Adrenal crisis and hydrocortisone emergency injection¶

An adrenal crisis (acute adrenal insufficiency) is a time-critical endocrine emergency in which the body's levels of cortisol drop so low that blood pressure collapses, blood glucose plummets, and fatal circulatory shock develops within hours. It strikes people with Addison's disease (primary adrenal insufficiency), congenital adrenal hyperplasia (CAH), pituitary disorders (secondary adrenal insufficiency), or patients on long-term steroid medications when their body faces sudden physical stress such as vomiting, diarrhea, fever, infection, trauma, or surgery. Because cardiovascular collapse occurs rapidly if cortisol is not replaced, immediate treatment with an intramuscular injection of 100 milligrams of hydrocortisone (for adults) and emergency hospital transport for intravenous saline resuscitation must happen without delay.

Sala boye sikoyo¶

1. Call your local emergency number immediately and declare "Suspected Adrenal Crisis, Needs IV Hydrocortisone and 0.9% Saline." Dial 911 in the United States and Canada, 112 across the European Union, 999 in the United Kingdom, or see all banimero ya mbalakaka. Tell the dispatcher that the patient is steroid-dependent and experiencing acute adrenal insufficiency, as standard ambulance protocols may not prioritize a vomiting patient unless adrenal crisis is explicitly stated.
2. Lay the person flat on their back with their legs elevated, or on their side if vomiting or unconscious. Do not let a person in adrenal crisis stand or sit upright, as extreme low blood pressure (orthostatic hypotension) can cause immediate loss of consciousness and cardiac arrest. If they are awake and not actively vomiting, lay them flat and prop their legs up 15 to 30 centimeters (6 to 12 inches) to return blood to the heart; if they are drowsy, unconscious, or vomiting, roll them onto their side in the recovery position to keep their airway clear.
3. Locate the patient's Emergency Steroid Injection Kit and check their Steroid Emergency Card. Look in their handbag, backpack, bedside drawer, or coat pocket for a bright red or yellow Adrenal Crisis Emergency Kit containing injectable hydrocortisone (either a two-chamber Act-O-Vial of hydrocortisone sodium succinate such as Solu-Cortef, a pre-filled liquid ampoule of hydrocortisone sodium phosphate, or a powder vial with a separate sterile water ampoule), needles, and syringes.
4. Prepare and inject the emergency intramuscular hydrocortisone immediately into the outer mid-thigh. Administer the standard emergency dose into the large vastus lateralis muscle on the outside middle third of the thigh: 100 milligrams for adults and adolescents aged 12 and older (or 50 milligrams for children aged 1 to 11 years, and 25 milligrams for infants under 1 year, following the child's personalized adrenal action plan). Push the needle straight in at a 90-degree angle and depress the plunger steadily.
5. Check capillary blood glucose or treat suspected low blood sugar if the person can swallow. Cortisol deficiency impairs the liver's ability to make glucose, frequently triggering severe hypoglycemia (blood sugar below \(3.9\text{ mmol/L}\) or \(70\text{ mg/dL}\)), especially in children. If the person is fully awake and able to swallow safely without gagging, give 15 to 20 grams of fast-acting oral sugar (such as 120 to 180 milliliters [4 to 6 fluid ounces] of fruit juice or regular non-diet soda, or 3 to 4 glucose tablets) or electrolyte solution; never put liquid or food into the mouth of a drowsy, confused, or vomiting person.
6. Keep the person warm and hand their Steroid Emergency Card and empty vial to the paramedics. Cover the patient with a blanket to prevent hypothermia while waiting for emergency medical services. When paramedics arrive, hand them the patient's official Steroid Emergency Card (NHS Steroid Emergency Card in the United Kingdom, NADF Emergency Protocol Letter in the United States, or European Emergency Card) and tell them the exact time and dose of the hydrocortisone injection so they can immediately start a 1,000 milliliter (1 liter) bolus of 0.9% normal saline and continuous intravenous steroid support.

