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Addisonian Crisis

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ADRENAL CRISIS (ADDISONIAN CRISIS) – EMERGENCY PROTOCOL

CLINICAL MANAGEMENT GUIDELINE – INDIA

🚨 MEDICAL EMERGENCY | IMMEDIATE TREATMENT REQUIRED

Mortality: 0.5-2% per crisis episode; Higher if delayed treatment

This is a CLINICAL diagnosis – TREAT FIRST, Confirm Later

Do NOT wait for lab results to initiate treatment

🔰 SYMBOL LEGEND

Symbol	Meaning
🚨	Emergency / Critical
✅	Recommended / First-line
⚠️	Caution / Important
❌	Contraindicated / Avoid
💊	Drug
🇮🇳	India-specific
⏱️	Time-critical

SECTION 1: RECOGNITION

1.1 DEFINITION

🚨 Adrenal Crisis (Addisonian Crisis) = Life-threatening medical emergency due to acute cortisol deficiency, characterized by:

- Severe hypotension / Shock (refractory to fluids and vasopressors)
- Volume depletion
- Often with precipitating event

📌 Can occur in KNOWN adrenal insufficiency (most common) OR as FIRST presentation

1.2 WHO IS AT RISK?

Patients with Known Adrenal Insufficiency

Condition

Primary adrenal insufficiency (Addison’s disease)

Secondary adrenal insufficiency (Pituitary disease)

Tertiary adrenal insufficiency (Chronic steroid use → HPA suppression)

Bilateral adrenalectomy

Congenital adrenal hyperplasia (CAH)

Patients Without Known Diagnosis (First Presentation)

Scenario

Undiagnosed Addison’s disease

Pituitary apoplexy

Bilateral adrenal hemorrhage (Waterhouse-Friderichsen)

Acute illness in patient with unrecognized adrenal insufficiency

1.3 PRECIPITANTS – THE TRIGGER

📌 Crisis is almost ALWAYS precipitated by a stressor in patients with adrenal insufficiency

🚨 Common Precipitants

Infection (most common) – Gastroenteritis, Respiratory, UTI, Sepsis

Non-compliance / Discontinuation of glucocorticoid replacement

Inadequate stress dosing during illness/surgery

Vomiting / Diarrhea (cannot absorb oral steroids)

Surgery / Trauma without adequate steroid cover

Severe physical stress

Emotional stress (less common precipitant)

Other Precipitants

Adrenal hemorrhage (anticoagulants, sepsis, trauma)

Pituitary apoplexy

Drugs: Ketoconazole, Etomidate, Rifampicin (↑ cortisol metabolism), Phenytoin, Checkpoint inhibitors

Pregnancy / Labor

Burns

Myocardial infarction

Hyperthyroidism treatment (↑ cortisol clearance)

1.4 CAUSES OF ADRENAL INSUFFICIENCY LEADING TO CRISIS

Primary Adrenal Insufficiency

Cause	Notes
Autoimmune adrenalitis	Most common in developed countries
Tuberculosis	Most common in India
Adrenal hemorrhage	Anticoagulants, Sepsis (Waterhouse-Friderichsen), Trauma
Bilateral adrenalectomy
Metastatic disease	Lung, Breast, Melanoma
Infections	Fungal (Histoplasma), HIV/CMV
Congenital adrenal hyperplasia
Adrenoleukodystrophy
Drugs	Ketoconazole, Etomidate

Secondary/Tertiary Adrenal Insufficiency

Cause	Notes
Chronic glucocorticoid therapy	Most common cause overall
Pituitary tumors / Surgery / Radiation
Pituitary apoplexy	Acute
Sheehan syndrome	Postpartum pituitary necrosis
Hypophysitis	Autoimmune, Checkpoint inhibitor-induced
Hypothalamic disease
Traumatic brain injury

SECTION 2: CLINICAL FEATURES

2.1 CARDINAL FEATURES

🚨 Feature	Description
Hypotension / Shock	Often refractory to fluids and vasopressors
Volume depletion	Dehydration
Altered consciousness	Confusion, Lethargy, Obtundation, Coma
Abdominal symptoms	Pain, Nausea, Vomiting (may mimic acute abdomen)
Precipitating event	Usually identifiable

2.2 SYMPTOMS

Cardiovascular

Symptom

Dizziness / Lightheadedness

Syncope / Near-syncope

Palpitations (compensatory tachycardia)

Gastrointestinal

Symptom	Notes
Nausea	Very common
Vomiting	May precipitate crisis (can’t absorb oral meds)
Abdominal pain	Can be severe; May mimic acute abdomen
Diarrhea
Anorexia

Neurological

Symptom

Weakness (profound)

Fatigue (severe)

Confusion

Lethargy

Other

Symptom

Fever (if infection precipitant; Or due to crisis itself)

