Adrenal Crisis

Adrenal crisis is an acute cortisol failure, and it can kill. It happens when the adrenal axis cannot answer a stressor. That covers true adrenal insufficiency, and it covers a patient whose axis has been shut down by steroid therapy. Without cortisol, the vessels go slack, plasma volume leaks away and blood glucose drops. In primary adrenal insufficiency, aldosterone goes too. The kidneys waste sodium and potassium climbs, so hyperkalemia joins the picture.

• Primary adrenal insufficiency (Addison disease): failure of the adrenal cortex itself, including congenital adrenal hyperplasia in children, per BSPED 2023. Cortisol and aldosterone are both deficient. For the landmark reference, see the Endocrine Society guideline of 2016 on primary adrenal insufficiency.
• Secondary adrenal insufficiency: the problem sits upstream. Pituitary or hypothalamic disease cuts ACTH, so the adrenal gland gets no signal. Aldosterone is usually preserved.
• Glucocorticoid-induced adrenal insufficiency: steroid therapy shuts the axis down. Glucocorticoid use above the physiologic dose for 3–4 weeks or longer suppresses the HPA axis. Mineralocorticoid function is expected to be preserved per ESE/ES 2024.
• Precipitants: the triggers that tip the patient over are infection with or without fever, trauma, surgery or procedures under anesthesia, labor and delivery, vomiting or diarrhea, dental procedures, and abrupt withdrawal or taper of glucocorticoids.
• Drugs and other routes: some drugs change how fast steroid leaves the body. Strong CYP3A4 inhibitors (for example ketoconazole, itraconazole, voriconazole, ritonavir, clarithromycin) push glucocorticoid levels up. Strong inducers (for example rifampicin, phenytoin, carbamazepine, phenobarbital, enzalutamide) speed clearance. High-dose inhaled or topical steroid (used for more than a year), an intra-articular injection within the previous 2 months, and multiple epidural injections also suppress the axis, per ESE/ES 2024.

It can be the first sign of a disease nobody has diagnosed yet. Treatment must not wait for laboratory or imaging results per ESE/ES 2024.

Typical Presentation

• Shock out of proportion to the trigger: hypotension or hypovolemic shock, plus at least one of nausea or vomiting, severe fatigue, fever, or impaired consciousness (lethargy, confusion, somnolence, collapse, delirium, coma or seizure). Labs back up the diagnosis. They are not required per ESE/ES 2024.
• Known or suspected steroid dependence: a known adrenal insufficiency diagnosis, pituitary disease, or glucocorticoid use above the physiologic dose (about 15–25 mg/day hydrocortisone, 4–6 mg/day prednisone or 0.25–0.5 mg/day dexamethasone) for 3–4 weeks or longer.
• Stopped, missed or vomited steroid doses: tablets stopped abruptly, not taken during an illness, or lost in transit.

Red Flags

• Hypotension that persists after the first fluid bolus
• Confusion, drowsiness, unresponsiveness or seizure
• Vomiting or diarrhea that prevents oral medicine
• Low glucose on point-of-care testing
• Hyperkalemia or hyponatremia on a blood sample, or ECG changes of hyperkalemia

Treatment starts first. Run these checks alongside the first steroid dose. None of them gets to delay it.

• Septic shock: the fever and the hypotension overlap. Infection is also the most common trigger, so both can coexist. Give the steroid and treat the source. Don't treat sepsis alone.
• Hemorrhagic or hypovolemic shock: look for visible or occult bleeding and a falling hemoglobin. Crisis can ride along with volume loss, so give the steroid anyway (Shock States).
• Diabetic ketoacidosis: vomiting and abdominal pain, with high glucose, ketones and acidosis. Crisis more often shows low or normal glucose. Check it rather than assume hyperglycemia.
• Anaphylaxis: hives, swelling and wheeze after an exposure. Treat with IM epinephrine first. Steroid is no substitute for epinephrine (Anaphylaxis).
• Opioid or sedative toxicity: depressed breathing and consciousness, with pinpoint pupils in opioid cases. Check glucose and the response to naloxone. Just don't assume toxicity alone explains the hypotension.

1. Scene safety and primary survey: assess airway, breathing, circulation and mental status. Treat life threats first.
2. Ask about steroids: ask the patient or family about steroid tablets, injections, an emergency card, a medical alert bracelet or a written emergency plan. Relay what is found to ALS.
3. Patient's own injection kit: if the patient carries hydrocortisone sodium succinate (Solu-Cortef Act-O-Vial 100 mg) and the local protocol allows it, help the patient or family give it IM right away instead of waiting on IV access (per local protocol; scope varies by state and agency). IM is contraindicated in idiopathic thrombocytopenic purpura, so give IV there. Field and outpatient options for children are covered in the Miller reference under References.
4. Oral doses are not reliable in crisis: don't count on tablets for a patient who is vomiting, drowsy or unresponsive. Use the injection route per protocol, per BSPED 2023.
5. Oxygen and position: oxygen for hypoxia or shock. Supine with legs raised for hypotension if breathing is adequate; sitting up if breathing is hard.
6. Glucose: check if the protocol allows. Treat low glucose per protocol if the patient can swallow safely.
7. Monitor and keep warm: vital signs and mental status at least every 5 minutes. Keep the patient warm and do not let them walk.
8. Call ALS early and report the steroid type and dose, the time of the last dose, vomiting, and the kit used.

