Suspected Adrenal Crisis
Known AI patient OR high clinical suspicion
All Pathways
EndocrinologyEmergency
Adrenal Crisis (Addisonian Crisis) Management
Adrenal Crisis (Addisonian Crisis) Management: Suspected Adrenal Crisis → Recognize Clinical Features → High-Risk Populations → 1. IMMEDIATE Hydrocortis...
Pathway Overview
13 steps
Algorithm Steps
13 total
01Start 02Action Recognize Clinical Features
Life-threatening presentation
- Profound hypotension/shock (refractory to fluids/pressors)
- Severe weakness, fatigue, lethargy
- Nausea, vomiting, abdominal pain
- Fever (may mimic sepsis)
- Altered mental status, confusion
- Hyperpigmentation (primary AI)
- History of AI or chronic steroid use
03Action High-Risk Populations
Who to suspect
- Known adrenal insufficiency (primary or secondary)
- Current or recent glucocorticoid use (ANY route)
- Bilateral adrenalectomy
- Pituitary disease/surgery
- Autoimmune conditions (autoimmune AI)
- Recent discontinuation of steroids
- Sepsis with refractory hypotension
04Action 1. IMMEDIATE Hydrocortisone
DO NOT DELAY - treat empirically
- Hydrocortisone 100 mg IV bolus STAT
- Adults: 100 mg IV push immediately
- Pediatrics: 50 mg/m² (max 100 mg) IV
- If hydrocortisone unavailable: Prednisolone 25 mg IV
- Dexamethasone 4 mg IV ONLY if testing needed (doesn't interfere with cortisol assay)
- DO NOT wait for labs to treat if clinical suspicion high
05Action 2. Aggressive IV Fluids
Volume expansion critical
- 0.9% Normal Saline 1L IV bolus
- Then 0.9% NS at 200-500 mL/hr
- Add D5NS if hypoglycemic
- May require 2-3L in first few hours
- Monitor for fluid overload
06Action 4. Treat Hypoglycemia
Common in adrenal crisis
- Check glucose immediately
- D50W 25-50 mL IV if hypoglycemic
- Use dextrose-containing fluids
- Monitor glucose frequently
07Action 5. Identify & Treat Precipitant
Crisis usually triggered by stress
- Infection (most common) - cultures, empiric antibiotics if septic
- Surgery or trauma
- Missed steroid doses / non-compliance
- GI illness with vomiting (can't absorb PO)
- Emotional stress
- Adrenal hemorrhage (consider CT)
08Action 6. Monitoring
Close observation
- Blood pressure, HR (q15-30min initially)
- Mental status
- Glucose (q1-2h)
- Electrolytes: Na, K (hyponatremia, hyperkalemia common)
- Cortisol, ACTH (before treatment if possible, but DON'T delay treatment)
09Decision Clinical Response?
Assess within 1-2 hours
10Outcome Improving
Continue therapy and taper
- Continue hydrocortisone, gradually taper
- When stable: transition to PO
- Add fludrocortisone when IV hydrocortisone stopped (primary AI)
- Establish maintenance dosing
- Patient education on sick-day rules
11Warning Refractory
No response to treatment
- Ensure adequate steroid dosing
- Aggressive fluid resuscitation
- Search for untreated infection/precipitant
- Consider alternative diagnoses
- ICU admission if not already
12Action 3. Ongoing Steroid Replacement
After initial bolus
- Hydrocortisone 200 mg/24h total
- Options: 50 mg IV q6h OR continuous infusion
- Continuous infusion may provide more stable levels
- No mineralocorticoid needed acutely (hydrocortisone has MC activity at high doses)
- Taper as patient improves
- Path rejoins step 06Shared downstream outcome
13Warning ⚠️ Vasopressor Warning
Pressors less effective without steroids
- Adrenal crisis causes catecholamine resistance
- Vasopressors may be ineffective until steroids given
- Always give hydrocortisone with pressors
- Response to pressors improves after steroids
Guideline Source
Diagnosis and Treatment of Primary Adrenal Insufficiency: Endocrine Society Clinical Practice Guideline + ESE/ES Joint Guideline 2024
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Does not differentiate primary vs secondary AI management in detail
- Pediatric doses differ (50-100 mg/m²)
- Does not cover chronic AI management
- Requires high clinical suspicion in undiagnosed patients
Applicable Regions
USEU
EU: ESE/ES joint guidelines also apply
US: Based on Endocrine Society guidelines
Version 1Next review: 2027-01-01
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Related Resources
Frequently Asked Questions
What is the Adrenal Crisis (Addisonian Crisis) Management?
The Adrenal Crisis (Addisonian Crisis) Management is a emergency clinical algorithm for Endocrinology. It provides a structured decision tree to guide clinical decision-making, based on Diagnosis and Treatment of Primary Adrenal Insufficiency: Endocrine Society Clinical Practice Guideline + ESE/ES Joint Guideline 2024.
What guideline is the Adrenal Crisis (Addisonian Crisis) Management based on?
This algorithm is based on Diagnosis and Treatment of Primary Adrenal Insufficiency: Endocrine Society Clinical Practice Guideline + ESE/ES Joint Guideline 2024 (DOI: 10.1210/jc.2015-1710).
What are the limitations of the Adrenal Crisis (Addisonian Crisis) Management?
Known limitations include: Does not differentiate primary vs secondary AI management in detail; Pediatric doses differ (50-100 mg/m²); Does not cover chronic AI management; Requires high clinical suspicion in undiagnosed patients. Individual patient factors may require deviation from these recommendations.
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