Leg cramps / Myalgia (electrolyte disturbances)

2.3 SIGNS

Vital Signs

Sign	Finding
Blood pressure	↓↓ Hypotension; Often < 90/60 mmHg
Postural hypotension	Marked drop on standing
Heart rate	↑ Tachycardia (compensatory)
Temperature	↑ Fever (infection) OR ↓ Hypothermia
Respiratory rate	May be increased

General Examination

Sign	Notes
Dehydration	Dry mucous membranes, Reduced skin turgor, Sunken eyes
Shock	Cold peripheries, Delayed capillary refill, Weak pulse
Altered consciousness	Confusion → Obtundation → Coma
Hyperpigmentation	PRIMARY AI only – Palmar creases, Buccal mucosa, Scars, Pressure points
Vitiligo	May be present (autoimmune association)
Abdominal tenderness	May mimic acute abdomen
Absent axillary/pubic hair	Women with chronic AI

Signs by Underlying Cause

Sign	Suggests
Hyperpigmentation	PRIMARY adrenal insufficiency (high ACTH)
NO hyperpigmentation	SECONDARY/TERTIARY (low ACTH)
Visual field defect	Pituitary tumor
Bilateral adrenal mass/hemorrhage on imaging	Adrenal hemorrhage/metastases
Signs of underlying infection	Precipitant

2.4 CLASSIC PRESENTATION SCENARIOS

Scenario 1: Known Addison’s Disease + Illness

Features

Patient with known primary AI

Develops gastroenteritis (vomiting, diarrhea)

Unable to take/absorb oral hydrocortisone

Develops hypotension, Weakness, Confusion

Diagnosis: Adrenal crisis due to GI illness

Scenario 2: Patient on Chronic Steroids + Surgery

Features

Patient on long-term prednisolone for RA/Asthma

Undergoes surgery WITHOUT stress dose steroids

Post-operatively develops hypotension, Shock

Refractory to fluids and vasopressors

Diagnosis: Adrenal crisis due to inadequate steroid cover

Scenario 3: First Presentation

Features

Previously healthy (or chronic fatigue, Weight loss)

Develops severe infection

Presents with shock, Hyperpigmentation

Hypotension refractory to treatment

Hyponatremia, Hyperkalemia

Diagnosis: Adrenal crisis as first presentation of Addison’s

Scenario 4: Waterhouse-Friderichsen Syndrome

Features

Severe sepsis (especially Meningococcal)

Bilateral adrenal hemorrhage

Rapid deterioration, Purpura, DIC

Refractory shock

Diagnosis: Adrenal crisis due to adrenal hemorrhage

2.5 CLINICAL CLUES TO ADRENAL CRISIS

🚩 Red Flags – Think Adrenal Crisis If:

Shock refractory to fluids and vasopressors

Hypotension + Hyponatremia + Hyperkalemia

Hyperpigmentation

History of adrenal/pituitary disease

History of chronic steroid use

Recent steroid withdrawal

Hypoglycemia (especially with hypotension)

Unexplained fever + Hypotension

Abdominal pain + Hypotension + Confusion

SECTION 3: DIAGNOSIS

3.1 CLINICAL DIAGNOSIS

🚨 CRITICAL PRINCIPLE

ADRENAL CRISIS IS A CLINICAL DIAGNOSIS

TREAT FIRST – Confirm Later

Do NOT wait for lab results

Delay in treatment = Increased mortality

Clinical Diagnostic Criteria

Criteria

Acute deterioration in health status

PLUS Hypotension (SBP < 100 mmHg) or Shock

PLUS Features that resolve with parenteral glucocorticoid

WITH Underlying adrenal insufficiency (known or suspected)

3.2 LABORATORY FINDINGS

Electrolytes

Finding	Mechanism	Notes
Hyponatremia	↓ Aldosterone (Na+ loss); ↓ Cortisol (↑ ADH)	Common in PRIMARY
Hyperkalemia	↓ Aldosterone (K+ retention)	Common in PRIMARY
Metabolic acidosis	↓ Aldosterone (H+ retention)
Normal electrolytes	May occur in SECONDARY (aldosterone intact)

Glucose

Finding	Notes
Hypoglycemia	↓ Gluconeogenesis; More common in children and secondary AI

Renal Function

Finding	Mechanism
Elevated urea	Dehydration; Prerenal
Elevated creatinine	Dehydration; Prerenal

Other

Test	Finding
Calcium	May be elevated
CBC	Eosinophilia; Lymphocytosis; Anemia (chronic)
TSH	May be elevated (cortisol needed for TSH suppression)

3.3 HORMONAL CONFIRMATION (When Stable)

📌 Draw blood for cortisol BEFORE giving steroids if possible, but DO NOT DELAY TREATMENT

