Adrenal CrisisICU / resuscitation

On prednisolone 10 mg for 2 years, stopped it 1 week ago; vomiting, abdominal pain, confusion; BP 78/46, Na⁺ 126, K⁺ 5.6, glucose 60 mg/dL

• Hypotension not responding to fluids
• Hypoglycaemia
• Na⁺ <125 or K⁺ >6
• Confusion or coma

• Septic shock
• Acute abdomen
• Gastroenteritis with dehydration
• Hypopituitarism / pituitary apoplexy
• Adrenal haemorrhage (anticoagulation, meningococcaemia)

• Admit: All suspected adrenal crisis
• ICU: Shock not responding to hydrocortisone and fluids, coma, severe electrolyte disturbance

• Anyone on ≥5 mg prednisolone (or equivalent) for >4 weeks may have adrenal suppression — steroid card and sick-day rules (ESE/ES 2024).
• Sick-day rules: double the daily dose with fever or illness; IM hydrocortisone 100 mg if vomiting and go to hospital.
• Hyperkalaemia and pigmentation point to primary (Addison) disease; secondary (pituitary or steroid-induced) usually has normal K⁺.

• Wait for a cortisol result before giving hydrocortisone
• Start fludrocortisone instead of hydrocortisone in the acute crisis
• Correct chronic hyponatraemia by >10 mmol/L in 24 h
• Stop long-term steroids abruptly

• Delaying hydrocortisone for tests
• Not increasing steroid dose during illness or surgery
• Over-rapid Na⁺ correction
• Missing adrenal insufficiency in refractory shock

Ward if responding within hours; ICU if shocked. Endocrinology review; confirm the diagnosis and cause once stable.