Addisonian Crisis

Adrenal crisis is a life-threatening emergency caused by acute glucocorticoid deficiency. Causes: primary Addison's (autoimmune, TB), secondary (pituitary, long-term steroid withdrawal), or bilateral adrenal haemorrhage/infarction…

NICE/SOCIETY FOR ENDOCRINOLOGY Emergency Steroid Protocol

The pathway

1 · Recognition — think of the diagnosis

Hypotension, hyponatraemia (130–135), hyperkalaemia, hypoglycaemia, eosinophilia, drowsiness
Risk factors: known Addison's, long-term steroid use, recent withdrawal
Precipitants: infection, surgery, trauma, missed steroid dose during illness
Pigmentation (primary), pallor (secondary)

2 · Immediate resuscitation

IV access x2
Bloods BEFORE hydrocortisone (cortisol level critical for diagnosis): cortisol, ACTH, U&E, glucose, FBC, LFTs, blood cultures
1L 0.9% NaCl over 1 hour
10% dextrose if BM <4
Do not delay treatment for results

3 · Hydrocortisone — give immediately

Hydrocortisone 100mg IV stat
Then 200mg/24h IV infusion (or 50mg IM/IV 6-hourly)
This is life-saving — do not withhold or delay
If no hydrocortisone: dexamethasone 4mg IV (does not interfere with short Synacthen test)

4 · Fluid replacement

1L 0.9% NaCl over 1h, then 1L over 2h
Reassess
Avoid hypotonic fluids — worsen hyponatraemia
Once BP stable: consider oral fludrocortisone (not required acutely as high-dose hydrocortisone has mineralocorticoid activity)
Monitor Na+ 4-6 hourly

5 · Investigations & diagnosis

9am cortisol <100nmol/L strongly suggests Addison's
Random cortisol <400 in acutely ill patient is inappropriately low
Short Synacthen test after acute phase
ACTH level distinguishes primary (high) from secondary (low/normal)
If Waterhouse-Friderichsen: meningococcal treatment also

6 · Prevention & sick day rules

All Addison's patients need a steroid emergency card and IM hydrocortisone kit. Sick day rules: double/triple steroid dose when unwell; if vomiting → IM hydrocortisone → A&E. Patient education is essential. MedicAlert bracelet. Endocrinology follow-up.

Drugs

Drug	Dose	Route	Notes
Hydrocortisone	100mg IV stat, then 50mg 6-hourly	IV/IM	Life-saving. Do not delay. Higher mineralocorticoid activity than dexamethasone.
0.9% NaCl	1L over 1h then reassess	IV	Avoid hypotonic fluids. Monitor Na+ — can rise fast once cortisol given.
10% Glucose	100ml bolus	IV	If BM <4. Hypoglycaemia common in adrenal crisis.
Fludrocortisone	100mcg once daily	PO	Only needed in primary Addison's. Not in acute phase — hydrocortisone covers mineralocorticoid.

When to escalate

Haemodynamic instability not responding to fluids and hydrocortisone → ITU,Suspected Waterhouse-Friderichsen syndrome → meningococcal antibiotics urgently,Cortisol <100nmol/L → endocrinology urgently, Synacthen test,Na+ not rising or worsening → reassess fluid type, check for SIADH,Recurrent crises → review sick day rules, patient education, MedicAlert

Reference: Society for Endocrinology — Emergency Management of Adrenal Crisis 2020

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