Suspected adrenal crisis
Known adrenal insufficiency, recent glucocorticoid use, or shock out of proportion to the illness. Treat first; test later.
All Pathways
EndocrinologyEmergency
Adrenal Crisis (Addisonian Crisis) Management
Adrenal Crisis (Addisonian Crisis) Management: Suspected adrenal crisis → Recognise adrenal crisis → Who is at risk → 1. Hydrocortisone NOW: adult 100 m...
Pathway Overview
18 steps
Algorithm Steps
18 total
01Start 02Action Recognise adrenal crisis
Hypotension or shock plus 1 or more: vomiting, severe fatigue, fever, reduced consciousness. At-risk patient who is vomiting or unwell: treat as impending crisis.
- Hypotension (including postural) or shock, often out of proportion to the trigger
- Plus 1 or more: nausea or vomiting, severe fatigue, fever, reduced consciousness (confusion, drowsiness, collapse, seizures)
- Impending crisis: at-risk patient who is vomiting, cannot take or absorb oral glucocorticoid, or has milder symptoms (lethargy, weakness, confusion). Give hydrocortisone now as in step 4
- Child: low glucose is common and can come before hypotension
- Abdominal pain and guarding can mimic an acute abdomen
- Labs support but are not needed: low Na, high K (primary AI), low glucose, raised urea and creatinine
- Primary AI: skin pigmentation. Secondary AI: pale skin, K often normal
03Action Who is at risk
Suspect it in these patients, whatever the glucocorticoid dose, type or route
- Known adrenal insufficiency (primary, secondary, or congenital adrenal hyperplasia)
- Current or recent glucocorticoid use by any route, including a recent taper or stop
- Pituitary disease or surgery; bilateral adrenalectomy
- Previous adrenal crisis, age over 65, adolescents
- Undiagnosed patient with shock that does not respond to fluids or vasopressors
04Action 1. Hydrocortisone NOW: adult 100 mg IV or IM
Do not wait for tests. Child: 50 mg/m2 (max 100 mg) IV or IM, or dose by age below.
- Adult: hydrocortisone 100 mg IV bolus; give IM if no IV access
- Child: 50 mg/m2 (max 100 mg). By age: under 3 years 25 mg; 3-12 years 50 mg; over 12 years 100 mg
- Child with their own adrenal crisis plan: follow that plan
- Not yet diagnosed: take cortisol and ACTH before the dose only if this causes no delay
- Also take UEC, glucose, blood gas and FBC; blood cultures if infection is possible
05Action If no hydrocortisone: give a parenteral alternative
Prednisolone IV where available; in Australia use methylprednisolone IV or IM. Dexamethasone is the last choice; avoid it in pregnancy.
- Shock or vomiting: use an IV or IM glucocorticoid. Oral prednisolone only if the patient can swallow and absorb it
- Australia: no injectable prednisolone is registered; methylprednisolone IV or IM is the parenteral alternative
- Dexamethasone only if no other glucocorticoid is available; it has no mineralocorticoid effect
- Pregnancy: avoid dexamethasone; it crosses the placenta
- Equivalents per 24 h: hydrocortisone 200 mg = prednisolone 50 mg = methylprednisolone 40 mg = dexamethasone 6-8 mg
- Change to hydrocortisone as soon as it is available
06Warning Fluid cautions: low sodium, older age, kidney or heart failure
Still give hydrocortisone and the first fluid bolus in shock. Never delay them for these cautions.
- Low Na: check Na every 2-4 h. Limit rise to 10 mmol/L in the first 24 h (child: 8 mmol/L), then 8 mmol/L per 24 h. Fast rise risks osmotic demyelination
- Older age, kidney impairment or heart failure: smaller boluses, reassess after each, watch for fluid overload
- Na rising too fast: get endocrinology or ICU advice now (5% glucose, desmopressin). Do not stop hydrocortisone
07Action 2. IV fluids: 0.9% sodium chloride
Adult: 1 L over the first hour. Child in shock: 10 mL/kg bolus (max 1000 mL), then reassess.
- Adult: 0.9% sodium chloride 1000 mL IV over the first hour
- Adult, after that: more IV fluid by response; often 4-6 L in 24 h
- Child in shock: 0.9% sodium chloride 10 mL/kg IV bolus (max 1000 mL); reassess; repeat until circulation is restored
- Child: senior review at 20 mL/kg total boluses; consider inotropes at 40 mL/kg
- Child, after that: deficit plus maintenance over 24 h as 0.9% sodium chloride with 5% glucose
- Low glucose: use 5% glucose in 0.9% sodium chloride
08Warning Shock persists: vasopressors fail without hydrocortisone
Check that hydrocortisone has been given.
- Shock in adrenal crisis resists fluids and vasopressors until a parenteral glucocorticoid is given
- Give hydrocortisone before or with any vasopressor. Never wait
- Shock despite hydrocortisone and fluids: start vasopressors and call ICU
09Action 3. Check glucose now; treat if below 4.0 mmol/L
Low glucose is more common in children.
- Adult: glucose 0.5-1 g/kg IV, max 25 g per dose (for example 10% glucose up to 250 mL); recheck in 15 min
- Child: 10% glucose 2-5 mL/kg IV (max 250 mL = 25 g); recheck at 15 and 30 min; target above 4.0 mmol/L
- Then give glucose-containing IV fluid and check glucose hourly
10Action 4. Continue hydrocortisone
Adult: 200 mg per 24 h by continuous IV infusion, or 50 mg IV or IM every 6 h.
