Synopsis
Identify adrenal crisis clinically, deliver hydrocortisone and fluid resuscitation without delay, correct complications and convert recovery into a robust prevention plan.
- Think of crisis in unexplained hypotension or shock, especially with vomiting, abdominal pain, fever, confusion, hypoglycaemia, hyponatraemia, hyperkalaemia or a steroid history.
- The Society for Endocrinology states that suspected crisis should receive hydrocortisone without delay; short-term high-dose glucocorticoid is far safer than missing the diagnosis.
- Administer 100 mg hydrocortisone intravenously or intramuscularly immediately, then 200 mg over 24 hours by continuous infusion or 50 mg every six hours until clinical recovery and endocrine review.
- Restore circulating volume using 0.9% sodium chloride, adjusting rate and total to blood pressure, urine output, sodium, heart failure and kidney status rather than giving an unobserved fixed volume.
- Take paired cortisol and ACTH before hydrocortisone only when tubes and access are ready and sampling creates no treatment delay. Never await the result.
- Normal potassium does not exclude crisis, particularly in secondary or glucocorticoid-induced insufficiency where aldosterone remains intact.
- Find and treat the precipitant: gastroenteritis, infection, trauma, surgery, labour, missed or abruptly stopped steroids, failure to stress-dose, poor absorption or an enzyme-inducing interaction.
- If shock persists after steroid and fluid, reassess ABCDE, sepsis, haemorrhage, cardiogenic or obstructive causes, adequacy of access and critical-care needs rather than attributing everything to cortisol deficiency.
- Before discharge, convert safely to oral replacement, provide sick-day education and injection competence, replace expired supplies and report a clear written plan to primary and specialist care.
Key red flags
Postural or persistent hypotension, tachycardia, cool peripheries, prolonged capillary refill, oliguria or shock may be prominent. Relative bradycardia does not exclude crisis when medicines or conduction disease are present.
Nausea, repeated vomiting, diarrhoea and severe abdominal pain can mimic a surgical abdomen or gastroenteritis. They also prevent oral steroid absorption and accelerate volume loss.
Profound weakness, drowsiness, delirium, seizure or coma may reflect hypotension, hyponatraemia or hypoglycaemia. Check bedside glucose immediately while resuscitation begins.
Known adrenal failure, pituitary disease, recent glucocorticoid reduction, multiple steroid routes, immunotherapy, bilateral adrenal disease or a Steroid Emergency Card materially raises pre-test probability.
Hyponatraemia, hyperkalaemia, raised urea/creatinine, low glucose, eosinophilia or hypercalcaemia can support the diagnosis, yet none is sufficiently sensitive to delay or withhold empirical treatment.
Investigation priorities
Quantify immediate physiological threat and treat reversible hypoglycaemia.
Management branches
Compatible acute illness with hypotension, vomiting, altered consciousness or major adrenal risk.
- Call for senior help, start ABCDE monitoring, establish IV access and check bedside glucose; draw cortisol/ACTH and routine bloods only if instantly available.
- Give hydrocortisone 100 mg IV or IM immediately and begin rapid 0.9% sodium chloride, repeatedly reassessing perfusion, lungs, urine output and comorbidity.
- Correct hypoglycaemia, severe hyperkalaemia and other life threats using local emergency protocols; start sepsis treatment promptly when infection is suspected.