Administer Emergency IV Hydrocortisone for Suspected Adrenal Crisis
STEP 1 — Gather Information
Collect history of adrenal insufficiency or steroid use, recent stressors (infection, trauma, surgery), symptoms (weakness, abdominal pain, nausea/vomiting), vital signs (BP, HR, RR, temp), point-of-care labs (Na, K, glucose), and if available, baseline cortisol and ACTH before steroids. If severe adrenal insufficiency symptoms or adrenal crisis suspected, proceed to Step 2; otherwise, consider alternative diagnoses and do not administer emergency hydrocortisone.
STEP 2 — Rule In / Rule Out
Is systolic blood pressure <90 mmHg or MAP <65 mmHg, or presence of altered mental status (confusion, delirium, syncope)? If yes → proceed to Step 3 (adrenal crisis likely). If no → consider less severe adrenal insufficiency; hold emergency hydrocortisone and pursue outpatient management.
STEP 3 — Classify or Stratify
Determine patient age and weight to select stress dose: Adults (≥18 years): 100 mg IV hydrocortisone bolus; Children: 50 mg/m2 IV hydrocortisone bolus (max 100 mg). Proceed to administer the calculated dose.
STEP 4 — Decide
Administer the calculated IV hydrocortisone bolus immediately, followed by continuous infusion of 200 mg hydrocortisone over 24 hours (or 50 mg IV every 6 hours) and initiate isotonic fluid resuscitation (e.g., 1 L normal saline bolus). Reassess clinically and continue stress dosing until stable.
Clinical Guardrails / Mimics / Pitfalls
Do not delay treatment awaiting ACTH stimulation test results; avoid dexamethasone as first-line agent due to lack of mineralocorticoid activity; ensure concurrent fluid resuscitation with isotonic saline to correct hypotension and hyponatremia; monitor for hypoglycemia and administer dextrose if needed; do not give oral hydrocortisone if patient is vomiting or unable to tolerate PO.
Concrete Clinical Example
A 48-year-old woman with known primary adrenal insufficiency presents with sudden vomiting, abdominal pain, hypotension 85/55, Na 128 mmol/L, K 5.6 mmol/L, glucose 48 mg/dL. She receives 100 mg hydrocortisone IV bolus, followed by 200 mg hydrocortisone over 24h via continuous infusion and 1 L normal saline bolus. Blood pressure improves to 118/70 within 2 hours, and symptoms resolve.
Source: Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, DOI:10.1210/jc.2015-1710