Cortisol

Test	Interpretation
Random cortisol	Should be HIGH in acute illness/stress
	< 3 μg/dL (83 nmol/L) = AI very likely
	< 10 μg/dL (276 nmol/L) in critically ill = AI likely
	< 15-18 μg/dL (414-500 nmol/L) in acute stress = Inappropriate
	> 18-20 μg/dL (500-550 nmol/L) = AI unlikely

ACTH

Finding	Interpretation
↑↑ High ACTH + ↓ Cortisol	PRIMARY adrenal insufficiency
↓ or Normal ACTH + ↓ Cortisol	SECONDARY/TERTIARY (Central)

Confirmatory Testing (Once Stable)

Test	Protocol
Short Synacthen Test (ACTH Stimulation)	Give Synacthen 250 μg IV/IM; Measure cortisol at 0, 30, 60 min
Interpretation	Peak cortisol < 18-20 μg/dL (500 nmol/L) = AI confirmed

3.4 DISTINGUISHING PRIMARY VS SECONDARY AI

Feature	Primary AI	Secondary AI
ACTH	↑↑	↓ or Normal
Aldosterone	↓	Normal
Hyponatremia	✅ Common	May occur (dilutional)
Hyperkalemia	✅ Common	❌ Absent (aldosterone intact)
Hyperpigmentation	✅ Present	❌ Absent
Salt craving	✅ Present	❌ Absent

3.5 ADDITIONAL INVESTIGATIONS

Investigation	Purpose
ECG	Hyperkalemia changes; Arrhythmias
CXR	Infection; Small heart (chronic AI)
Blood cultures	Infection workup
Urine analysis/culture	UTI
Blood glucose	Hypoglycemia
CT Adrenals	Hemorrhage, Calcification (TB), Masses
CT/MRI Pituitary	If secondary AI suspected

SECTION 4: MANAGEMENT – OVERVIEW

4.1 Treatment Principles

🚨 Adrenal Crisis Management

⏱️ Time-Critical: Treat Immediately
Do NOT wait for laboratory results before starting treatment.

Step 1: IV Hydrocortisone

💊 100 mg IV bolus immediately
Then 50–100 mg IV every 6–8 hours
OR 200 mg continuous IV infusion over 24 hours

Step 2: IV Fluids

Administer 0.9% Normal Saline for aggressive fluid resuscitation

1 liter in the first hour
4–6 liters during the first 24 hours

Step 3: Treat Hypoglycemia

Check blood glucose levels.

If hypoglycemia is present, give IV Dextrose immediately.

Step 4: Identify and Treat Precipitating Cause

Identify the underlying trigger.

Most common cause: Infection

Start appropriate antibiotics if infection is suspected.

Step 5: Monitor and Taper

Closely monitor:

Vital signs
Electrolytes
Blood glucose

Once the patient is clinically stable, transition to oral maintenance steroid therapy.

4.2 KEY POINTS

🚨 Critical Points

Hydrocortisone is life-saving – Give IMMEDIATELY

High-dose hydrocortisone has mineralocorticoid activity – No need for fludrocortisone acutely

Aggressive IV fluids – These patients are severely volume depleted

Treat the precipitant – Usually infection

Do NOT use dexamethasone if you need to do ACTH stim test later (dexamethasone doesn’t cross-react with cortisol assay; hydrocortisone does – but treatment takes priority)

SECTION 5: STEP-BY-STEP MANAGEMENT

STEP 1: HYDROCORTISONE – IMMEDIATE

5.1 Initial Bolus

💊 Drug	Dose	Route	Timing
Hydrocortisone sodium succinate	100 mg	IV bolus	IMMEDIATELY

5.2 Maintenance

Regimen	Dose
Intermittent bolus	50-100 mg IV q6-8h
OR Continuous infusion	200 mg IV over 24 hours (8.3 mg/hr)

5.3 Why Hydrocortisone?

Advantage

✅ Has BOTH glucocorticoid AND mineralocorticoid activity

✅ At high doses (≥ 50 mg), mineralocorticoid effect is sufficient

✅ No need for separate fludrocortisone in acute phase

✅ Rapid onset

✅ Widely available

5.4 Alternative Glucocorticoids (If Hydrocortisone Unavailable)

💊 Drug	Dose	Notes
Dexamethasone	4 mg IV	⚠️ NO mineralocorticoid activity; May need fludrocortisone in primary AI
		✅ Use if ACTH stim test planned (doesn’t interfere with cortisol assay)
Methylprednisolone	40 mg IV	Minimal mineralocorticoid activity
Prednisolone	25 mg IV/PO	Less preferred; Oral absorption may be impaired

5.5 Glucocorticoid Equivalence

Drug	Equivalent Dose	Mineralocorticoid Activity
Hydrocortisone 100 mg	–	✅ Yes
Prednisolone 25 mg	≈	Minimal
Methylprednisolone 20 mg	≈	None
Dexamethasone 4 mg	≈	None

