Adrenal Crisis - a life-threatening emergency 

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 time-critical, life-threatening emergency and must be treated immediately. Follow the instructions below - foreign language translations are also available. For more information on the Sick Day Rules, please click here.

COVID: If you are a healthcare professional managing a patient with COVID, please click here to view the latest guidance from the Society for Endocrinology.

Adrenal crisis 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 you or someone you are caring for, do not delay :

Step 1: Inject yourself, or the person you are caring for, with your hydrocortisone ampoule (100mg). Click here to follow an injection video for support.

Step 2: Seek immediate medical attention - call 999.

Step 3: Clearly state to 999 that you are steroid-dependent and having an adrenal crisis AND describe symptoms, e.g. vomiting, diarrhoea, dehydration, injury/shock.

Step 4: Be prepared with NHS or ADSHG steroid emergency cards to hand over to paramedics.

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

As the standalone Steroid Dependent patient JRCALC guidelines:

• Immediately inject 100mg hydrocortisone i.v. or i.m. followed by rapid rehydration with i.v. administration of 0.9% saline solution (or equivalent).

• There is no toxic dose for hydrocortisone but advanced hypocortisolemia may rapidly prove fatal.

• If there is any doubt about previous steroid administration, it is better to administer further hydrocortisone. Diagnostic measures should never delay treatment and if adrenal crisis is suspected, treatment should be initiated without delay.

• 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.

• When handover to the emergency department team convey if the cause of the adrenal crisis also needs hospital assessment/ management. Please maintain the patient on hydrocortisone until clinical recovery and further guidance by an endocrinologist.

• Do not hesitate to give high doses of hydrocortisone to a pregnant woman; hydrocortisone is inactivated in the placenta and does not affect the unborn baby. However, failure to treat a pregnant woman with adrenal insufficiency can result in death of mother and/or loss of the child.

* Note  Lower hydrocortisone doses/ saline infusion rates are appropriate for children. Visit the Society of Endocrinology website for more details. 

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 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 hydrocortisone/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

Visit the Society for Endocrinology Adrenal Crisis page for further detail

• Watch our latest video on management on Addison's with Covid-19
• How to avoid precipitating an acute adrenal crisis (Article by Professor Wass)
• Our latest advice for people with Addison's and Coronavirus

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

Download and complete the ADSHG adrenal crisis guidelines

These guidelines allow you to keep on you at all times the emergency medical treatment guidance ambulance or hospital staff would need, in the event of an adrenal crisis.