Adrenal Crisis — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

🎓 Want to practice? Do a case challenge with this pathway → (get a case, choose management step by step, scored).

Full pathway

1. [Decision] Adrenal crisis suspected?
   Is adrenal crisis suspected? (Adrenal crisis = acute decompensation of adrenal insufficiency: refractory hypotension/shock (poor response to fluids and vasopressors), fatigue, nausea/vomiting, hypoglycemia, hyponatremia and hyperkalemia, abdominal pain. Precipitants: infection, stress, surgery, missed/stopped steroids. Be especially alert in known or suspected adrenal insufficiency.)
   • Suspected / confirmed crisis → Treat immediately (no delay)
   • Does not fit → Does not fit
2. [End] Does not fit
   Evaluate other causes of shock/hypotension and manage along the appropriate pathway; in patients with a history of adrenal insufficiency, watch for progression under stress and have a stress-dose plan ready.
3. [End] Treat immediately (no delay)
   Treat immediately, do not delay for confirmation: 1) Hydrocortisone 100 mg IV (or IM) now, then 200 mg/24 h (continuous infusion preferred, or 50 mg q6h). 2) Rapid fluids: 0.9% sodium chloride (~1 L in the first hour, continue per status), add glucose for hypoglycemia. 3) Find and treat the precipitant (infection, etc.). High-dose hydrocortisone in the acute phase has mineralocorticoid effect, so fludrocortisone is not separately needed. Endocrine consult, transition to oral on recovery and provide a stress-dose plan.

Source guidelines & references

• Endocrine Society Guideline on primary adrenal insufficiency. J Clin Endocrinol Metab 2016
• UK Society for Endocrinology guidance on adrenal crisis prevention and emergency management

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

Other pathways