Key Points
- Treat suspected adrenal crisis immediately; do not wait for cortisol or stimulation testing.
- Give hydrocortisone 100 mg IV or IM, then 200 mg over 24 hours or 50 mg every 6 hours.
- Rapid isotonic saline is a core treatment, adjusted for heart and kidney function.
- Correct hypoglycemia promptly with dextrose.
- Hyperkalemia points more strongly toward primary adrenal failure but can be absent in secondary or glucocorticoid-induced disease.
- Recent chronic glucocorticoid exposure is an important risk factor even when the patient has never been formally diagnosed with adrenal insufficiency.
- Fludrocortisone is not required while stress-dose hydrocortisone is being given.
- Every survivor needs sick-day rules, emergency steroid access, and medical-alert identification.
Algorithm
- Recognize unexplained shock, vomiting, hypoglycemia, or electrolyte disturbance in a patient at risk for adrenal insufficiency.
- Draw cortisol and ACTH only if this can be done immediately without delaying treatment.
- Give hydrocortisone 100 mg IV/IM and start isotonic saline; add dextrose for hypoglycemia.
- Treat the precipitating infection, hemorrhage, trauma, or other stressor.
- Monitor blood pressure, glucose, sodium, potassium, urine output, and response to resuscitation; add vasopressor support if needed.
- Continue hydrocortisone 200 mg per 24 hours during the acute phase.
- Transition to oral glucocorticoid when stable and restore mineralocorticoid therapy in primary adrenal insufficiency as appropriate.
- Before discharge, provide emergency injection education, sick-day dosing instructions, and endocrine follow-up.
Clinical Synopsis & Reasoning
Suspect adrenal crisis in unexplained hypotension, shock resistant to usual therapy, severe weakness, vomiting, abdominal pain, fever, confusion, hypoglycemia, or hyponatremia, especially with known adrenal insufficiency or current/recent glucocorticoid use. Primary adrenal failure can also cause hyperkalemia, salt craving, and chronic hyperpigmentation because mineralocorticoid deficiency and elevated ACTH coexist. Secondary or glucocorticoid-induced adrenal insufficiency generally preserves aldosterone, so hyperkalemia is less typical. Triggers include infection, surgery, trauma, vomiting that prevents oral steroid absorption, abrupt steroid cessation, pituitary apoplexy, bilateral adrenal hemorrhage, and failure to increase glucocorticoid during physiologic stress. The 2024 Endocrine Society/ESE guideline emphasizes that patients with current or recent glucocorticoid exposure and hemodynamic instability, vomiting, or diarrhea may have glucocorticoid-induced adrenal crisis even if formal HPA-axis testing was never performed. If feasible, draw cortisol and ACTH before hydrocortisone, along with electrolytes, glucose, renal function, CBC, cultures, and targeted testing for the trigger. Do not wait for cortisol results or a cosyntropin test in a critically ill patient.
Treatment Strategy & Disposition
Give hydrocortisone 100 mg IV or IM immediately, followed by 200 mg over 24 hours by continuous infusion or 50 mg IV every 6 hours. Begin rapid isotonic saline resuscitation, commonly about 1 liter in the first hour in an adult unless heart or kidney disease requires a more cautious rate. Add dextrose for hypoglycemia. Treat sepsis, hemorrhage, vomiting, or another precipitating illness. At stress-dose hydrocortisone levels, additional fludrocortisone is not required acutely because hydrocortisone has sufficient mineralocorticoid activity; restart or begin mineralocorticoid replacement later in primary adrenal insufficiency as steroid doses fall. Vasopressors may be necessary in profound shock but often become more effective after glucocorticoid and volume replacement. Once stable and able to take oral medication, taper from stress dosing to a maintenance regimen guided by endocrinology and the underlying illness. If hydrocortisone is unavailable, an alternative glucocorticoid can be used, but hydrocortisone is preferred because of its combined glucocorticoid and mineralocorticoid activity.
Epidemiology / Risk Factors
- Primary adrenal insufficiency is uncommon, but adrenal crisis is a recurring risk throughout the patient's life.
- Autoimmune adrenalitis is a major cause of primary disease in many settings.
- Exogenous glucocorticoid therapy is a much more common pathway to HPA-axis suppression and secondary adrenal insufficiency.
- Gastroenteritis and infection are frequent triggers because they increase cortisol demand and can prevent oral medication absorption.