STEP 2: IV FLUID RESUSCITATION

5.6 Fluid Choice

💧 Fluid	Recommendation
0.9% Normal Saline	✅ First-line
5% Dextrose in Normal Saline	✅ If hypoglycemic

5.7 Fluid Volume

Time	Volume
First hour	1000 mL (rapid bolus)
First 4-6 hours	2-3 L
First 24 hours	4-6 L (guided by response)

5.8 Why Aggressive Fluids?

Rationale

Patients are severely volume depleted

Aldosterone deficiency (PRIMARY AI) → Sodium and water loss

Vomiting/diarrhea worsen dehydration

Hypotension is primarily due to volume depletion

5.9 Fluid Monitoring

Monitor

Urine output – Target > 0.5 mL/kg/hr

Blood pressure – Target MAP > 65 mmHg

Heart rate – Should decrease with resuscitation

Clinical perfusion – Capillary refill, Skin temperature

⚠️ Avoid overload in elderly/cardiac patients

STEP 3: CORRECT HYPOGLYCEMIA

5.10 Management

If Hypoglycemic

50 mL of 50% Dextrose IV bolus (25 g)

OR 100-200 mL of 25% Dextrose

OR 500 mL of 10% Dextrose

Switch to Dextrose-containing maintenance fluids (D5NS)

Monitor glucose q1-2 hours initially

STEP 4: IDENTIFY AND TREAT PRECIPITANT

5.11 Search for Precipitant

Investigation

History: Infection, Missed doses, Surgery, Trauma

Examination: Source of infection

Blood cultures

Urine analysis and culture

CXR

Other directed investigations

5.12 Treat Infection

If Infection Suspected

Empiric broad-spectrum antibiotics

Do NOT delay antibiotics

Adjust based on culture results

Common Regimens

Community-acquired: Ceftriaxone 2 g IV + Azithromycin (if respiratory)

Urinary source: Ceftriaxone or Fluoroquinolone

Sepsis/Unknown: Piperacillin-tazobactam or Meropenem

STEP 5: ADDITIONAL MEASURES

5.13 Vasopressors

When to Use

If hypotension persists despite adequate fluids and hydrocortisone

💊 Noradrenaline – First-line vasopressor

Start at 0.05-0.1 μg/kg/min; Titrate to MAP > 65 mmHg

⚠️ Important

Hypotension in adrenal crisis is often refractory to vasopressors UNTIL glucocorticoid given

Response to vasopressors improves after hydrocortisone

5.14 Correct Electrolyte Abnormalities

Abnormality	Management
Hyponatremia	Usually corrects with IV NS + Hydrocortisone; Do NOT use hypertonic saline unless severe/symptomatic
Hyperkalemia	Usually corrects with IV NS + Hydrocortisone; Standard hyperkalemia treatment if severe (Calcium gluconate, Insulin-dextrose, Salbutamol)

5.15 Monitor for Complications

Complication	Management
Arrhythmias (Hyperkalemia)	ECG monitoring; Treat hyperkalemia
Seizures (Hypoglycemia, Hyponatremia)	Correct glucose and sodium; Benzodiazepines
Shock (Refractory)	Vasopressors; Ensure adequate steroid dose

SECTION 6: MONITORING

6.1 ACUTE PHASE MONITORING

Parameter	Frequency	Target
Blood pressure	Continuous / q15 min initially	SBP > 100; MAP > 65
Heart rate	Continuous	Decreasing (compensation reducing)
Urine output	Hourly	> 0.5 mL/kg/hr
Oxygen saturation	Continuous	> 94%
Temperature	q2-4 hours	Monitor for fever (infection)
Glucose	q1-2 hours initially	> 70 mg/dL
Sodium	q6-12 hours	Gradual normalization
Potassium	q6-12 hours	< 5.5 mEq/L
Mental status	Frequent	Improving

6.2 EXPECTED CLINICAL RESPONSE

Time	Expected Response
1-2 hours	Blood pressure improving
4-6 hours	Significant hemodynamic improvement
12-24 hours	Clinical stabilization
24-72 hours	Resolution of acute crisis
Days	Electrolytes normalizing

6.3 SIGNS OF IMPROVEMENT

✅ Improving

Blood pressure rising

Heart rate decreasing

Urine output increasing

Mental status clearing

Sodium rising

Potassium falling

Glucose stable

6.4 SIGNS OF NON-RESPONSE / DETERIORATION

🚨 Worsening

Persistent hypotension despite treatment

Worsening mental status

Oliguria / Anuria

Worsening metabolic acidosis

Uncontrolled hyperkalemia

Action

Ensure adequate hydrocortisone dose

Ensure adequate fluid resuscitation

Consider alternative diagnosis

Escalate care (ICU if not already)