Adrenal crisis recognition and emergency injection decision tree¶

Use this clinical flowchart to decide within seconds whether a steroid-dependent patient needs oral "Sick Day Rule" tablet doubling or an immediate intramuscular hydrocortisone rescue injection.

flowchart TD
    Start["Patient with Addison's Disease, CAH, Pituitary Failure,<br/>or Long-Term Steroid Therapy Develops Acute Stress or Illness"] --> CrisisCheck{"Are ANY Red Flag Crisis Signs Present?<br/>1. Persistent vomiting or severe diarrhea<br/>2. Severe dizziness, fainting, or pale clammy skin<br/>3. Confusion, extreme lethargy, or slurred speech<br/>4. Severe abdominal, flank, or back pain<br/>5. Major trauma, fracture, or unresponsiveness"}

    CrisisCheck -->|"YES: Any single sign present<br/>OR unable to keep pills down"| InjectNow["IMMEDIATE ADRENAL CRISIS PROTOCOL:<br/>1. Lay flat (or recovery position if vomiting/unconscious)<br/>2. Inject IM Hydrocortisone into outer mid-thigh NOW:<br/>   - Adults & Teens (12+ yrs): 100 mg<br/>   - Children (1 to 11 yrs): 50 mg<br/>   - Infants (< 1 yr): 25 mg"]

    InjectNow --> CallEMS["Call 911 / 112 / 999 Immediately:<br/>State 'Life-Threatening Adrenal Crisis'<br/>Request Paramedic IV 0.9% Normal Saline + Hospital Transport"]

    CallEMS --> GlucoseStep{"Is the patient awake and able<br/>to swallow without vomiting?"}
    GlucoseStep -->|"Ɛɛ"| GiveSugar["Check blood glucose if meter available<br/>Give small sips of electrolyte drink or juice if hypoglycemic<br/>Keep lying flat until ambulance stretcher arrives"]
    GlucoseStep -->|"No: Vomiting or drowsy"| AirwayProtect["Keep Nothing by Mouth (NPO)<br/>Maintain lateral recovery position and keep warm<br/>Hand Steroid Emergency Card to EMS crew"]

    CrisisCheck -->|"NO: Mild-to-moderate illness only,<br/>fully alert, no vomiting"| OneVomitCheck{"Has the patient vomited ONCE<br/>within 30 minutes of taking oral steroid?"}

    OneVomitCheck -->|"Yes: Single vomit only"| RepeatOral["Take a DOUBLE oral hydrocortisone dose immediately with sips of water<br/>Wait 30 minutes: if vomiting occurs a SECOND time,<br/>proceed immediately to IM Injection + 911 / 112 / 999"]

    OneVomitCheck -->|"No: Keeping oral pills down"| SickDayRules["Apply Oral Sick Day Rules:<br/>- Fever >= 37.5 C (99.5 F): DOUBLE daily oral hydrocortisone<br/>- High Fever >= 39.0 C (102.2 F): TRIPLE daily oral dose<br/>- Spread doses every 4 to 6 hours around the clock (including overnight)<br/>- Drink electrolyte fluids; watch closely for crisis red flags"]

Understanding why adrenal crisis kills so fast: the cortisol and aldosterone cascade¶

In a person with healthy adrenal glands, the adrenal cortex continuously secretes cortisol (a glucocorticoid hormone) and aldosterone (a mineralocorticoid hormone). Under normal resting conditions, a healthy adult produces roughly 15 to 25 milligrams of cortisol per day. When hit by a high fever, infection, trauma, or vomiting, a healthy pituitary gland commands the adrenal glands to surge cortisol output 3-fold to 10-fold, up to 100 to 300 milligrams per day.

In a patient with adrenal insufficiency, the adrenal glands cannot produce this surge. Unless extra replacement steroid is given by mouth or injection, four physiological failures occur simultaneously:

1. Loss of vascular tone and catecholamine unresponsiveness (Vasoplegic Shock)¶

Cortisol maintains the sensitivity of alpha-1 and beta-1 adrenergic receptors on blood vessels and the heart. Without cortisol, natural adrenaline (epinephrine) and noradrenaline (norepinephrine) cannot constrict arteries. Blood vessels dilate uncontrollably, peripheral resistance collapses, and blood pressure plummets into refractory vasoplegic shock that resists vasopressor drips until intravenous hydrocortisone is given.