Doses vary by protocol; follow local protocols and medical direction. Once adrenal crisis is suspected, the glucocorticoid goes in. Don't let labs or imaging delay it.

• Hydrocortisone (Paramedic/RN/CCT): adult 100 mg IV or IM immediately (IO per protocol). Then 200 mg/24 hr by continuous infusion, or 50 mg IV or IM every 6 hr, until recovery per ESE/ES 2024. Give the 100 mg bolus IV over 30 seconds or IM. See Hydrocortisone
• Steroid kit (Paramedic/RN/CCT): the Solu-Cortef Act-O-Vial 100 mg, which gives 100 mg in 2 mL after mixing, is the emergency-kit size. Inject IM into a large muscle, except in idiopathic thrombocytopenic purpura, where IM is contraindicated and IV is used instead. Repeat doses follow the protocol schedule in ALS and ED sections
• IV or IO access (Paramedic/RN/CCT): two large-bore IVs if possible. IO if IV access fails (IO access)
• Fluid (Paramedic/RN/CCT): rapid 0.9% saline bolus for hypotension. ESE/ES 2024 calls for rapid volume resuscitation with 0.9% saline or an equivalent, and it sets no fixed volume. Take the volume from protocol, then reassess lungs, SpO₂ and perfusion after each bolus. See Normal Saline
• Glucose (Paramedic/RN/CCT): check glucose now and repeat per protocol. Treat low glucose with dextrose per protocol. See Dextrose
• Vasopressor (Paramedic/RN/CCT, ICU): start if hypotension persists after adequate fluid and steroid, per protocol. See Norepinephrine
• Monitoring: continuous cardiac monitoring, BP and SpO₂. 12-lead ECG for hyperkalemia changes or arrhythmia (12-lead ECG)
• Airway: vomiting, declining consciousness or failure to protect the airway: advanced airway per protocol (Intubation)
• Pediatric dosing: age- or weight-based hydrocortisone; see Special Populations

• Maintain glucocorticoid: hydrocortisone 200 mg/24 hr continuous infusion, or 50 mg IV every 6 hr, until clinical recovery. Step down only with endocrinology input. Don't stop abruptly, per ESE/ES 2024.
• Diagnostics: glucose, sodium, potassium, BUN, creatinine and CBC. Send cortisol and ACTH only if the draw adds no delay. Blood cultures and lactate when infection is possible.
• Electrolytes: treat hyponatremia and hyperkalemia per protocol. Correct sodium per protocol. See Hyperkalemia and Hypoglycemia
• Glucose: check glucose frequently and continue dextrose if glucose stays low, per the glycemic protocol.
• Vasopressors and ventilation: escalate per the shock protocol if hypotension persists after adequate fluid and steroid. Airway and ventilator support per the ICU team.
• Find the trigger: infection, bleeding, surgery, a new medication or a missed steroid dose. Treat it while the steroid runs.
• Consults: bring in endocrinology early, for the steroid plan and for primary adrenal insufficiency. In primary adrenal insufficiency, mineralocorticoid replacement is needed after recovery, per the Endocrine Society 2016 guideline.
• Disposition: admit if symptoms persist or instability develops. Shock, a depressed level of consciousness or an ongoing vasopressor need points to ICU or step-down care.

• EMS: take any patient with suspected adrenal crisis to a hospital that can give IV steroid, fluid and glucose monitoring. Give the first steroid dose before you leave. Don't hold transport for labs, or for a hunt for the steroid kit.
• Transport: keep watching glucose, rhythm, BP and mental status. Hold to the maintenance schedule started in the ED (50 mg every 6 hr, or 200 mg/24 hr). The kit travels with the patient.
• Handoff: the steroid type, dose, route and time of each dose, total fluid volume, glucose trend, last steroid dose at home, the response, and the emergency card or medical alert information.
• Interfacility: keep the infusion, the glucose plan and the fluid plan running. Send the patient's own emergency kit and any paperwork along.