Look for uncontrolled precipitant

SECTION 7: TAPERING AND TRANSITION

7.1 WHEN TO TAPER

Criteria to Begin Taper

Hemodynamically stable

Eating and drinking

Precipitant controlled

Electrolytes improving

Usually after 24-72 hours

7.2 TAPERING PROTOCOL

Day	Hydrocortisone Dose
Day 1 (Crisis)	100 mg IV bolus → 50-100 mg q6-8h
Day 2	50 mg IV/PO q6-8h (150-200 mg/day)
Day 3	25-50 mg PO q6-8h (75-150 mg/day)
Day 4	20 mg AM + 10 mg Noon + 10 mg PM (40 mg/day)
Day 5	20 mg AM + 10 mg PM (30 mg/day)
Day 6+	Return to maintenance (15-25 mg/day)

7.3 TRANSITION TO ORAL MAINTENANCE

Oral Hydrocortisone Regimen

💊 Hydrocortisone	Typical Maintenance
Dose	15-25 mg/day
Regimen	10 mg AM + 5 mg Noon + 5 mg Late afternoon
OR	15 mg AM + 5 mg Afternoon

Add Fludrocortisone (PRIMARY AI Only)

💊 Fludrocortisone	Dose
When to start	Once hydrocortisone < 50 mg/day
Dose	0.05-0.2 mg once daily (usually 0.1 mg)
Not needed in	Secondary/Tertiary AI (aldosterone intact)

7.4 DISCHARGE CRITERIA

✅ Ready for Discharge

Hemodynamically stable on oral medication

Tolerating oral intake

Precipitant treated/controlled

Electrolytes stable

Patient/Family educated on sick day rules

Emergency injection kit provided

Medical alert identification arranged

Follow-up appointment scheduled

SECTION 8: PREVENTION OF FUTURE CRISES

8.1 SICK DAY RULES – PATIENT EDUCATION

Mild Illness (Cold, Minor Infection, Low-grade Fever)

Rule

DOUBLE the usual hydrocortisone dose

Continue fludrocortisone unchanged

Increase fluid and salt intake

Continue until recovered

Return to normal dose when well

Moderate Illness (Higher Fever, Vomiting, Diarrhea)

Rule

TRIPLE the usual hydrocortisone dose

If unable to keep oral meds down → Injectable hydrocortisone

Seek medical attention

Severe Illness / Emergency

🚨 Rule

100 mg Hydrocortisone IM/IV immediately

Then 50-100 mg every 6-8 hours

Seek emergency medical care

8.2 STRESS DOSING FOR PROCEDURES

Procedure	Recommendation
Minor (Dental work)	Double dose on morning of procedure
Moderate (Endoscopy)	50 mg IV/IM before procedure; Double oral × 24-48h
Major surgery	100 mg IV pre-op → 50-100 mg IV q8h → Taper over 3-5 days

8.3 EMERGENCY INJECTION KIT

Every Patient MUST Have

Hydrocortisone injection kit (100 mg)

Syringes and needles

Instructions for self-injection / Family injection

Train patient AND family on IM injection

Self-Injection Technique

Step	Action
1	Reconstitute hydrocortisone (if powder)
2	Draw up 100 mg
3	Inject into outer thigh (IM)
4	Call for emergency help
5	Lie down; Do not drive

8.4 MEDICAL IDENTIFICATION

Every Patient MUST Have

Medical alert bracelet or necklace

Emergency card in wallet

Phone ICE contact with diagnosis

Card Should State

Information

“I have ADRENAL INSUFFICIENCY”

“In emergency, I need HYDROCORTISONE 100 mg IV/IM immediately”

“Do NOT wait for blood tests”

Emergency contact details

Doctor’s contact

8.5 PATIENT EDUCATION CHECKLIST

✅ Every Patient Must Know

Never stop steroids suddenly

Double dose if unwell

Triple dose if moderately ill

Use injection if vomiting / Can’t take oral

Seek medical help if not improving

Always carry emergency injection

Wear medical alert identification

Inform all healthcare providers

Carry steroid card

SECTION 9: DRUG DOSES – QUICK REFERENCE

9.1 ACUTE CRISIS MANAGEMENT

Step	Drug	Dose
1	💊 Hydrocortisone	100 mg IV bolus → 50-100 mg q6-8h OR 200 mg/24h infusion
2	💧 0.9% Normal Saline	1L in first hour → 4-6L in 24h
3	💊 Dextrose	D50 50 mL IV if hypoglycemic
4	Antibiotics	Empiric if infection suspected
5	💊 Noradrenaline	0.05-0.1 μg/kg/min if refractory hypotension

