Adrenal Crisis - Emergency Help

For paramedics, caring for a steroid-dependent patient in adrenal crisis:

Diagnostic measures should never delay treatment, and if an adrenal crisis is suspected, treatment should be initiated without delay. Adrenal crisis requires time-critical treatment with parenteral steroids and intravenous (IV) fluids.

Here we provide more information 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 an 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 handing over 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 the death of the 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. 

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

Diagnostic measures should never delay treatment, and if an adrenal crisis is suspected, treatment should be initiated without delay. Adrenal crisis requires time-critical treatment with parenteral steroids and intravenous (IV) fluids.

These guidelines are provided by our Clinical Advisory Panel as an aid for A&E emergency teams receiving patients following or in a suspected 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