2. Massive renal salt and water wasting (Hypovolemic Shock)¶

In Primary Adrenal Insufficiency (Addison's disease and salt-wasting Congenital Adrenal Hyperplasia), the adrenal cortex also lacks aldosterone, which tells the kidneys to retain sodium and water while excreting potassium. Without aldosterone and cortisol, the kidneys dump sodium and water into the urine. Combined with vomiting or diarrhea, circulating blood volume drops by 20 to 30 percent (3 to 5 liters in an adult) within hours, causing hypovolemic shock and acute kidney injury.

3. Dangerous electrolyte derangements: Hyponatremia and Hyperkalemia¶

As sodium is lost in urine and antidiuretic hormone (ADH) rises, blood sodium levels plummet (acute hyponatremia, often below \(130\text{ mmol/L}\)), causing cerebral edema, confusion, and seizures. Simultaneously, in primary adrenal insufficiency, blood potassium climbs above \(5.5\text{ to }7.0\text{ mmol/L}\) (hyperkalemia), poisoning cardiac conduction and triggering peaked T-waves, bradycardia, and sudden ventricular fibrillation or asystolic cardiac arrest.

4. Failure of hepatic gluconeogenesis (Severe Hypoglycemia)¶

Cortisol instructs the liver to manufacture glucose from amino acids and glycerol (gluconeogenesis). When cortisol disappears during fasting or illness, liver glycogen empties rapidly and blood glucose drops below \(3.0\text{ mmol/L}\) (\(54\text{ mg/dL}\)). In infants and young children with Congenital Adrenal Hyperplasia (CAH) or hypopituitarism, neuroglycopenic hypoglycemia is often the first sign of crisis, presenting as limpness, unresponsiveness, or seizures.

Kokokanisa mitindo misato ya insuffisance surrénale¶

Koyeba crise surrénale oyo ezali koya to oyo ezali kosala: bokoli ya bilembo¶

Botala bilembo oyo, mingi mingi soki ebandi na gastro-entérite (kosanza/diarrhee esalaka koleka 50% ya ba crises nionso ya surrénale), ba infections ya urinaire to ya respiratoire, extraction ya mino, molunge makasi, to traumatisme.

Bilembo ya likebisi ya yambo (Fenetre ya liboso ya crise: miniti kino mwa bangonga) .¶

• Kolɛmba ya mbalakaka, oyo eleki makasi na nzoto mpe bolɛmbu ya misisa: Mokakatano ya kotombola motó to kotambola na shambre.
• Kozoka makasi, kozanga mposa ya kolya, mpe kolɛmba ya libumu: Mbala mingi bakanisaka ete ezali simple indigestion.
• Kzunguzungu ya posture mpe kozala na motó ya pole: Vision ekómaka molili ntango nyonso oyo ofandi to otelemi.
• Motó mpasi makasi, kosilika, kozanga kopema, to mobulungano: Bilembo ya ebandeli ya kokita ya tansiɔ, hyponatremie, mpe cortisol ya bɔɔngɔ́ oyo ezali kokita.
• Fièvre oyo ekoki kolimbolama te to température ya nzoto oyo ezali subnormale (malili mpe koningana): Kobungisa cortisol ebebisaka thermorégulation.

Ba drapeaux rouges ya crise surrénale mobimba (Urgence médicale oyo ezali na likama ya bomoi)¶

• Kosanza mbala na mbala to kozoka ya mayi: Soki ba tablettes ya monoko esanza likolo, misuni ya nzoto ekoki ko absorber remplacement ya monoko te, yango ekomisaka injection intramusculaire obligatoire.
• Pasi makasi, ya makasi na libumu, na nse ya mokɔngɔ, to na flanque/makolo: Elembo ya crise surrénale oyo ekoki komekola libumu ya lipaso ya makasi.
• Loposo ya langi ya motane, ya malili, ya kopɔla, ya tache na retard ya recharge capillaire (\(>2\text{ secondes}\)).
• Tachycardie mpe hypothénormose profonde: Pulse ya mbangu ya faible (\(>110\text{ kino }130\text{ bpm}\)) na tansion systolique na se ya \(90\text{ mmHg}\).
• Encéphalopathie, koloba malamu te, stupor, crises, to coma: Mbala mingi bakanisaka libunga lokola kolangwa masanga, . stroke, to sepsis.