9.2 ALTERNATIVE GLUCOCORTICOIDS

Drug	Dose	Notes
Dexamethasone	4 mg IV q12h	No mineralocorticoid effect
Methylprednisolone	40 mg IV q12h	Minimal mineralocorticoid effect
Prednisolone	25 mg PO q6h	If IV unavailable

9.3 MAINTENANCE THERAPY

Drug	Dose
💊 Hydrocortisone	15-25 mg/day in divided doses
💊 Fludrocortisone (Primary AI only)	0.05-0.2 mg once daily

9.4 SICK DAY DOSING

Severity	Hydrocortisone Dose
Mild illness	2× usual dose
Moderate illness	3× usual dose
Severe / Vomiting	100 mg IM/IV

9.5 SURGICAL STRESS DOSING

Surgery	Pre-op	Intra/Post-op
Minor	Double oral	Double × 24h
Moderate	50 mg IV	Double × 24-48h
Major	100 mg IV	50-100 mg IV q8h → Taper

SECTION 10: SPECIAL SITUATIONS

10.1 ADRENAL CRISIS IN PREGNANCY

Key Points

Consideration

Adrenal crisis can occur in pregnancy

Diagnosis can be challenging (Physiological changes mimic some features)

Hydrocortisone is SAFE in pregnancy

Fludrocortisone is SAFE in pregnancy

May need higher maintenance doses in 3rd trimester

Labor/Delivery: Stress dose hydrocortisone required

Labor and Delivery Protocol

Phase	Dose
Early labor	Hydrocortisone 25-50 mg IV
Active labor	Hydrocortisone 100 mg IV
Delivery	Continue 50-100 mg IV q6-8h
Post-delivery	Taper over 24-72 hours

10.2 ADRENAL CRISIS IN CHILDREN

Key Points

Consideration

Hypoglycemia more common in children

Weight-based dosing required

CAH is common cause in infants

Family education critical

Pediatric Dosing

Drug	Dose
Hydrocortisone	50-100 mg/m² IV bolus (or 2-4 mg/kg, max 100 mg)
Maintenance	50-100 mg/m²/day IV in divided doses
Fluids	20 mL/kg NS bolus → Maintenance
Dextrose	2-4 mL/kg of D25 if hypoglycemic

10.3 ADRENAL CRISIS IN PATIENTS ON ANTICOAGULANTS

Suspect Adrenal Hemorrhage

Clues

Patient on warfarin/heparin/DOACs

Sudden onset of: Abdominal/Flank pain, Hypotension, Fever

Falling hematocrit

CT: Bilateral adrenal hemorrhage

Management

Action

Treat crisis standard protocol (Hydrocortisone + Fluids)

Reverse anticoagulation if severe bleeding

CT Adrenals to confirm

Will likely need lifelong steroid replacement

10.4 BILATERAL ADRENALECTOMY

Key Points

Consideration

100% dependent on exogenous steroids

High risk of crisis

MUST have emergency injection kit

Education critical

10.5 SECONDARY ADRENAL INSUFFICIENCY

Key Differences

Feature	Primary AI	Secondary AI
Aldosterone	↓	Normal
Hyperkalemia	Yes	No
Hyperpigmentation	Yes	No
Fludrocortisone needed	Yes	No

Management

Same as primary EXCEPT:

No fludrocortisone needed (aldosterone intact)

Usually less severe hyponatremia

Consider other pituitary hormone deficiencies

10.6 STEROID WITHDRAWAL CRISIS

Scenario

Features

Patient on chronic steroids (> 3 weeks)

Abruptly stops or rapidly tapers steroids

Develops fatigue, Hypotension, Nausea

Management

Action

Same treatment as adrenal crisis

Restart steroids

Slow, gradual taper when stable

May take months for HPA axis to recover

SECTION 11: 🇮🇳 INDIA-SPECIFIC CONSIDERATIONS

11.1 COMMON CAUSES IN INDIA

Cause	Notes
Tuberculosis	Most common cause of primary AI in India
Autoimmune	Increasing, especially urban areas
Chronic steroid use	Common; Often over-the-counter; Hidden in Ayurvedic preparations
Post-TB	May have adrenal calcification

11.2 DRUG AVAILABILITY

Drug	Availability	Cost
Hydrocortisone injection 100 mg	✅ Widely available	₹30-100
Hydrocortisone oral 10/20 mg	✅ Available	₹50-150/month
Fludrocortisone 0.1 mg	⚠️ Variable availability	₹200-400/month
Dexamethasone injection	✅ Widely available	₹10-50
Normal Saline	✅ Widely available	₹30-50/L

11.3 PRACTICAL CHALLENGES

Challenge	Solution
Fludrocortisone availability	Patients should maintain adequate supply; Alternative suppliers
Non-compliance	Education; Family involvement; Regular follow-up
Hidden steroids in Ayurvedic preparations	Detailed medication history; Educate patients
Delayed presentation	Community awareness; Primary care education
Cost of long-term therapy	Generic options; Government schemes

