Adrenal crisis: recognition and emergency glucocorticoid

Manage now— do this, in order

• Treat on suspicion and confirm retrospectively: send one clotted sample for serum cortisol (with ACTH if the laboratory can process it) only if it costs no time, then give hydrocortisone. A dose given to a patient who did not need it does no harm; a dose withheld from one who did may be fatal. Treatment must never be delayed for the results of investigations, and never perform a Synacthen test on a shocked patient.
• First line, adults: hydrocortisone sodium succinate 100 mg by IV bolus. If a vein cannot be obtained quickly, give it intramuscularly into the anterolateral thigh and keep trying for the vein.Doctor / Nurse
• Continuation, adults: 200 mg hydrocortisone in the first 24 hours — 50 mg IV or IM every 6 hours or a continuous infusion; no dose may be omitted. Fludrocortisone is not required acutely. If hydrocortisone is unavailable: dexamethasone 4 mg IV (give saline generously; does not cross-react in the cortisol assay), prednisolone 25 mg IV or orally, methylprednisolone 20 mg IV, or cortisone acetate 125 mg orally as a last resort.Doctor / Nurse
• Children — immediate stat bolus of hydrocortisone sodium succinate IV or IM: under 1 year 25 mg, 1–5 years 50 mg, over 5 years 100 mg (equivalently 100 mg/m²), then approximately 100 mg/m² per 24 hours divided 6-hourly. Never delay the first dose to calculate a body surface area.Doctor / Nurse
• Fluid: 1 L of 0.9% sodium chloride over 30–60 minutes with the hydrocortisone bolus; several litres usually needed over 24 hours, up to 1 L/hour only with continuous cardiac monitoring; slower with reassessment after each litre in cardiac or renal disease and the elderly. Children: 0.9% sodium chloride 10–20 mL/kg over 10–20 minutes, reassess and repeat. Cardiac monitoring is mandatory from the outset — the potassium may be high and volumes are large.
• Glucose: check capillary glucose immediately and hourly; treat below 4.0 mmol/L with IV 10% glucose — adult 100–200 mL, child 2 mL/kg by slow IV injection, followed by an infusion if recurrent.
• Potassium and sodium: hyperkalaemia usually responds to volume and glucocorticoid alone — treat in its own right (IV calcium, insulin–glucose, nebulised salbutamol) only if 6.5 mmol/L or more or hyperkalaemic ECG changes. Where sodium is below 125 mmol/L, allow no more than a 10 mmol/L rise in 24 hours, rechecking electrolytes every 4–6 hours and slowing the infusion if it climbs faster than about 0.4 mmol/L per hour — osmotic demyelination is a disease inflicted, not presented with.Doctor / NurseNot available at your setup — Serum electrolytes.
• Treat the precipitant: bacterial infection frequently precipitates adrenal crisis — give broad-spectrum antibiotics empirically after cultures while awaiting results. Remember glucocorticoid masks the signs of disease: perforation may be silent, and the white cell count is raised by glucocorticoid itself.Not available at your setup — Blood culture.
• If the pressure has not improved after 2 L of crystalloid and 100 mg hydrocortisone within an hour: repeat hydrocortisone 100 mg IV (an IM dose may not have absorbed in a shocked patient); give more volume; look for a second shock state (haemorrhage, MI, PE, tension pneumothorax, tamponade, anaphylaxis, above all uncontrolled sepsis); start noradrenaline titrated to MAP around 65 mmHg — but the steroid must precede the pressor: escalating noradrenaline in an untreated crisis achieves nothing.Doctor / NurseNot available at your setup — Infusion pump.