Bedside Snapshot
- Use It For
- Adrenal crisis and stress dosing in adrenal insufficiency; septic shock (adjunct); severe community-acquired pneumonia in the ICU; severe allergic states when oral steroids are not feasible
- Adult Dose
- Adrenal crisis: 100 mg IV/IM now, then 200 mg/24 hr
- Septic shock: 50 mg IV every 6 hr or 200 mg/24 hr infusion
- Severe CAP: 200 mg/24 hr infusion, then taper
- Asthma, no oral route: 100 mg IV every 6 hr
- Pediatric Dose
- Adrenal crisis: 2 mg/kg IV/IM (IO off-label, per protocol), max 100 mg, per NASEMSO p.108; then 1 mg/kg (max 50 mg) every 6 hr once stable, per BSPED 2023; neonates 4 mg/kg. Weight unknown: length-based tape
- Onset / Duration
- IV/IM: effects within 1 hr; for sustained levels redose every 4–6 hr (guideline regimens use every 6 hr) or infuse; excretion nearly complete by 12 hr; biologic effect 8–12 hr
- Do Not Give / Hold If
- Nothing absolute in suspected adrenal crisis. Otherwise contraindicated: systemic fungal infection; hypersensitivity; intrathecal use; IM route in ITP. Never epidural (label warning). Not indicated: sepsis without shock
- Watch For
- Hyperglycemia (glucose); hypernatremia and fluid retention (Na⁺, edema); hypokalemia (K⁺, ECG); delirium; masked infection and GI bleeding
- Reversal / Rescue
- No reversal agent: supportive care (insulin, K⁺ replacement). In crisis, also give isotonic fluids and treat hypoglycemia with dextrose. Never stop a long course abruptly
- Must Remember
- Suspected adrenal crisis: give 100 mg IV/IM before any test. Use the patient's own Act-O-Vial IM if protocol allows; do not wait for IV access
Indications
Emergency & Prehospital
- Adrenal crisis and shock with steroid dependence: the patient has known or suspected adrenal insufficiency (Addison disease, congenital adrenal hyperplasia, pituitary disease) or recent steroid use, and now has shock, collapse or vomiting. NASEMSO's shock protocol reaches for it in adrenal insufficiency, long-term steroid dependence or fluid-refractory shock on vasopressors. It is preferred over methylprednisolone and dexamethasone (NASEMSO v3.0, pp. 108–109)
- Severe allergic reaction: an adjunct only. Give IM epinephrine first. The label supports it when oral therapy is not feasible
- Severe asthma or COPD: reach for it only when an oral steroid cannot be taken (COPD is off-label). Oral prednisone, or IV methylprednisolone or dexamethasone, gets used more often
ED / ICU / Transport
- Septic shock: an add-on to fluids and vasopressors (norepinephrine, vasopressin), not a substitute for them. The adult recommendation is conditional (SSC 2026, SCCM 2024), and the use is off-label. See sepsis and septic shock
- Severe community-acquired pneumonia in the ICU: SCCM 2024 gives it a strong recommendation for severe bacterial CAP, and ATS 2025 agrees. Neither covers nonsevere CAP or influenza pneumonia. Look at the taper: CAPE COD (with taper) reduced mortality, while REMAP-CAP (no taper) did not (off-label)
- Stress dosing in known adrenal insufficiency: major surgery, trauma, labor, critical illness
- ARDS: SCCM 2024 conditionally recommends corticosteroids and names no preferred agent. See ARDS
Other Uses
- Chronic adrenal insufficiency: an oral maintenance glucocorticoid, with fludrocortisone added in primary disease
- Labeled inflammatory and immune disorders: when an IV or IM steroid is needed. Specialists handle these.
Dosing & Administration
Every adult row follows the US label or the guideline named in it. Pediatric rows go to AHA/AAP 2025 first, then NASEMSO v3.0, then the US label. Check the note under the pediatric table.
Available Forms
- Solu-Cortef Act-O-Vial, preservative-free single-dose vials: 100 mg in 2 mL (50 mg/mL) after mixing, the emergency-kit size; 250 mg in 2 mL; 500 mg in 4 mL; 1,000 mg in 8 mL.