Features

Findings

Most common cause in India

May have history of TB or TB contact

CT may show: Enlarged adrenals (acute) or Calcified adrenals (chronic)

May need ATT if active TB

Management

Action

Standard crisis management

Start ATT if active TB

⚠️ Rifampicin increases cortisol metabolism – May need higher hydrocortisone doses during ATT (increase by 50-100%)

Adrenal function rarely recovers – Usually lifelong replacement needed

SECTION 12: SUMMARY TABLES

12.1 DIAGNOSTIC CLUES

Finding	Suggests
Hypotension + Hyponatremia + Hyperkalemia	PRIMARY AI
Hypotension + Hyponatremia (without hyperkalemia)	SECONDARY AI
Hyperpigmentation	PRIMARY AI
Hypoglycemia + Hypotension	Adrenal crisis
Refractory shock	Think adrenal crisis

12.2 IMMEDIATE MANAGEMENT CHECKLIST

✅ Action	Done
Hydrocortisone 100 mg IV bolus	☐
IV access × 2 large bore	☐
0.9% NS 1L rapid infusion	☐
Check glucose – Treat if low	☐
Blood samples: Cortisol, ACTH, U&E, Glucose, Cultures	☐
ECG (Hyperkalemia)	☐
Search for precipitant	☐
Continuous monitoring	☐

12.3 TREATMENT PROTOCOL SUMMARY

Step	Intervention	Dose/Details
1	Hydrocortisone IV	100 mg bolus → 50-100 mg q6-8h
2	IV Fluids	NS 1L/hr × 1h → 4-6L/24h
3	Dextrose	If hypoglycemic
4	Treat precipitant	Antibiotics if infection
5	Monitor	BP, HR, UO, Glucose, Electrolytes
6	Taper when stable	→ Oral maintenance over 3-5 days

12.4 SICK DAY RULES SUMMARY

Illness Severity	Action
Mild	Double oral dose
Moderate	Triple oral dose
Severe / Vomiting	100 mg IM/IV + Seek help

12.5 PATIENT ESSENTIALS CHECKLIST

✅ Every Patient Must Have

Emergency hydrocortisone kit

Training on self-injection

Medical alert ID

Steroid card

Written sick day rules

Emergency contact numbers

Regular follow-up

12.6 PRIMARY VS SECONDARY AI COMPARISON

Feature	Primary AI	Secondary AI
Site	Adrenal	Pituitary/Hypothalamus
ACTH	↑↑	↓/Normal
Aldosterone	↓	Normal
Hyperkalemia	Yes	No
Hyperpigmentation	Yes	No
Fludrocortisone	Needed	Not needed
Salt craving	Yes	No

📚 ABBREVIATIONS

Abbreviation	Full Form
ACTH	Adrenocorticotropic Hormone
AI	Adrenal Insufficiency
ATT	Antitubercular Therapy
BP	Blood Pressure
CAH	Congenital Adrenal Hyperplasia
CMV	Cytomegalovirus
CT	Computed Tomography
D25/D50	25%/50% Dextrose
DIC	Disseminated Intravascular Coagulation
DOAC	Direct Oral Anticoagulant
ECG	Electrocardiogram
GI	Gastrointestinal
HIV	Human Immunodeficiency Virus
HPA	Hypothalamic-Pituitary-Adrenal
HR	Heart Rate
ICE	In Case of Emergency
ICU	Intensive Care Unit
IM	Intramuscular
IV	Intravenous
MAP	Mean Arterial Pressure
MRI	Magnetic Resonance Imaging
NS	Normal Saline
PO	Per Oral
RA	Rheumatoid Arthritis
SBP	Systolic Blood Pressure
TB	Tuberculosis
U&E	Urea and Electrolytes
UO	Urine Output
UTI	Urinary Tract Infection

📖 KEY REFERENCES

Source

Bornstein SR et al. Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. JCEM 2016

Puar TH et al. Adrenal Crisis: Still a Deadly Event in the 21st Century. Am J Med 2016

Rushworth RL et al. Adrenal Crisis. NEJM 2019

Husebye ES et al. Adrenal Insufficiency. Lancet 2021

Bancos I et al. Diagnosis and Management of Adrenal Insufficiency. Lancet Diabetes Endocrinol 2015

Hahner S et al. High Incidence of Adrenal Crisis in Educated Patients with Chronic Adrenal Insufficiency. JCEM 2015

Harrison’s Principles of Internal Medicine, 21st Edition

Williams Textbook of Endocrinology, 14th Edition

Document Version: 1.0

Last Updated: December 2025

For: Healthcare Professionals Only

Related Guidelines: Addison’s Disease (Primary Adrenal Insufficiency); Cushing’s Syndrome

Key Points:

- 🚨 TREAT FIRST – Do NOT wait for labs
- 💊 Hydrocortisone 100 mg IV immediately
- 💧 Aggressive IV Normal Saline
- 🔍 Search for and treat precipitant
- 📋 Patient education and emergency kit are ESSENTIAL for prevention

End of Guideline

🛡️

Medical Advisory

Clinical guidelines are subject to change. Physicians should exercise their regular clinical judgment. This protocol does not replace individual institutional policies. Verified for Q1 2026.

