None
cosyntropin_stimulated_30min_cortisol_ug_dl: Optional[float] = None
cosyntropin_stimulated_60min_cortisol_ug_dl: Optional[float] = None
@dataclass
class HydrocortisoneRegimen:
initial_iv_bolus_mg: float
maintenance_schedule: str
daily_total_dose_mg: float
alternative_continuous_infusion_rate_mg_hr: float
diagnostic_steroid_substitute: str
clinical_rationale: str
@dataclass
class CosyntropinTestResult:
test_type: str
peak_cortisol_ug_dl: float
normal_cutoff_ug_dl: float
is_insufficient: bool
etiology: AdrenalInsufficiencyType
interpretation: str
@dataclass
class AdrenalCrisisDecisionReport:
meets_adrenal_crisis_criteria: bool
diagnostic_rationale: str
severity_classification: ClinicalCrisisSeverity
hydrocortisone_recommendation: HydrocortisoneRegimen
cosyntropin_analysis: Optional[CosyntropinTestResult]
fluid_resuscitation_protocol: Dict[str, Union[str, float]]
electrolyte_management: Dict[str, str]
tapering_and_fludrocortisone_transition: Dict[str, Union[str, List[str]]]
class AcuteAdrenalCrisisEngine:
"""
Clinical Decision Support Engine for Acute Adrenal Crisis Diagnostic Gating,
Cosyntropin Kinetics Interpretation, Stress-Dose Titration, and Fluid Resuscitation.
"""
@classmethod
def evaluate_diagnostic_criteria(
cls, p: AdrenalCrisisPatientPresentation
) -> Tuple[bool, str, ClinicalCrisisSeverity]:
"""
Evaluates Endocrine Society Consensus Criteria for Acute Adrenal Crisis:
1. Severe absolute hypotension (SBP < 90 mmHg) or relative hypotension (drop >= 20 mmHg)
unresponsive or poorly responsive to fluids/vasopressors.
2. PLUS at least TWO supporting clinical/metabolic criteria:
- Severe acute abdominal pain, nausea, vomiting, or diarrhea
- Profound lethargy, confusion, or delirium
- Hyponatremia (Na < 135 mEq/L)
- Hyperkalemia (K > 5.0 mEq/L)
- Hypoglycemia (Glucose < 70 mg/dL)
- Fever or hypothermia
"""
sbp_drop = p.baseline_typical_sbp - p.systolic_bp_mmhg
has_hypotension = p.systolic_bp_mmhg < 90 or sbp_drop >= 20
supporting_points = []
if p.acute_abdominal_pain_vomiting_diarrhea:
supporting_points.append("Severe gastrointestinal symptoms (abdominal pain/vomiting/diarrhea)")
if p.profound_weakness_lethargy_delirium:
supporting_points.append("Profound weakness / altered mental status")
if p.serum_sodium_meq_l < 135.0:
supporting_points.append(f"Hyponatremia ({p.serum_sodium_meq_l} mEq/L)")
if p.serum_potassium_meq_l > 5.0:
supporting_points.append(f"Hyperkalemia ({p.serum_potassium_meq_l} mEq/L)")
if p.serum_glucose_mg_dl < 70.0:
supporting_points.append(f"Hypoglycemia ({p.serum_glucose_mg_dl} mg/dL)")
if p.temperature_celsius >= 38.0 or p.temperature_celsius < 36.0:
supporting_points.append(f"Temperature instability ({p.temperature_celsius} °C)")
meets_criteria = has_hypotension and len(supporting_points) >= 2
if p.refractory_to_fluids_and_pressors and has_hypotension:
severity = ClinicalCrisisSeverity.REFRACTORY_SHOCK
elif meets_criteria:
severity = ClinicalCrisisSeverity.SEVERE_ACUTE_CRISIS
elif has_hypotension or len(supporting_points) >= 2:
severity = ClinicalCrisisSeverity.INCIPIENT_IMPENDING_CRISIS
else:
severity = ClinicalCrisisSeverity.STABLE_OUTPATIENT
if meets_criteria:
rationale = (
f"Meets Endocrine Society criteria for Acute Adrenal Crisis: Hemodynamic instability "
f"(SBP {p.systolic_bp_mmhg} mmHg, drop of {sbp_drop} mmHg) with {len(supporting_points)} "
f"major metabolic/clinical manifestations: {', '.join(supporting_points)}."