- Solu-Cortef 100 mg plain vial: no diluent; add no more than 2 mL of bacteriostatic water or bacteriostatic sodium chloride.
- Oral: tablets for maintenance; Alkindi Sprinkle granules 0.5, 1, 2 and 5 mg for children.
Adult Dosing
| Indication | Dose & Route | Repeat / Max | Notes |
|---|---|---|---|
| Adrenal crisis (suspected or known) | 100 mg IV/IM immediately (IO off-label, per protocol) | Then 200 mg/24 hr: continuous IV infusion or 50 mg IV/IM every 6 hr until recovery; higher doses may be considered at very high body weight | Do not wait for cortisol. Rapid IV 0.9% saline resuscitation (ESE 2024 gives no volume); check glucose. No step-down schedule is stated by the sources used; reduce as the patient recovers. |
| Stress dosing in known adrenal insufficiency | 100 mg IV | Then 200 mg/24 hr infusion, or 50 mg IV/IM every 6 hr | Labor: 100 mg IV at onset, then the infusion. Taper as the stressor resolves. |
| Septic shock (adjunct) | 50 mg IV every 6 hr, or 200 mg/24 hr continuous infusion | Usual 200 mg/day for 7 days or until ICU discharge; SCCM 2024 advises against >400 mg/day for <3 days | Conditional (SSC 2026, SCCM 2024); no set vasopressor threshold. Optional fludrocortisone 50 mcg daily (APROCCHSS). |
| Severe CAP, ICU (CAPE COD regimen) | 200 mg/24 hr continuous IV infusion, started within 24 hr of the first severity criterion | Full dose 4 days (7 if not improving), then 100 mg/day for 2 (or 4) days, then 50 mg/day for 2 (or 3) days: 8 or 14 days total; stop at ICU discharge | SCCM 2024 strong; ATS 2025 supports. Excluded: influenza (positive rapid PCR), aspiration, and vasopressor-dependent shock at enrollment. |
| Acute severe asthma, oral steroid cannot be taken | 100 mg IV every 6 hr | Max 400 mg/day; higher doses add no benefit (BTS/SIGN) | Switch to oral prednisone or prednisolone once it can be kept down. |
| Other labeled indications when oral therapy is not feasible | 100–500 mg IV/IM initially (label range) | Repeat every 2, 4 or 6 hr; high doses rarely beyond 48–72 hr (hypernatremia) | Anaphylaxis: optional adjunct only, after IM epinephrine; the top of this range (500 mg) is not a routine EMS or ED dose. Push 100 mg over 30 sec; 500 mg or more over 10 min (label). |
| Chronic adrenal insufficiency (maintenance) | 15–25 mg/day PO in 2–3 divided doses | Largest dose on waking; double for fever or illness; inject if vomiting or unable to take it | Primary adrenal insufficiency also needs fludrocortisone (median 0.1 mg/day). |
Pediatric Dosing
| Indication | Dose (per kg) & Route | Max Single / Max Total | Notes |
|---|---|---|---|
| Adrenal crisis (older than 28 days) | 2 mg/kg IV/IM (IO off-label, per protocol) | Max 100 mg/dose; repeat every 6 hr; once stable, 1 mg/kg (max 50 mg) every 6 hr | Initial: NASEMSO v3.0 p.108 (item 10); preference note p.109. Repeat: BSPED 2023. Off-label: the label gives no pediatric adrenal-crisis dose. Weight unknown: length-based tape. |
| Adrenal crisis, body-surface-area dosing | 50–100 mg/m² IV/IM | Then 50–100 mg/m²/day divided every 6 hr or as an infusion; bolus not above the adult 100 mg | Published guidance tabulated in BSPED 2023 (e.g. Bornstein 2016); off-label. BSPED's own recommendation is the weight-based dose above. Follow the family's written emergency plan if it states a dose. |