Step-by-step guide: How to prepare and inject intramuscular hydrocortisone¶

Emergency hydrocortisone kits come in three main formats depending on your country and pharmacy supply. Because drawing up a medication with trembling hands during an emergency is stressful, follow the specific instructions below for the vial type inside the patient's kit.

Pediatric and adult emergency dosing reference table¶

Before drawing up the injection, confirm the patient's age-based dose (drawn from the United Kingdom Society for Endocrinology, British Society for Paediatric Endocrinology and Diabetes [BSPED], and United States Endocrine Society consensus guidelines):

Method A: How to use a two-chamber Act-O-Vial (Solu-Cortef 100 mg / 2 mL)¶

The Solu-Cortef Act-O-Vial (hydrocortisone sodium succinate) is the most common emergency device in the United States, Canada, Australia, and parts of Europe. It is a single glass bottle divided into two halves by a middle rubber stopper: the bottom half holds white hydrocortisone powder, and the top half holds \(2\text{ milliliters}\) of sterile water.

1. Wash or sanitize your hands if quick, and set the kit on a flat surface. Do not waste minutes scrubbing if the patient is collapsing; speed is more important than sterile perfection.
2. Press down firmly on the plastic activator cap at the top of the vial. Place the bottle upright on a hard table and push straight down with the heel of your palm on the top plastic cap until you feel it click and see the middle rubber divider drop into the bottom chamber, releasing the sterile water into the white powder.
3. Gently rock and swirl the vial for 10 to 15 seconds until the liquid is clear. Do not shake violently (which creates foam bubbles), just tilt and roll the bottle between your palms until all white powder dissolves completely.
4. Flip off the small plastic center tab on top of the cap. This exposes the flat rubber circle in the center of the top cap. (If an alcohol swab is handy, wipe the rubber top once and let it dry for a second.)
5. Attach the needle tightly to the syringe, remove the needle cap, and pull back the plunger to the 2 mL mark (air). Putting \(1\text{ to }2\text{ mL}\) of air into the syringe first makes drawing the liquid out of the pressurized vial much easier.
6. Push the needle straight down through the center of the rubber circle and inject the air into the vial. Keep the needle tip inside the bottle.
7. Turn the vial and syringe upside down (vial on top, syringe underneath) at eye level. Make sure the tip of the needle stays submerged below the liquid level inside the neck of the bottle so you draw liquid, not air.
8. Pull the plunger straight down to draw out the full dose. Pull all the way to the \(2\text{ mL}\) mark for an adult/adolescent (100 mg), the \(1.0\text{ mL}\) mark for a child aged 1 to 11 (50 mg), or the \(0.5\text{ mL}\) mark for an infant under 1 year (25 mg).
9. Tap out large air bubbles and remove the needle from the vial. With the needle still pointing toward the ceiling, flick the barrel of the syringe with your finger so any large air bubbles rise to the top, push the plunger up slightly until a tiny bead of liquid appears at the needle tip, and pull the needle straight out of the bottle. (Do not panic over tiny champagne-sized micro-bubbles; in an intramuscular thigh injection, small air bubbles are completely harmless.)

Method B: How to use a pre-mixed liquid glass ampoule (Hydrocortisone Sodium Phosphate 100 mg / 1 mL)¶

Commonly prescribed in the United Kingdom (such as Efcortesol or generic hydrocortisone sodium phosphate) and parts of Europe, this comes as a ready-to-use clear liquid inside a small sealed glass neck ampoule, requiring no mixing.