)
else:
rationale = (
f"Does not meet strict Endocrine Society criteria (Hypotension: {has_hypotension}, "
f"Supporting points: {len(supporting_points)}/2)."
)
return meets_criteria, rationale, severity
@classmethod
def interpret_cosyntropin_test(
cls, p: AdrenalCrisisPatientPresentation
) -> Optional[CosyntropinTestResult]:
"""
Interprets dynamic Corticotropin / ACTH stimulation testing:
- Normal peak cortisol cutoff: >= 18.0 ug/dL (500 nmol/L) at 30 or 60 min.
- Primary AI: Peak Cortisol < 18.0 ug/dL AND Baseline ACTH >= 60 pg/mL (>= 2x ULN).
- Secondary AI: Peak Cortisol < 18.0 ug/dL AND Baseline ACTH < 30 pg/mL (low or inappropriately normal).
"""
vals = []
if p.cosyntropin_stimulated_30min_cortisol_ug_dl is not None:
vals.append(p.cosyntropin_stimulated_30min_cortisol_ug_dl)
if p.cosyntropin_stimulated_60min_cortisol_ug_dl is not None:
vals.append(p.cosyntropin_stimulated_60min_cortisol_ug_dl)
if not vals:
if p.baseline_cortisol_ug_dl is not None:
if p.baseline_cortisol_ug_dl < 3.0:
etiology = AdrenalInsufficiencyType.PRIMARY_ADDISONS if (p.baseline_acth_pg_ml and p.baseline_acth_pg_ml > 60) else AdrenalInsufficiencyType.INDETERMINATE
return CosyntropinTestResult(
test_type="Morning Basal Cortisol Screening",
peak_cortisol_ug_dl=p.baseline_cortisol_ug_dl,
normal_cutoff_ug_dl=18.0,
is_insufficient=True,
etiology=etiology,
interpretation=f"Morning basal serum cortisol is profoundly low ({p.baseline_cortisol_ug_dl} ug/dL < 3.0 ug/dL), virtually diagnostic of Adrenal Insufficiency.",
)
return None
peak = max(vals)
normal_cutoff = 18.0
is_insufficient = peak < normal_cutoff
if not is_insufficient:
etiology = AdrenalInsufficiencyType.NORMAL_ADRENAL_RESERVE
interp = f"Normal adrenocortical peak response ({peak} ug/dL >= {normal_cutoff} ug/dL). Excludes primary adrenal insufficiency."
else:
if p.baseline_acth_pg_ml is not None:
if p.baseline_acth_pg_ml >= 60.0:
etiology = AdrenalInsufficiencyType.PRIMARY_ADDISONS
interp = f"Subnormal peak cortisol ({peak} ug/dL < {normal_cutoff} ug/dL) with elevated ACTH ({p.baseline_acth_pg_ml} pg/mL >= 60 pg/mL). Confirms Primary Adrenal Insufficiency."
else:
etiology = AdrenalInsufficiencyType.SECONDARY_TERTIARY_CENTRAL
interp = f"Subnormal peak cortisol ({peak} ug/dL < {normal_cutoff} ug/dL) with low/normal ACTH ({p.baseline_acth_pg_ml} pg/mL). Confirms Secondary/Tertiary Central Adrenal Insufficiency."
else:
etiology = AdrenalInsufficiencyType.INDETERMINATE
interp = f"Subnormal peak cortisol ({peak} ug/dL < {normal_cutoff} ug/dL). Establishes Adrenal Insufficiency; pending baseline ACTH to classify primary vs central."
return CosyntropinTestResult(
test_type="Standard 250 mcg Cosyntropin (ACTH 1-24) Stimulation Test",
peak_cortisol_ug_dl=peak,
normal_cutoff_ug_dl=normal_cutoff,
is_insufficient=is_insufficient,
etiology=etiology,
interpretation=interp,
)
@staticmethod
def calculate_hydrocortisone_dosing(
age_years: float, weight_kg: float, is_adult: bool
) -> HydrocortisoneRegimen:
"""
Calculates stress-dose hydrocortisone regimen according to international guidelines:
- Adults: 100 mg IV STAT bolus, followed by 200 mg/24h (either 200 mg continuous infusion or 50 mg IV q6h).