| Neonates (younger than 28 days corrected gestational age) | 4 mg/kg IV | Repeat every 6 hr; 2 mg/kg every 6 hr once stable | BSPED 2023 (off-label); specialist dosing. Preservative-free diluent; hypertrophic cardiomyopathy reported in premature infants. |
| Septic shock | Fluid-refractory shock requiring vasopressors, or adrenal insufficiency or long-term steroid dependence: 2 mg/kg IV/IM (max 100 mg) | Max 100 mg/dose; no ongoing dose is stated by the sources used | Dose: NASEMSO v3.0 p.108 item 10 (hydrocortisone preferred). SSC 2026: suggests against if fluids and vasoactives restore stability; no recommendation when shock persists. |
| Acute severe asthma, unable to keep oral steroid down | 4 mg/kg IV | Repeat every 4 hr (BTS/SIGN); max 100 mg per dose (adult cap, NASEMSO p. 13) | Oral prednisolone is preferred once it can be kept down. |
| Other labeled indications | 0.56–8 mg/kg/day IV/IM in 3–4 divided doses (20–240 mg/m²/day) | Labeled range of initial doses, not a maximum | Dose depends on the disease; anaphylaxis adjunct per protocol. |
AHA/AAP 2025 comes first for pediatric doses, when it states one. NASEMSO National Model EMS Clinical Guidelines v3.0 (2022) is next, then the US label. Where no source gives a dose, none is shown. A pediatric maximum never goes above the adult maximum dose (NASEMSO Universal Care Guideline, p. 13). Unless a row is marked labeled, the dose is off-label. Check weight with pediatric weight-based dosing and length-based tape. From a 100 mg/2 mL Act-O-Vial, 25 mg is 0.5 mL and 50 mg is 1 mL.
Continuous Infusion
| Setting | Example Concentration | Start | Titrate | Usual Range / Max |
|---|---|---|---|---|
| Adult: adrenal crisis, stress dosing, septic shock, severe CAP | Example (institution-specific): 100 mg in 100 mL D5W or 0.9% NaCl (1 mg/mL); use within 12 hr (label) | 200 mg/24 hr (about 8.3 mg/hr), after a 100 mg bolus in adrenal crisis | Not titrated to BP; CAP: step down to 100, then 50 mg/24 hr | 200 mg/24 hr (septic shock: 7 days) |
| Pediatric adrenal crisis | Per PICU or pharmacy standard | 50–100 mg/m²/day after the bolus (published guidance tabulated in BSPED 2023, e.g. Bornstein 2016; off-label) | Step down as the child recovers | Adult maximum 200 mg/24 hr |
Preparation & Administration
- Act-O-Vial: press the activator, agitate gently, swab the stopper and withdraw; no further dilution for IV push or IM. IM: large muscle, outer thigh in kits; avoid the deltoid (subcutaneous atrophy).
- IV infusion: 100 mg in 100–1,000 mL D5W, 0.9% NaCl or D5/0.9% NaCl; do not mix with other drugs. Use within 12 hr at room temperature (protect from light) or 24 hr refrigerated.
- Never intrathecal or epidural: epidural injection has caused spinal cord infarction, paralysis, stroke and death. Keep it out of the spine.
Dosing Notes: Start with the equivalence: hydrocortisone 20 mg ≈ prednisone 5 mg ≈ methylprednisolone 4 mg ≈ dexamethasone 0.75 mg. Keep one difference in mind. Hydrocortisone carries the most mineralocorticoid (salt-retaining) effect. Dexamethasone carries almost none.
Contraindications & Precautions
Contraindications
- None absolute in suspected adrenal crisis. Withholding it is the greater risk.
- Systemic fungal infection (unless needed to control a drug reaction); known hypersensitivity; intrathecal administration
- IM injection in immune (idiopathic) thrombocytopenic purpura is out. Go IV only.
- Live vaccines during immunosuppressive doses. Replacement doses are not a barrier.