- Adult: hydrocortisone 200 mg/24 h continuous IV infusion, or 50 mg IV or IM every 6 h
- Child: 50-100 mg/m2/day IV divided every 6 h
- Child by age, every 6 h: under 6 weeks 5-10 mg; 6 weeks-2 years 10 mg; 3-6 years 12.5 mg; 7-12 years 25 mg; over 12 years 25 mg
- Child with poor response in the first hour: consider a repeat bolus dose
- No fludrocortisone needed while hydrocortisone is 50 mg/day or more
11Action 5. Find and treat the trigger
Infection is the most common trigger. Sepsis: give antibiotics without delay.
- Infection, including gastroenteritis: cultures; antibiotics now if sepsis is possible
- Missed or stopped glucocorticoid; vomiting so oral doses are not absorbed
- Surgery, trauma, labour, severe emotional stress
- New drugs: starting levothyroxine; CYP3A4 inducers (for example carbamazepine, mitotane, St John's wort)
- Check TSH and fT4. Do not start levothyroxine before glucocorticoid cover
- Adrenal haemorrhage (anticoagulants, sepsis): consider CT
12Action 6. Monitor and call endocrinology
Call endocrinology early. High K with ECG changes: treat now; do not wait for hydrocortisone to work.
- BP, HR and conscious state every 15-30 min until stable
- Glucose and blood gas hourly for 2 h, then every 2-4 h
- UEC every 2-4 h; keep Na rise within the limit above
- K usually falls with fluids and hydrocortisone. High K with ECG changes: treat as hyperkalaemia now
- Endocrinology: tapering, cause, primary or secondary AI
13Decision Improving within 1-2 hours?
BP, perfusion, conscious state and glucose
- If Yes
- Improving
14Action Improving: continue 200 mg/24 h, taper from day 2
Adult: 200 mg/24 h for 24 h, then 100 mg/24 h the next day. Taper with endocrinology.
- Adult: hydrocortisone 200 mg/24 h for 24 h, then 100 mg/24 h the next day
- Eating and stable: change to oral hydrocortisone at a raised dose (child: triple dose, about 30-50 mg/m2/day), then taper to maintenance
- Primary AI: start fludrocortisone 100 micrograms daily once hydrocortisone is below 50 mg/day (child: 50-100 micrograms/day, with endocrinology)
- Not yet diagnosed: confirm the diagnosis after recovery (short Synacthen test, cortisol, ACTH, renin, aldosterone)
15Action Before discharge: prevent the next crisis
Steroid emergency card, injection kit and training, sick day rules, endocrine follow-up. Child: IM dose by age.
- Steroid emergency card and medical alert ID
- Hydrocortisone 100 mg injection kit; train patient and carers to give it IM
- Child emergency IM dose: under 3 years 25 mg; 3-12 years 50 mg; over 12 years 100 mg, or as the child's own plan
- Sick day rules (adult): fever above 38 C double, above 39 C triple the oral dose; vomiting or unable to take tablets: hydrocortisone 100 mg IM (child: dose by age) and seek care
- Endocrinology follow-up; review the trigger and interacting drugs
- Pregnancy: maintenance dose often raised 20-40% from 24 weeks; labour: hydrocortisone 100 mg IV, then 200 mg/24 h
16Outcome Recovered: discharge with crisis plan
Endocrinology follow-up arranged.
If No- Not improving
17Action Not improving: escalate to ICU
Check hydrocortisone was given at full dose. Look for sepsis, bleeding or another cause of shock.
- Confirm hydrocortisone dose given; child: consider a repeat bolus
- Reassess fluid status; avoid fluid overload
- Vasopressors as for septic shock
- Look for untreated sepsis, adrenal haemorrhage, cardiac or other cause of shock
- ICU admission
18Outcome ICU care with endocrinology input
Continue hydrocortisone 200 mg/24 h (adult).
Guideline Source
Diagnosis and Treatment of Primary Adrenal Insufficiency: Endocrine Society Clinical Practice Guideline (Bornstein et al., 2016)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Children: doses by age and body surface area are in each step; if the child has their own adrenal crisis plan, follow it.
- Alternatives to hydrocortisone are dose equivalents, not trial-based; seek endocrinology advice early.
- Does not cover long-term replacement or planned perioperative stress dosing in detail.
- Undiagnosed adrenal insufficiency depends on clinical suspicion; treat first and confirm after recovery.
Applicable Regions
AUUSEU
AU: Paediatric fluid, glucose and age-based hydrocortisone doses follow the RCH Melbourne clinical practice guideline (updated Oct 2024). No injectable prednisolone is registered in Australia; methylprednisolone IV or IM is the parenteral alternative if hydrocortisone is unavailable.
EU: NICE NG243 (UK, 2024) adrenal insufficiency guideline, Society for Endocrinology (UK) adult emergency guidance and the 2024 ESE/Endocrine Society guideline on glucocorticoid-induced adrenal insufficiency also apply.
US: Based on the Endocrine Society primary adrenal insufficiency guideline (2016) and the 2024 ESE/Endocrine Society joint guideline.
Version 2Next review: 2027-09-30
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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 (Bornstein et al., 2016).
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 (Bornstein et al., 2016) (DOI: 10.1210/jc.2015-1710).
What are the limitations of the Adrenal Crisis (Addisonian Crisis) Management?
Known limitations include: Children: doses by age and body surface area are in each step; if the child has their own adrenal crisis plan, follow it.; Alternatives to hydrocortisone are dose equivalents, not trial-based; seek endocrinology advice early.; Does not cover long-term replacement or planned perioperative stress dosing in detail.; Undiagnosed adrenal insufficiency depends on clinical suspicion; treat first and confirm after recovery.. Individual patient factors may require deviation from these recommendations.
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