- Pediatrics:
* Age < 3 years: 25 mg IV bolus, then 25-30 mg/day divided q6h
* Age 3 - 12 years: 50 mg IV bolus, then 50-60 mg/day divided q6h
* Age > 12 years: 100 mg IV bolus, then 100-200 mg/day divided q6h
- Diagnostic Bridge: Dexamethasone 4.0 mg IV (zero immunoassay interference).
"""
if is_adult or age_years >= 12.0:
bolus = 100.0
maintenance = "50 mg IV every 6 hours (or continuous infusion of 200 mg/24 hours)"
daily_total = 200.0
infusion_rate = round(200.0 / 24.0, 1) # ~8.3 mg/hr
rationale = (
"Standard adult emergency stress dosing provides maximal glucocorticoid and "
"saturating mineralocorticoid coverage (~200 mg hydrocortisone = ~1.0 mg fludrocortisone equivalency)."
)
elif age_years >= 3.0:
bolus = 50.0
maintenance = "12.5 to 15 mg IV every 6 hours (total 50-60 mg/24h)"
daily_total = 50.0
infusion_rate = round(50.0 / 24.0, 1)
rationale = "Pediatric (3-12 years) stress dosing calibrated to body surface area (~50-100 mg/m2/day)."
else:
bolus = 25.0
maintenance = "6.25 to 7.5 mg IV every 6 hours (total 25-30 mg/24h)"
daily_total = 25.0
infusion_rate = round(25.0 / 24.0, 1)
rationale = "Infant/Toddler (< 3 years) emergency stress bolus to prevent catastrophic hypoglycemic seizure and shock."
return HydrocortisoneRegimen(
initial_iv_bolus_mg=bolus,
maintenance_schedule=maintenance,
daily_total_dose_mg=daily_total,
alternative_continuous_infusion_rate_mg_hr=infusion_rate,
diagnostic_steroid_substitute="Dexamethasone 4.0 mg IV STAT (Pediatric: 0.1 - 0.2 mg/kg, max 4 mg)",
clinical_rationale=rationale,
)
@staticmethod
def calculate_fluid_resuscitation(
weight_kg: float, is_adult: bool, glucose_mg_dl: float
) -> Dict[str, Union[str, float]]:
"""
Calculates fluid resuscitation and glucose rescue parameters.
"""
if is_adult:
initial_vol = 1000.0
fluid_type = "0.9% Normal Saline (or 5% Dextrose in Normal Saline - D5NS if hypoglycemic)"
rate = "1000 mL IV in the first hour, then 500 mL/hr for 2 hours, then 2000-3000 mL over remainder of 24h."
else:
initial_vol = round(weight_kg * 20.0, 1)
fluid_type = "0.9% Normal Saline bolus (20 mL/kg); add D5W/D10W immediately if hypoglycemia present"
rate = f"{initial_vol:.0f} mL IV bolus over 30-60 minutes; repeat up to 40-60 mL/kg if perfusion impaired."
hypo_rescue = "None indicated (Blood glucose >= 70 mg/dL)"
if glucose_mg_dl < 70.0:
if is_adult:
hypo_rescue = "Administer 50 mL of 50% Dextrose (D50W) IV STAT bolus (25 g elemental dextrose); infuse D5NS maintenance."
else:
hypo_rescue = f"Administer 2.0 mL/kg of 10% Dextrose (D10W) IV STAT ({round(weight_kg * 2.0, 1)} mL); maintain continuous dextrose infusion."
return {
"initial_bolus_ml": initial_vol,
"recommended_iv_fluid": fluid_type,
"infusion_timeline": rate,
"hypoglycemia_rescue_protocol": hypo_rescue,
"potassium_guardrail": (
"DO NOT ADD POTASSIUM TO IV FLUIDS during initial resuscitation. Hyperkalemia is common "
"in primary AI and will normalize rapidly with volume expansion and hydrocortisone."
),
}
@staticmethod
def generate_electrolyte_protocol(
sodium: float, potassium: float, glucose: float
) -> Dict[str, str]:
"""
Provides guardrails for electrolyte and glucose anomalies in acute adrenal crisis.
"""
na_action = "Serum sodium within normal limits."
if sodium < 130.0:
na_action = (
f"Severe Hyponatremia ({sodium} mEq/L) driven by cortisol-deficiency-induced non-osmotic ADH "
"secretion (euvolemic/hypovolemic). Correct cautiously (< 8-10 mEq/L in 24 hours) to prevent "
"osmotic demyelination syndrome (ODS). Hydrocortisone alone will prompt rapid aquaresis."