Precautions
- Infection: it masks fever. Watch for latent tuberculosis, hepatitis B reactivation, Strongyloides hyperinfection, and varicella or measles exposure in non-immune patients. Avoid it in cerebral malaria
- Sepsis without shock: no benefit has been shown. Save it for septic shock
- Diabetes, heart failure, hypertension, renal insufficiency: expect higher glucose, sodium and water retention, and potassium loss
- Recent MI (left ventricular free-wall rupture); GI disease (ulcer, diverticulitis, fresh anastomosis); myasthenia gravis and psychiatric history (acute weakness, psychosis); suspected pheochromocytoma (can trigger a fatal crisis); traumatic brain injury (no high-dose corticosteroids)
Hold / Reassess If
- Septic shock resolved and vasopressors off: stop or taper per ICU protocol
- Glucose above target despite insulin, or Na⁺ rising on high doses
- New delirium or psychosis, GI bleeding, or new infection
Treat first, test later: Hypotensive and steroid-dependent? Hydrocortisone goes in before any test. Send cortisol and ACTH only when the draw costs no time. Overtreatment is far less dangerous. Missing an adrenal crisis is not.
Adverse Effects & Toxicity
Common
- Hyperglycemia; hypernatremia and fluid retention; hypokalemia; insomnia, mood change; perineal burning after IV injection
- With prolonged use: Cushingoid features, osteoporosis, poor wound healing, growth suppression in children
Serious / Life-Threatening
| Effect | Recognition | Management |
|---|---|---|
| Hypernatremia, fluid overload | Rising Na⁺, edema, crackles; high doses beyond 48–72 hr | Restrict sodium; reduce dose |
| Hypokalemia | Low K⁺, U waves, ectopy; worse with diuretics, amphotericin B or digoxin | Replace K⁺; ECG monitoring |
| Infection (masked, opportunistic, reactivated) | Fever and peritoneal signs may be blunted | Culture early; treat; reassess the steroid |
| GI bleeding or perforation | Melena, falling hemoglobin, abdominal pain with few signs | Resuscitate, imaging, surgical consult |
| Acute myopathy, ICU weakness | Weakness, especially with neuromuscular blockers | Limit blocker exposure; recovery can take weeks to years |
Overdose & Toxicity Management
- Acute overdose: rarely dangerous. Give supportive care and check glucose and electrolytes. There is no antidote.
- Chronic excess: adrenal suppression can last months. Never stop a long course abruptly. Give stress doses during illness.
Monitoring
| Parameter | When / How Often | Target / Act If |
|---|---|---|
| Clinical: BP, MAP, mental status | Continuously in shock; every assessment | Hypotension despite fluids and steroid: start a vasopressor and seek the trigger. New delirium: reassess dose and other causes |
| Clinical: vasopressor dose | Hourly in septic shock | Falling requirement supports response; record at handoff |
| Laboratory: glucose | At presentation, then per glycemic protocol | |
| Laboratory: sodium, potassium, ECG | Baseline and daily; ECG in crisis | |
| Infection and GI bleeding | Daily temperature, WBC, cultures as indicated; stool and hemoglobin on high-dose therapy | Fever may be blunted: culture early. Bleeding: resuscitate and consult; stress ulcer prophylaxis per ICU protocol |
Interactions & Compatibility
| Drug / Class | Effect | What To Do |
|---|---|---|
| Strong CYP3A4 inducers (rifampin, phenytoin, carbamazepine, phenobarbital) | Faster cortisol clearance | Replacement and stress doses may need to be higher |
| CYP3A4 inhibitors (ketoconazole, erythromycin) | Higher steroid levels (ketoconazole slows some corticosteroids by up to 60%) | Watch for steroid adverse effects |
| Potassium-depleting drugs (loop and thiazide diuretics, amphotericin B), digoxin | Hypokalemia; arrhythmia with digoxin | Monitor K⁺ and ECG |
| Insulin and other antidiabetic drugs | Higher glucose | Adjust doses; monitor glucose |
| Warfarin | Response usually reduced | Monitor INR closely |
| NSAIDs and aspirin | More GI ulceration and bleeding | Avoid or add GI protection per protocol |
| Neuromuscular blockers; anticholinesterases in myasthenia gravis | Acute myopathy; severe weakness | Limit blocker duration; stop anticholinesterases 24 hr before if possible |
| Etomidate | Suppresses adrenal cortisol synthesis after one dose | Consider stress-dose hydrocortisone for refractory shock |
Estrogens, cyclosporine (seizures reported) and cholestyramine belong on the list too.