- Delayed recognition is common because nausea, abdominal pain, fever, weakness, and hypotension overlap with sepsis and other emergencies.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| Serum cortisol | Supports diagnosis when obtained before steroids | Can be difficult to interpret during critical illness | Do not delay treatment for result |
| Plasma ACTH | Distinguishes primary from central adrenal insufficiency | Best drawn before hydrocortisone | Markedly elevated ACTH supports primary disease |
| Electrolytes and glucose | Detects hyponatremia, hyperkalemia, and hypoglycemia | Immediate and serial | Hyperkalemia is more typical of primary disease |
| Renal function | Assesses volume depletion and AKI | Serial | Improves with resuscitation if prerenal |
| CBC/cultures | Evaluates infection and anemia | Targeted to trigger | Treat suspected sepsis in parallel |
| Cosyntropin stimulation test | Confirms adrenal insufficiency in stable circumstances | Not an emergency test during shock | Perform after stabilization when diagnosis remains uncertain |
| CT/MRI targeted imaging | Evaluates hemorrhage, infection, pituitary disease, or other cause | Selective | Imaging should follow stabilization |
Typical ED Orders
| Order | Dose/Action |
|---|---|
| Hydrocortisone | 100 mg IV or IM immediately |
| Fluids | Rapid isotonic saline, commonly about 1 L in the first hour if tolerated |
| Maintenance steroid | Hydrocortisone 200 mg over 24 hours or 50 mg IV every 6 hours |
| Hypoglycemia | IV dextrose with repeated glucose monitoring |
| Trigger treatment | Cultures and antimicrobials for infection, hemorrhage control, or other cause-specific therapy |
| Monitoring | Blood pressure, glucose, electrolytes, renal function, urine output, and mental status |
Pharmacology
| Medication | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Hydrocortisone | Replaces glucocorticoid and provides mineralocorticoid activity at stress doses | Minutes to hours | First-line adrenal crisis therapy | 100 mg IV/IM then 200 mg/24 h |
| 0.9% saline | Restores sodium and intravascular volume | Minutes | Initial resuscitation | Individualize rate in heart or kidney disease |
| Dextrose | Raises serum glucose | Minutes | Hypoglycemia | Recheck glucose frequently |
| Norepinephrine | Alpha-predominant vasopressor support | Minutes | Persistent shock after fluids and steroids | Bridge while definitive therapy takes effect |
| Fludrocortisone | Mineralocorticoid replacement | Days | Chronic primary adrenal insufficiency | Not needed during high-dose hydrocortisone |
| Prednisolone | Alternative glucocorticoid | Hours | When hydrocortisone unavailable or during later oral transition | Less mineralocorticoid activity than hydrocortisone |
Prognosis / Complications
- Blood pressure and symptoms often improve rapidly after hydrocortisone and adequate volume replacement.
- Delayed treatment can lead to refractory shock, severe hypoglycemia, arrhythmia, neurologic injury, and death.
- Recurrent crises are often preventable with education, stress dosing, and access to injectable hydrocortisone.
- Patients with primary adrenal insufficiency require lifelong glucocorticoid and usually mineralocorticoid replacement.
- Glucocorticoid-induced adrenal insufficiency may recover over time, but recovery is variable and should be assessed during a supervised taper.
Patient Education / Counseling
- Carry a steroid emergency card or medical-alert identification at all times.
- Keep an emergency hydrocortisone injection kit and ensure family or close contacts know how to use it.
- Use sick-day dose escalation for febrile illness and seek parenteral treatment when vomiting prevents oral medication absorption.
- Never stop chronic glucocorticoids abruptly after prolonged exposure without a clinician-directed plan.
- Seek emergency care for persistent vomiting, fainting, severe weakness, confusion, or inability to keep stress-dose steroids down.
Notes
Adrenal crisis is one of the clearest examples of a condition in which treatment should precede diagnostic certainty. Hydrocortisone and saline are low-delay, high-benefit interventions in a compatible shock syndrome, while waiting for a cortisol result can be dangerous. Once the immediate crisis is reversed, the second task is preventing the next one. That requires identification of the underlying adrenal disorder, a safe maintenance or taper plan, written stress-dosing rules, medical-alert identification, and an emergency injection kit that the patient and household know how to use.
References
- Endocrine Society Guideline: Primary Adrenal Insufficiency — Link
- 2024 ESE/Endocrine Society Guideline: Glucocorticoid-Induced Adrenal Insufficiency — Link
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