1. Tap the top neck of the glass ampoule with your fingernail. This makes sure all the liquid drops down into the main bottom body of the glass ampoule and none is trapped in the top cap.
2. Find the colored dot on the neck of the ampoule and snap the glass top away from the dot. Hold the bottom of the ampoule in one hand, place your other thumb directly over the colored dot on the neck (wrapping a tissue, gauze pad, or the corner of your shirt around the top to protect your fingers from glass), and push firmly backward away from the dot until the glass top snaps cleanly off.
3. Insert the needle attached to your syringe into the open ampoule without touching the broken glass rim. Tilt the ampoule slightly if needed and pull the plunger back to draw up the full \(1\text{ mL}\) liquid for an adult (or \(0.5\text{ mL}\) for a child aged 1 to 11, \(0.25\text{ mL}\) for an infant). If your kit includes a filter needle for drawing from glass, swap to the intramuscular injection needle before injecting into the leg.
4. Point the syringe upward, tap the barrel, and push the plunger slightly until a drop appears at the tip.

Step-by-step: Injecting into the outer mid-thigh (vastus lateralis)¶

Once your syringe is loaded with hydrocortisone, administer the injection into the outer middle third of the thigh immediately:

1. Locate the target zone on the thigh. Visually divide the patient's thigh from the hip bone crease at the top to the kneecap at the bottom into three equal horizontal bands. The safe target is the middle third, on the outer side (lateral aspect) of the thigh. Expose the skin if quick, though in a dire emergency you can inject through thin, clean single-layer clothing if removing tight pants would delay care.
2. Stretch the skin flat (or gently bunch the muscle in a very thin person or young child). Place your non-dominant hand on the thigh and stretch the skin taut between your thumb and index finger.
3. Dart the needle straight in at a 90-degree angle. Hold the syringe barrel like a dart between your thumb and fingers and push the needle smoothly and firmly straight into the thigh muscle at a 90-degree angle to the skin surface, inserting roughly two-thirds to the full length of the needle so the tip sits deep inside the muscle belly. Modern guidelines from the World Health Organization, CDC, and UK NHS confirm that you do NOT need to pull back/aspirate for blood before injecting into the lateral thigh because no major blood vessels run through this zone.
4. Push the plunger all the way down smoothly over 3 to 5 seconds. A steady, moderate push reduces muscle stinging while getting the steroid into the rich capillary bed of the thigh muscle rapidly.
5. Wait 2 seconds, pull the needle straight out at the same 90-degree angle, and press the spot. Press a piece of gauze, tissue, or your clean finger firmly over the injection site for 10 to 20 seconds. Do not rub or massage the site vigorously, as rubbing can force the medication back up into the subcutaneous fat layer where it absorbs more slowly.
6. Make the needle safe immediately. Activate the hinged safety shield if using a safety needle, or place the uncapped syringe directly into a hard plastic container or sharps box so neither you nor the paramedics suffer an accidental needlestick.

Why hospital transport and IV 0.9% normal saline are mandatory after the injection¶

A common and dangerous misconception is that once a patient receives their 100 milligram hydrocortisone injection at home and starts feeling slightly better 30 minutes later, they can stay home and rest. Every patient who receives an emergency hydrocortisone injection for suspected adrenal crisis must be transported by ambulance to an emergency department.

Here is why the home injection is only the bridge to hospital resuscitation:

1. A single IM dose of hydrocortisone wears off in 4 to 6 hours: Intramuscular hydrocortisone has a short biological half-life. If the underlying trigger (such as viral gastroenteritis, bacterial sepsis, influenza, or pneumonia) is still active when that single injection wears off 4 hours later, the patient will crash straight back into a second, deeper adrenal crisis unless they are on continuous hospital intravenous hydrocortisone (\(200\text{ mg}\) per 24 hours by continuous IV infusion, or \(50\text{ mg}\) IV/IM every 6 hours).
2. Hydrocortisone alone cannot replace lost blood volume: A patient in adrenal crisis has lost liters of intravascular fluid and sodium. Standard emergency medicine guidelines (Endocrine Society, UK Society for Endocrinology, and NICE) mandate an immediate intravenous bolus of \(1,000\text{ milliliters}\) (\(1\text{ liter}\)) of isotonic \(0.9\%\) sodium chloride (normal saline) infused within the first 30 to 60 minutes for adults (or \(20\text{ mL/kg}\) isotonic saline bolus for children), followed by 3 to 4 additional liters over the first 24 hours, often paired with \(5\%\) dextrose (\(D5\text{NS}\)) to correct hypoglycemia.
3. Life-threatening electrolyte shifts require hospital ECG and lab monitoring: Only a hospital laboratory can measure serum potassium (to prevent hyperkalemic cardiac arrest), serum sodium (to prevent correcting chronic hyponatremia faster than \(8\text{ to }10\text{ mmol/L}\) per 24 hours, which causes osmotic demyelination syndrome), and identify occult bacterial infections requiring intravenous antibiotics.