IV Compatibility
- Labeled diluents are D5W, 0.9% NaCl and D5/0.9% NaCl. Give it on a separate line, or flush before and after. Verify with an institutional compatibility resource.
Special Populations
- Pediatrics: children with adrenal insufficiency can crash fast, with hypoglycemia and hyponatremia. Find doses in the Pediatric Dosing table. Long courses slow growth.
- Neonates: avoid the benzyl alcohol (bacteriostatic) diluent. The Act-O-Vial diluent is preservative-free.
- Pregnancy: animal studies show cleft palate, and there are no adequate human studies. It is the preferred glucocorticoid in adrenal insufficiency, because the placenta inactivates much of it. Never withhold it in crisis or shock. Observe the newborn after large doses.
- Lactation: cortisol is normal in breast milk, and dangerous infant exposure is unlikely. A better-studied steroid may be preferred (LactMed). Medium to large doses can cut milk supply. An emergency dose is never withheld.
- Older Adults: start non-emergency dosing low. Delirium, hyperglycemia, fluid retention and osteoporosis come more easily here.
- Renal Impairment: no adjustment is established. Watch fluid, sodium and potassium.
- Hepatic Impairment: cirrhosis enhances the effect. No labeled adjustment exists.
- Obesity / Dosing Weight: adult doses stay fixed. At very high weight, higher crisis doses may be considered. Pediatric doses use actual weight, up to the adult cap.
- Thyroid Disease: clearance falls in hypothyroidism and rises in hyperthyroidism.
Field & Transport Considerations
- Scope: this is paramedic and above, plus RN and critical-care transport. EMT is not in the national model. Its own-medication exceptions cover only SL nitroglycerin and auto-injectors, and the model dropped the old 'assist patients with their own medications' wording. A patient or family member may have a hydrocortisone emergency kit. Paramedic-level EMS can give it (IM, or IV) under protocol. Whether EMS can use the patient's own supply depends on state law and agency protocol. Route: the FDA label lists IV or IM only. IO is off-label, used only when IV access cannot be obtained and the protocol allows it. In 2020 the Pediatric Endocrine Society found only a small number of states and provinces with legislation letting EMS give patient-carried medication, and with EMS glucocorticoid protocols. Check current state rules. It varies by state and agency protocol.
- Patient's own supply: look for a medical alert bracelet, a steroid emergency card or a written plan. Got an Act-O-Vial from the patient or family, and your protocol allows it? Give it IM at once. Don't wait for IV access. The Pediatric Endocrine Society urges exactly this.
- Storage & Stability: store at 20–25°C (68–77°F), and keep vehicle heat down. Once mixed, use it within 12 hr at room temperature, protected from light.
- Carried Concentration: both the 100 mg and the 250 mg Act-O-Vials mix to 2 mL, which means 50 mg/mL and 125 mg/mL. Say the dose in mg and the volume out loud.
- Crisis bundle: hydrocortisone, isotonic fluid bolus (adults: rapid 0.9% saline per ESE 2024; children 10 mL/kg per BSPED 2023, or 20 mL/kg in shock per NASEMSO p.108), glucose check, cardiac monitor for hyperkalemia. No steroid on board? Tell the receiving ED now, so it is ready when the patient arrives.
- Interfacility Transport: day of course, last bolus time or infusion rate, and whether fludrocortisone is ordered.
- Handoff Essentials: dose (mg), route, time and who gave it, response, glucose, K⁺ or ECG findings, fluids given.
Clinical Pearls
Shock that ignores fluids and pressors: Adrenal insufficiency or recent steroids, plus hypotension out of proportion to the trigger, vomiting or confusion? Treat it as adrenal crisis until proven otherwise. Give 100 mg hydrocortisone first. The diagnosis can wait.