• Pediatrics: the doses on this page are the BSPED 2023 (UK) values. Age bands and weight-based doses are both BSPED options, and for the same child they can be far apart. A 6-year-old of about 20 kg gets 100 mg by age band but 40 mg at 2 mg/kg. With no weight, use the age band for the IM or IV dose: under 1 year 25 mg, 1–5 years 50 mg, 6 years and older 100 mg. Other published band sets differ. One regimen in BSPED 2023's comparison table uses 0–2 years 25 mg, 2–6 years 50 mg and over 6 years 100 mg. With a known weight, children over 28 days corrected gestational age get 2 mg/kg IV first (max 100 mg; IO per protocol). Then 2 mg/kg every 6 hr while unstable (4-hourly or an infusion can be considered), then 1 mg/kg (max 50 mg) every 6 hr once stable and improving. Neonates under 28 days corrected gestational age get 4 mg/kg IV first, then 4 mg/kg every 6 hr while unstable, then 2 mg/kg every 6 hr once stable and improving. A published regimen (BNFc, listed in BSPED 2023) uses 50–100 mg/m² initially, then 50–100 mg/m² per day. Where these differ, follow local protocol or medical direction. Low glucose below 3 mmol/L (about 54 mg/dL) gets 2 mL/kg of 10% glucose IV, rechecked after 15 min and repeated if needed. That is the BSPED dose. US pediatric protocols commonly use 0.5–1 g/kg (D10 5–10 mL/kg) with a different threshold, so follow local protocol. Shock or moderate to severe dehydration gets a 10 mL/kg 0.9% saline bolus, repeated if needed. For maintenance, BSPED suggests 0.9% saline with 5% glucose (100 mL/kg/day for the first 10 kg, 50 mL/kg/day for the next 10 kg, then 20 mL/kg/day). BSPED 2023 says to give emergency hydrocortisone to any unwell child with adrenal insufficiency, without delay. See weight-based dosing, length-based tape and pediatric vital signs
• Pregnancy: never hold back hydrocortisone in adrenal crisis. For glucocorticoid-induced adrenal insufficiency, ESE/ES 2024 sets stress regimens for labor and cesarean section. At labor onset: hydrocortisone 100 mg IV, then 200 mg/24 hr by infusion (or 50 mg IV every 6 hr). For cesarean section: 100 mg IV at induction, then 200 mg/24 hr (or 50 mg IV every 6 hr). Hydrocortisone is still the recommended crisis steroid. Reach for another glucocorticoid only when hydrocortisone is unavailable (see Dexamethasone). Notify obstetrics early.
• Older Adults: risk factors include a previous adrenal crisis, age above 65, adolescence and the move from pediatric to adult care, and higher comorbidity (ESE/ES 2024). Watch for delirium. It can be the sign of crisis.
• Renal Impairment: no hydrocortisone adjustment is established for renal impairment. Manage fluid and potassium by renal status and reassessment.
• Hepatic Impairment: no hydrocortisone adjustment is established for hepatic impairment. Set the steroid plan by the clinical course and endocrinology advice.
• Obesity: in very high body weight, higher doses may be considered, per ESE/ES 2024.

• Error: waiting for cortisol, ACTH or imaging before the first steroid dose. Hydrocortisone goes first, per ESE/ES 2024.
• Error: treating a steroid-dependent patient in shock with fluid and vasopressors alone. That shock resists both until a parenteral glucocorticoid is given, per ESE/ES 2024.
• Error: using dexamethasone in place of hydrocortisone when hydrocortisone is available. Hydrocortisone is the recommended crisis steroid. Dexamethasone has little mineralocorticoid effect (Dexamethasone). If only another parenteral glucocorticoid is on the shelf, give it per local protocol instead of waiting. ESE/ES 2024 notes that some centers use equivalent parenteral doses of methylprednisolone or dexamethasone. Head-to-head data are lacking.
• Error: giving oral tablets to a vomiting or drowsy patient. Use the injection route per protocol, per BSPED 2023.
• Error: mixing the powder wrong or giving it by the wrong route. The 100 mg plain vial takes no more than 2 mL of bacteriostatic water or bacteriostatic saline. Bacteriostatic water contains benzyl alcohol, and its label says it is not for use in neonates. For neonates and infants, discuss the diluent with pharmacy first. Prefer the Act-O-Vial, whose diluent is preservative-free. The Act-O-Vial mixes inside the vial. Use mixed solution within 12 hours at room temperature. Hydrocortisone is contraindicated intrathecally. Epidural use has caused spinal cord infarction (Solu-Cortef label).
• Error: leaving glucose unchecked. Hypoglycemia shows up in crisis. Check it early and repeat it.
• Error: stopping the steroid abruptly, or missing the sick-day dose increase in a patient on replacement. Illness or procedure calls for extra steroid cover, per ESE/ES 2024.
• Error: giving the adult 100 mg dose to an infant. Use the age band or the weight-based dose, per BSPED 2023.