Prevention: Mastering the "Sick Day Rules" before a crisis starts¶

Up to half of all hospital admissions for adrenal crisis can be prevented when patients and families aggressively apply Oral Sick Day Rules at the very first sign of physical illness, fever, or trauma. Because a steroid-dependent body cannot raise its own cortisol, you must manually mimic nature's stress response:

Summary of standard international Sick Day Rules (Adult & Pediatric Principles)¶

How to advocate with paramedics and emergency room doctors¶

When accompanying a patient in adrenal crisis to the hospital, use these three steps: 1. Present the official Steroid Emergency Card immediately at triage: In the United Kingdom, hand over the red NHS Steroid Emergency Card. In the United States and Canada, hand over the National Adrenal Diseases Foundation (NADF) or Endocrine Society Emergency Room Protocol Letter. These cards instruct triage staff that IV hydrocortisone (\(100\text{ mg}\)) and IV \(0.9\%\) normal saline (\(1,000\text{ mL}\) bolus) must be given within 15 to 30 minutes of arrival, BEFORE waiting for laboratory blood test results. 2. Keep the patient lying flat on a stretcher: Never let a dizzy or hypotensive patient sit upright in a waiting room chair, as sitting upright pools blood in the lower extremities and can trigger syncope or cardiac arrest. 3. Carry two unexpired kits at all times: Check expiration dates every 6 months, keep one kit at home and one in a travel bag, and store vials between \(20^\circ\text{C}\) and \(25^\circ\text{C}\) (\(68^\circ\text{F}\) to \(77^\circ\text{F}\)).

Mituna oyo batunaka mingi¶

Ba sources e vérifié¶

• Endocrine Society (United States) and European Society of Endocrinology: Clinical Practice Guideline on the Diagnosis and Treatment of Primary Adrenal Insufficiency (Bornstein et al., Journal of Clinical Endocrinology & Metabolism) and Joint Clinical Practice Guideline on Glucocorticoid-Induced Adrenal Insufficiency (2024).
• Society for Endocrinology (United Kingdom) and Royal College of Physicians (United Kingdom): Emergency Guidance for the Management of Acute Adrenal Insufficiency (Adrenal Crisis) in Adult Patients and National Patient Safety Alert: Steroid Emergency Card to Support Early Recognition and Treatment of Adrenal Crisis in Adults.
• British Society for Paediatric Endocrinology and Diabetes (BSPED, United Kingdom) and National Institute for Health and Care Excellence (NICE, United Kingdom): Guideline for the Management of Adrenal Insufficiency in Children and Young People (NG243: Adrenal Insufficiency: Identification and Management, 2024).
• National Adrenal Diseases Foundation (NADF, United States) and Addison's Disease Self-Help Group (ADSHG, United Kingdom): Emergency Injection Instructions for Solu-Cortef Act-O-Vial and Hydrocortisone Sodium Phosphate Ampoules, Sick Day Rules, and EMS Handover Protocols.
• World Health Organization (WHO): Best Practices for Injections and Related Procedures Toolkit (intramuscular vastus lateralis anatomical landmarks and non-aspiration recommendations).

Ba guides oyo etali yango¶

• Shock recognition and first aid management
• Diabetic emergencies: hypoglycemia and DKA first aid
• Food poisoning, acute gastroenteritis, and dehydration
• Sepsis and septic shock recognition
• Disabilities and medical needs emergency planning