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Addisonian Crisis

Protocol Content

ADRENAL CRISIS (ADDISONIAN CRISIS) – EMERGENCY PROTOCOL

CLINICAL MANAGEMENT GUIDELINE – INDIA

🔰 SYMBOL LEGEND

SECTION 1: RECOGNITION

1.1 DEFINITION

1.2 WHO IS AT RISK?

1.3 PRECIPITANTS – THE TRIGGER

1.4 CAUSES OF ADRENAL INSUFFICIENCY LEADING TO CRISIS

SECTION 2: CLINICAL FEATURES

2.1 CARDINAL FEATURES

2.2 SYMPTOMS

2.3 SIGNS

2.4 CLASSIC PRESENTATION SCENARIOS

2.5 CLINICAL CLUES TO ADRENAL CRISIS

SECTION 3: DIAGNOSIS

3.1 CLINICAL DIAGNOSIS

3.2 LABORATORY FINDINGS

3.3 HORMONAL CONFIRMATION (When Stable)

3.4 DISTINGUISHING PRIMARY VS SECONDARY AI

3.5 ADDITIONAL INVESTIGATIONS

SECTION 4: MANAGEMENT – OVERVIEW

4.1 Treatment Principles

4.2 KEY POINTS

SECTION 5: STEP-BY-STEP MANAGEMENT

STEP 1: HYDROCORTISONE – IMMEDIATE

STEP 2: IV FLUID RESUSCITATION

STEP 3: CORRECT HYPOGLYCEMIA

STEP 4: IDENTIFY AND TREAT PRECIPITANT

STEP 5: ADDITIONAL MEASURES

SECTION 6: MONITORING

6.1 ACUTE PHASE MONITORING

6.2 EXPECTED CLINICAL RESPONSE

6.3 SIGNS OF IMPROVEMENT

6.4 SIGNS OF NON-RESPONSE / DETERIORATION

SECTION 7: TAPERING AND TRANSITION

7.1 WHEN TO TAPER

7.2 TAPERING PROTOCOL

7.3 TRANSITION TO ORAL MAINTENANCE

7.4 DISCHARGE CRITERIA

SECTION 8: PREVENTION OF FUTURE CRISES

8.1 SICK DAY RULES – PATIENT EDUCATION

8.2 STRESS DOSING FOR PROCEDURES

8.3 EMERGENCY INJECTION KIT

8.4 MEDICAL IDENTIFICATION

8.5 PATIENT EDUCATION CHECKLIST

SECTION 9: DRUG DOSES – QUICK REFERENCE

9.1 ACUTE CRISIS MANAGEMENT

9.2 ALTERNATIVE GLUCOCORTICOIDS

9.3 MAINTENANCE THERAPY

9.4 SICK DAY DOSING

9.5 SURGICAL STRESS DOSING

SECTION 10: SPECIAL SITUATIONS

10.1 ADRENAL CRISIS IN PREGNANCY

10.2 ADRENAL CRISIS IN CHILDREN

10.3 ADRENAL CRISIS IN PATIENTS ON ANTICOAGULANTS

10.4 BILATERAL ADRENALECTOMY

10.5 SECONDARY ADRENAL INSUFFICIENCY

10.6 STEROID WITHDRAWAL CRISIS

SECTION 11: 🇮🇳 INDIA-SPECIFIC CONSIDERATIONS

11.1 COMMON CAUSES IN INDIA

11.2 DRUG AVAILABILITY

11.3 PRACTICAL CHALLENGES

11.4 TB-RELATED ADRENAL INSUFFICIENCY

SECTION 12: SUMMARY TABLES

12.1 DIAGNOSTIC CLUES

12.2 IMMEDIATE MANAGEMENT CHECKLIST

12.3 TREATMENT PROTOCOL SUMMARY

12.4 SICK DAY RULES SUMMARY

12.5 PATIENT ESSENTIALS CHECKLIST

12.6 PRIMARY VS SECONDARY AI COMPARISON

📚 ABBREVIATIONS

📖 KEY REFERENCES

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Addisonian Crisis

Protocol Content

ADRENAL CRISIS (ADDISONIAN CRISIS) – EMERGENCY PROTOCOL

CLINICAL MANAGEMENT GUIDELINE – INDIA