Adrenal Crisis Can Kill

Healthcare professionals managing a patient with COVID-19 and Adrenal Insufficiency - please view the latest guidance from the European Society of Endocrinology.

Advice for Non-COVID-19 related Emergencies:

Each year, typically 8% of people with Addison's Disease experience adrenal crisis. This means they need extra steroid medication immediately, in the form of an emergency injection of intra-muscular hydrocortisone. This is a medical emergency and must be treated immediately. Follow the instructions below - foreign language translations are also available.

The danger signs include :

Extreme weakness, feeling terrible, vomiting, headache
Light-headedness or dizziness on sitting up or standing up
Feeling very cold, uncontrollable shaking; back, limb or abdominal pain
Confusion, drowsiness, loss of consciousness

If this happens to yourself or someone you are caring for, do not delay :

inject yourself (or the person you are caring for) with your hydrocortisone ampoule (100mg)
seek immediate medical attention - call 999, stating "Addisonian crisis"
Other key phrases to use are: Steroid-dependent, risk of adrenal crisis, adrenal insufficiency crisis, Addison’s/ Addisonian emergency
AND describe symptoms (vomiting, diarrhoea, dehydration, injury/shock).

If you are a paramedic, caring for a patient in adrenal crisis :

The JRCalc guidelines (2019) state "If significantly unwell, the patient should be given hydrocortisone and fluids (normal saline) as soon as practicable" :

Stabilise the patient with normal saline (intravenously) and injected hydrocortisone prior to transportation
Keep the patient lying down - they may become profoundly hypotensive when sitting upright
Where the patient cannot be transported flat on a stretcher they must not be moved until full circulatory volume has been restored with IV fluids and they have received injected hydrocortisone
Get them to an emergency medical facility urgently

* Note : Lower hydrocortisone doses/ saline infusion rates are appropriate for children

A&E management of adrenal crisis: the first 24 hours

These guidelines are provided by our Clinical Advisory Panel, as an aid for A&E emergency teams receiving Addisonian patients following an adrenal crisis :

For Adults, administer parenteral hydrocortisone 100mg stat (IM preferable) and repeat 6 hourly until the patient is haemodynamically stable and clinical improvement (alternative 200mg/24hrs by continuous IV infusion).
Infants and children should receive an initial parenteral injection of 50mg hydrodortisone/m2 (usually 25mg in infants and 50mg in children) followed by 50mg/24h in infants and 100mg/24h in children.

Administer 1 litre IV 0.9% saline stat (adjust for infants and children), and continue saline resuscitation at an appropriate rate until haemodynamic stability and correction of any electrolyte disturbance and AKI
Monitor U&E at least 12 hourly during initial resuscitation and continue regular monitoring until any hyponatraemia, hyperkalaemia or renal impairment are corrected
Identify and treat any precipitating cause for Addisonian crisis:
- vomiting/diarrhoeal illness
- infection
- myocardial infarction

* Note : Lower hydrocortisone doses/ saline infusion rates are appropriate for children

What is an adrenal crisis?

In an emergency, people with Addison's Disease (or anyone who is "steroid-dependent") may experience symptoms of extreme weakness, a significant drop in blood pressure, drowsiness or mental confusion. This is known as an "adrenal crisis" (or "Addisonian crisis") and means they need extra steroid medication immediately, in the form of an emergency injection of intra-muscular hydrocortisone.

How do you know it is an adrenal crisis?

How do I give an emergency injection?

Check out these short videos :

Video : 1. When to give an emergency injection (4 minutes)
Video : 2. Emergency injections: Personal stories (5 minutes)
Video : 3.1 How to administer a liquid hydrocortisone emergency injection using a safety syringe (3 minutes)
Video : 3.2 How to administer a liquid hydrocortisone emergency injection using a standard syringe (3 minutes)
Video : 3.3 How to administer a Solu-Cortef emergency injection using a safety syringe (3 minutes)
Video : 3.4 How to administer a Solu-Cortef emergency injection using a standard syringe (3 minutes)
Video : 3.5 How to administer a Solu-Cortef emergency injection using an Act-o-Vial Safety Syringe (3 minutes)

View our Emergency Injection Guide

Last updated: 22/04/2020

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