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enda-emergency-hc-adrenal-crisis

Recommends immediate IV hydrocortisone stress dosing for patients with suspected adrenal crisis presenting with severe adrenal insufficiency symptoms such as hypotension, hyponatremia, hyperkalemia, or acute abdominal pain. Use when clinician observes signs of adrenal crisis (e.g., syncope, delirium, marked abdominal tenderness) prior to diagnostic test results.

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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

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780g-pump-adjustment

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