Box 1.

Emergency treatment of adrenal crisis

  • 100 mg hydrocortisone by iv injection, followed by 200 mg hydrocortisone/24 h continuous iv infusion in glucose 5%/24 h, or 50 mg* 6 hourly im†

  • Rapid rehydration with sodium chloride 0.9% providing no evidence of hyponatraemia:

    • Resuscitation with 500 ml fluid bolus of sodium chloride 0.9% over 15 minutes and then replacement of any electrolyte deficits

    • Rehydration (3–4 litres of sodium chloride 0.9% solution in 24 h); careful monitoring of electrolytes and fluid balance

    • Drinking ad libitum

  • Cardiac monitoring (if necessary transfer to the intensive care unit for monitoring)

  • Refer to endocrinology for further advice on diagnosis, starting regular oral steroids or tapering steroids back to usual dose, and education regarding ‘sick day rules’ prior to discharge

  • More detailed information can be found at www.endocrinology.org/adrenal-crisis. See also NICE guidance on intravenous fluid therapy in adults in hospital27 and guidance for management of hyponatraemia.28

  • ↵*In severe obesity consider substituting 50 mg hydrocortisone with 100 mg hydrocortisone.

  • ↵† While it is recommended hydrocortisone 50 mg every 6 h is given im, hydrocortisone can be given iv if patients are anticoagulated or clinically indicated.