Table 3

Treatment of an acute adrenal crisis

  • 100 mg intravenous bolus stat followed by 50–100 mg intravenous or intramuscular four times a day continued for 24–48 hours until the patient can take oral medication (alternative 200 mg/24 hours by continuous intravenous infusion).

  • Fludrocortisone should be restarted when the hydrocortisone dose falls to <50 mg/day.

  • Dehydroepiandrosterone replacement is not required.

  • Monitor renal profile at least every 12 hours and continue regular monitoring until electrolyte imbalance and acute kidney injury are corrected.

Intravenous fluids
  • 1 L normal saline intravenous infusion over an hour followed by repeated infusion at a slower rate (usually 4–6 L in 24 hours).

  • Frequent haemodynamic monitoring and measurement of serum electrolytes to avoid fluid overload.

Other treatment
  • Admission to the high-dependency unit.

  • Prophylaxis of gastric stress ulcer and low-dose heparin.

  • Antibiotic treatment.

To prevent future adrenal crises
  • Explore the medical and behavioural causes precipitating adrenal crisis, (eg, compliance issues).

  • Patient education.

  • Annual influenza immunisation (and pneumococcal vaccination when older than 60 years).

  • Emergency hydrocortisone injection (every patient should be issued with an emergency injection kit and advised of training for patients and carers/families on their use).

  • Sick day rules guidance.

  • Advise to register with local ambulance service as ‘steroid dependent’.

  • Steroid card/medic bracelet.