)
k_action = "Serum potassium within normal limits."
if potassium > 5.0:
k_action = (
f"Hyperkalemia ({potassium} mEq/L) resulting from aldosterone deficiency (isolated to primary AI). "
"RESOLVES RAPIDLY with Hydrocortisone and Normal Saline. AVOID standard insulin/dextrose shifts "
"unless life-threatening ECG changes (sine wave, loss of P wave) are present, as insulin can trigger "
"lethal intractable hypoglycemia in the absence of cortisol."
)
return {
"hyponatremia_strategy": na_action,
"hyperkalemia_strategy": k_action,
}
@staticmethod
def generate_tapering_and_fludrocortisone_plan() -> Dict[str, Union[str, List[str]]]:
"""
Outlines multi-day steroid taper and oral fludrocortisone transition.
"""
return {
"transition_trigger": (
"Initiate tapering when patient is hemodynamically stable for >= 24 hours, afebrile, "
"and able to tolerate oral medication and meals."
),
"stepwise_tapering_schedule": [
"Day 1 (Acute Crisis): Hydrocortisone 100 mg IV bolus, then 50 mg IV q6h (200 mg/day).",
"Day 2 (Stabilization): Hydrocortisone 50 mg IV every 8 hours (150 mg/day).",
"Day 3 (Clinical Improvement): Hydrocortisone 25 mg IV or PO every 8 hours (75 mg/day).",
"Day 4 (Transition Phase): Hydrocortisone 20 mg PO on waking, 10 mg PO at 14:00 (30 mg/day).",
"Day 5+ (Maintenance): Return to patient's baseline maintenance (typically 15-25 mg/day in divided doses).",
],
"fludrocortisone_rules": (
"Fludrocortisone (0.05 - 0.2 mg PO once daily in the morning) is required ONLY in Primary Adrenal "
"Insufficiency. DO NOT initiate during acute resuscitation because stress doses of hydrocortisone "
"(>= 50 mg/day) provide 100% saturating mineralocorticoid receptor activity. Start fludrocortisone "
"on Day 4 or when hydrocortisone dose drops below 50 mg/day."
),
"discharge_sentinels": [
"1. Provide emergency intramuscular Hydrocortisone (100 mg vial) with syringes and teach self-injection.",
"2. Issue medical alert bracelet / necklace stating 'Adrenal Insufficiency - Requires Emergency Hydrocortisone'.",
"3. Patient and family education on 'Sick Day Rules' (double oral dose for fever > 38°C; triple dose for severe illness).",
"4. Refer for endocrinology outpatient follow-up within 1-2 weeks.",
],
}
@classmethod
def run_clinical_assessment(
cls, p: AdrenalCrisisPatientPresentation
) -> AdrenalCrisisDecisionReport:
"""
Runs the comprehensive end-to-end clinical assessment.
"""
meets_crisis, rationale, severity = cls.evaluate_diagnostic_criteria(p)
hydro = cls.calculate_hydrocortisone_dosing(p.age_years, p.weight_kg, p.is_adult)
cosyntropin = cls.interpret_cosyntropin_test(p)
fluids = cls.calculate_fluid_resuscitation(p.weight_kg, p.is_adult, p.serum_glucose_mg_dl)
electrolytes = cls.generate_electrolyte_protocol(
p.serum_sodium_meq_l, p.serum_potassium_meq_l, p.serum_glucose_mg_dl
)
taper_fludro = cls.generate_tapering_and_fludrocortisone_plan()
return AdrenalCrisisDecisionReport(
meets_adrenal_crisis_criteria=meets_crisis,
diagnostic_rationale=rationale,
severity_classification=severity,
hydrocortisone_recommendation=hydro,
cosyntropin_analysis=cosyntropin,
fluid_resuscitation_protocol=fluids,
electrolyte_management=electrolytes,
tapering_and_fludrocortisone_transition=taper_fludro,
)
# =====================================================================
# SELF-CONTAINED CLINICAL VALIDATION SUITE
# =====================================================================
def verify_clinical_scenarios():
