Treat Suspected Adrenal Crisis with Immediate Parenteral Hydrocortisone and Fluid Resuscitation

STEP 1 — Gather Information

Collect vital signs (BP, HR, RR, SpO2), point-of-care labs (Na, K, glucose), assess for symptoms of adrenal crisis (weakness, abdominal pain, vomiting, confusion), known adrenal insufficiency, recent stressors (infection, trauma, surgery), and medications affecting cortisol metabolism. If hypotension, hyponatremia, hyperkalemia, or unexplained shock are present, proceed to STEP 2.

STEP 2 — Rule In / Rule Out

Is there a known diagnosis of primary adrenal insufficiency or high clinical suspicion (hypotension with hyponatremia/hyperkalemia, unexplained shock)? If YES → proceed to STEP 3. If NO → consider alternative causes of shock and obtain urgent endocrine consultation before administering steroids.

STEP 3 — Classify or Stratify

Classify patient as adult (≥18 years) or child (<18 years) to determine weight‑based dosing: adult hydrocortisone bolus 100 mg; child hydrocortisone bolus 50 mg/m² (use body surface area). Fluid bolus: adult 1000 mL isotonic saline; child 20 mL/kg normal saline (repeat up to 60 mL/kg within 1 h if shock persists). Proceed to STEP 4 with calculated doses.

STEP 4 — Decide

Administer hydrocortisone bolus IV/IM immediately. Start rapid fluid resuscitation per classification. Begin continuous hydrocortisone infusion 200 mg/24 h (adult) or 50–100 mg/m²/24 h (child) via IV, or give 6‑hourly bolus doses. Reassess clinical response and electrolytes hourly; continue fluids as needed.

Clinical Guardrails / Mimics / Pitfalls

Do not delay hydrocortisone awaiting diagnostic test results. Do not use dexamethasone as first‑line agent due to lack of mineralocorticoid activity and Cushingoid risk. Avoid oral glucocorticoids if vomiting or unable to tolerate. Do not give fludrocortisone during acute resuscitation if hydrocortisone dose exceeds 50 mg/24 h (hydrocortisone provides sufficient mineralocorticoid effect). Monitor for hypoglycemia and give dextrose 0.5–1 g/kg if needed. Avoid excessive fluid resuscitation in patients with known heart failure without monitoring.

Concrete Clinical Example

A 45‑year‑old woman with known Addison’s disease presents with vomiting, hypotension 80/50 mm Hg, serum Na 125 mmol/L, K 5.8 mmol/L, glucose 55 mg/dL. She receives 100 mg hydrocortisone IV bolus, 1 L normal saline over the first hour, then hydrocortisone infusion 200 mg/24 h. Glucose is corrected with 25 g dextrose IV. Blood pressure improves to 110/70 mm Hg after 2 h.

Source: Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, DOI:10.1210/jc.2015-1710

TODO: consider adding scripts/calc.py for the enda-emergency-adrenal-crisis-treatment calculator