A patient on long-term corticosteroid therapy develops an acute adrenal (addisonian) crisis in the dental chair. Which finding is the immediately life-threatening feature?

Correct answer: A. Profound hypotension and cardiovascular collapse

• A. CORRECT. Acute adrenal insufficiency is fundamentally a CIRCULATORY emergency. Cortisol is required for vascular responsiveness to catecholamines and, with aldosterone, for sodium and volume retention. Without it the patient develops refractory HYPOTENSION and SHOCK that does not respond to fluids or pressors alone. Accompanying features are weakness, abdominal pain, nausea, fever, hyponatremia, hyperkalemia and hypoglycemia. Management: terminate the procedure, supine with legs elevated, oxygen, 100 mg hydrocortisone IV/IM, IV fluids, and activate EMS.
• B. Atrial fibrillation is not characteristic. Hyperkalemia in adrenal crisis can produce peaked T waves and conduction disturbance, but shock is the lethal feature.
• C. Hypertension is the opposite of what occurs. Chronic Cushingoid states from exogenous steroid EXCESS cause hypertension; the crisis of steroid DEFICIENCY causes hypotension.
• D. Hyperventilation is a feature of an anxiety attack, not adrenal crisis, and is not itself life-threatening.

Note: Steroid history is the whole game. Ask about dose, duration and how recently it stopped — the HPA axis can remain suppressed for up to a year after prolonged therapy. Current guidance is that most routine dental care does not need supplemental steroid, but the treating physician should be consulted for major surgical procedures.