print("=" * 80)
print("OpenPHR Cookbook 380: Acute Adrenal Crisis & Corticosteroid Titration Suite")
print("=" * 80)
# Test Case 1: Adult Addisonian Adrenal Crisis in Septic Shock (70 kg, SBP 76, K 5.9, Glucose 54)
pt_adult_crisis = AdrenalCrisisPatientPresentation(
age_years=44.0,
weight_kg=70.0,
is_adult=True,
heart_rate_bpm=124,
systolic_bp_mmhg=76,
diastolic_bp_mmhg=44,
baseline_typical_sbp=122,
temperature_celsius=38.9,
refractory_to_fluids_and_pressors=True,
acute_abdominal_pain_vomiting_diarrhea=True,
profound_weakness_lethargy_delirium=True,
serum_sodium_meq_l=125.0,
serum_potassium_meq_l=5.9,
serum_glucose_mg_dl=54.0,
baseline_cortisol_ug_dl=1.8,
baseline_acth_pg_ml=142.0,
cosyntropin_stimulated_30min_cortisol_ug_dl=2.4,
cosyntropin_stimulated_60min_cortisol_ug_dl=2.6,
)
rep1 = AcuteAdrenalCrisisEngine.run_clinical_assessment(pt_adult_crisis)
assert rep1.meets_adrenal_crisis_criteria is True, "Must meet adrenal crisis criteria"
assert rep1.severity_classification == ClinicalCrisisSeverity.REFRACTORY_SHOCK
assert rep1.hydrocortisone_recommendation.initial_iv_bolus_mg == 100.0
assert rep1.hydrocortisone_recommendation.daily_total_dose_mg == 200.0
assert rep1.cosyntropin_analysis is not None
assert rep1.cosyntropin_analysis.etiology == AdrenalInsufficiencyType.PRIMARY_ADDISONS
assert "D50W" in rep1.fluid_resuscitation_protocol["hypoglycemia_rescue_protocol"]
print("[*] Test Case 1 (Adult Refractory Adrenal Shock - Primary Addison's) PASSED")
print(f" - Meets Criteria: {rep1.meets_adrenal_crisis_criteria} ({rep1.severity_classification.value})")
print(f" - Hydrocortisone Bolus: {rep1.hydrocortisone_recommendation.initial_iv_bolus_mg} mg IV STAT")
print(f" - Maintenance: {rep1.hydrocortisone_recommendation.maintenance_schedule}")
print(f" - Cosyntropin Interpretation: {rep1.cosyntropin_analysis.interpretation}")
print(f" - Hypoglycemia Rescue: {rep1.fluid_resuscitation_protocol['hypoglycemia_rescue_protocol'][:60]}...")
# Test Case 2: Pediatric Adrenal Crisis (Age 4, 16 kg, Hypoglycemic Lethargy, SBP 68)
pt_peds_crisis = AdrenalCrisisPatientPresentation(
age_years=4.0,
weight_kg=16.0,
is_adult=False,
heart_rate_bpm=148,
systolic_bp_mmhg=68,
diastolic_bp_mmhg=38,
baseline_typical_sbp=95,
temperature_celsius=38.2,
acute_abdominal_pain_vomiting_diarrhea=True,
profound_weakness_lethargy_delirium=True,
serum_sodium_meq_l=128.0,
serum_potassium_meq_l=5.4,
serum_glucose_mg_dl=42.0,
baseline_cortisol_ug_dl=2.1,
)
rep2 = AcuteAdrenalCrisisEngine.run_clinical_assessment(pt_peds_crisis)
assert rep2.meets_adrenal_crisis_criteria is True, "Peds must meet adrenal crisis criteria"
assert rep2.hydrocortisone_recommendation.initial_iv_bolus_mg == 50.0, "Child age 4 receives 50 mg bolus"
assert "D10W" in rep2.fluid_resuscitation_protocol["hypoglycemia_rescue_protocol"]
print("\n[*] Test Case 2 (Pediatric Adrenal Crisis - Age 4, 16 kg) PASSED")
print(f" - Recommended Hydrocortisone Bolus: {rep2.hydrocortisone_recommendation.initial_iv_bolus_mg} mg IV")
print(f" - Hypoglycemia Rescue: {rep2.fluid_resuscitation_protocol['hypoglycemia_rescue_protocol']}")
print("\n>>> ALL CLINICAL VERIFICATION TESTS PASSED (100% CONCORDANCE) <<<")
if __name__ == "__main__":
verify_clinical_scenarios()