Use the kit they carry: Plenty of ambulances don't stock hydrocortisone. Long transports can push the first dose back by hours. A family-supplied Act-O-Vial, given IM by EMS where protocol allows, closes that gap.
Exam discriminator: primary adrenal crisis brings hyponatremia, hyperkalemia and hypoglycemia, often with hyperpigmentation. Secondary insufficiency (pituitary or steroid-induced) usually leaves potassium alone.
No fludrocortisone needed in the crisis: At stress doses, hydrocortisone brings its own mineralocorticoid effect. BSPED 2023 says that effect is often enough. Restart maintenance fludrocortisone once the patient is stable and eating.
Septic shock: fludrocortisone is optional. In APROCCHSS, hydrocortisone 50 mg every 6 hr plus fludrocortisone 50 mcg daily for 7 days gave 90-day mortality of 43.0%, against 49.1%. The guidelines set no fludrocortisone rule.
Anaphylaxis still needs epinephrine: A steroid takes hours to work, and it does not treat airway edema, bronchospasm or shock. Give IM epinephrine first. Hydrocortisone is an add-on at most.
Pharmacology
Mechanism of Action
- It is identical to endogenous cortisol. It binds glucocorticoid receptors, which alter gene transcription and suppress inflammatory mediators and immune responses.
- It restores vascular response to catecholamines and supports glucose production. That reverses the vasoplegia and hypoglycemia of adrenal crisis.
- At stress doses, the mineralocorticoid effect drives sodium retention and potassium excretion. That is the cause of hypernatremia with prolonged high doses.
Pharmacokinetics
| Route | Onset | Peak | Duration |
|---|---|---|---|
| IV | Within 1 hr | — | Redose every 4–6 hr (guideline regimens use 6 hr) or infuse; excretion nearly complete by 12 hr |
| IM | Rapidly absorbed; similar to IV | — | Similar to IV |
| PO | — | — | Short half-life; split into 2–3 daily doses |
- Half-life: about 1.5 hr in healthy adults, IV or PO. The biologic effect lasts 8–12 hr.
- Metabolism: hepatic CYP3A4. Inhibitors slow clearance and inducers speed it. Cirrhosis and hypothyroidism slow it too.
Names & Classification
- Generic Name
- Hydrocortisone (cortisol); injection: hydrocortisone sodium succinate
- Brand Names
- Solu-Cortef (injection; Act-O-Vial and plain vials); Cortef (tablets); Alkindi Sprinkle (pediatric oral granules)
- Pharmacologic Class
- Short-acting glucocorticoid with mineralocorticoid activity
- Therapeutic Class
- Adrenal replacement; anti-inflammatory and immunosuppressant corticosteroid
- Controlled Substance
- Not controlled
- ISMP High-Alert
- No
- Look-Alike / Sound-Alike
- Solu-Cortef / Solu-Medrol (similar brand names; both are succinate powders in Act-O-Vials); hydrocortisone / hydrocodone
References
- Pharmacia & Upjohn Company (Pfizer). (2024). Solu-Cortef (hydrocortisone sodium succinate for injection, USP) [prescribing information] (revised July 2024). DailyMed, National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=65eefd58-b166-4d71-ade6-45c8fdf86922 ; and National Institute of Child Health and Human Development. (2026). Hydrocortisone. In Drugs and Lactation Database (LactMed) (updated March 15, 2026). National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK500976/ ; and Eton Pharmaceuticals. (2026). Alkindi Sprinkle (hydrocortisone) oral granules [prescribing information] (revised April 2026). DailyMed, National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=26c13a5f-7119-4c6a-bf10-fda4e07d7682
- Prescott, H. C., Antonelli, M., Alhazzani, W., Møller, M. H., et al. (2026). Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock 2026. Critical Care Medicine. https://doi.org/10.1097/CCM.0000000000007075
- Weiss, S. L., Peters, M. J., Oczkowski, S. J. W., Belley-Cote, E., et al. (2026). Surviving Sepsis Campaign international guidelines for the management of sepsis and septic shock in children 2026. Pediatric Critical Care Medicine, 27(4), 379–434. https://doi.org/10.1097/PCC.0000000000003927
- Chaudhuri, D., Nei, A. M., Rochwerg, B., Balk, R. A., et al. (2024). 2024 focused update: Guidelines on use of corticosteroids in sepsis, acute respiratory distress syndrome, and community-acquired pneumonia. Critical Care Medicine, 52(5), e219–e233. https://doi.org/10.1097/CCM.0000000000006172
- Jones, B. E., Ramirez, J. A., Oren, E., Soni, N. J., et al. (2025). Diagnosis and management of community-acquired pneumonia: An official American Thoracic Society clinical practice guideline. American Journal of Respiratory and Critical Care Medicine. https://doi.org/10.1164/rccm.202507-1692ST
- Annane, D., Renault, A., Brun-Buisson, C., Megarbane, B., et al. (2018). Hydrocortisone plus fludrocortisone for adults with septic shock (APROCCHSS; landmark trial). New England Journal of Medicine, 378(9), 809–818. https://doi.org/10.1056/NEJMoa1705716
- Dequin, P.-F., Meziani, F., Quenot, J.-P., Kamel, T., et al. (2023). Hydrocortisone in severe community-acquired pneumonia (CAPE COD). New England Journal of Medicine, 388(21), 1931–1941; and REMAP-CAP Investigators. (2025). Effect of hydrocortisone on mortality in patients with severe community-acquired pneumonia: The REMAP-CAP Corticosteroid Domain randomized clinical trial. Intensive Care Medicine, 51(4), 665–680. https://doi.org/10.1056/NEJMoa2215145 ; https://doi.org/10.1007/s00134-025-07861-w
- Beuschlein, F., Else, T., Bancos, I., Hahner, S., et al. (2024). European Society of Endocrinology and Endocrine Society joint clinical guideline: Diagnosis and therapy of glucocorticoid-induced adrenal insufficiency. Journal of Clinical Endocrinology & Metabolism, 109(7), 1657–1683; and Bornstein, S. R., Allolio, B., Arlt, W., Barthel, A., et al. (2016). Diagnosis and treatment of primary adrenal insufficiency: An Endocrine Society clinical practice guideline (landmark guideline). Journal of Clinical Endocrinology & Metabolism, 101(2), 364–389. https://doi.org/10.1210/clinem/dgae250 ; https://doi.org/10.1210/jc.2015-1710
- Mushtaq, T., Ali, S. R., Boulos, N., Boyle, R., et al. (2023). Emergency and perioperative management of adrenal insufficiency in children and young people: British Society for Paediatric Endocrinology and Diabetes consensus guidance. Archives of Disease in Childhood, 108(11), 871–878. https://doi.org/10.1136/archdischild-2022-325156 ; and British Thoracic Society and Scottish Intercollegiate Guidelines Network. (2019). SIGN 158: British guideline on the management of asthma (acute asthma recommendations retained after the 2024 BTS/NICE/SIGN update). SIGN. https://www.sign.ac.uk/media/1773/sign158-updated.pdf
- Miller, B. S., Spencer, S. P., Geffner, M. E., Gourgari, E., et al. (2020). Emergency management of adrenal insufficiency in children: Advocating for treatment options in outpatient and field settings. Journal of Investigative Medicine, 68(1), 16–25. https://doi.org/10.1136/jim-2019-000999
- National Association of State EMS Officials. (2022). National Model EMS Clinical Guidelines, Version 3.0 (rev. March 2022): Shock pp. 108–109; Universal Care p. 13 (copy hosted by Iowa HHS). https://hhs.iowa.gov/media/198/download
- National Highway Traffic Safety Administration. (2021). National EMS Scope of Practice Model 2019, including Change Notices 1.0 and 2.0 (DOT HS 813 151). https://mn.gov/oems/assets/National_EMS_Scope_of_Practice_Model_2021_%20%28002%29_tcm1221-744908.pdf
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- For Educational Purposes Only: This content is intended for educational reference and should not be used for clinical decision-making.
- Not a Substitute for Professional Judgment: Always consult your local protocols, institutional guidelines, and supervising physicians.
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