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endo.adrenal-crisis.core.v1PRODUCTION
endo.adrenal-crisis.core.v1

Adrenal crisis

endocrinologyacuteadultpediatric
Hard-required inputs
0 / 9
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Recognize adrenal crisis pattern: shock + hyponatremia +/- hyperkalemia +/- hypoglycemia in Addisonian/steroid-treated patient (Bornstein JCEM 2016 ESE; Rushworth Endocr Rev 2019)

Inputs
3
Actions
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Advance rule
Set
Advance when

crisis pattern present and steroid candidate identified (Bornstein JCEM 2016 ESE)

Patient inputs (13)

Pediatric weight-based hydrocortisone dosing differs from adult bolus (Bornstein JCEM 2016 ESE)

Known AI + missed stress dose is most common precipitant (Hahner JCEM 2015; Rushworth Endocr Rev 2019)

Chronic exogenous steroid HPA suppression; abrupt taper precipitates crisis (Bornstein JCEM 2016 ESE)

Pregnancy alters dosing and triggers MFM consult (Bornstein JCEM 2016 ESE)

Hyponatremia is hallmark; corrected Na guides fluid composition (Bornstein JCEM 2016 ESE; Rushworth Endocr Rev 2019)

Hyperkalemia is hallmark of primary AI; gates ECG and emergency K management (Bornstein JCEM 2016 ESE)

Hypoglycemia common; pediatric especially (Bornstein JCEM 2016 ESE; Hahner JCEM 2015)

Refractory hypotension defines crisis; drives fluid + vasopressor decisions (Bornstein JCEM 2016 ESE; Rushworth Endocr Rev 2019)

Tachycardia + shock index estimation (Bornstein JCEM 2016 ESE)

Etomidate, ketoconazole, rifampin, phenytoin, checkpoint inhibitors precipitate (Bornstein JCEM 2016 ESE; Rushworth Endocr Rev 2019)

Random cortisol drawn pre-steroid — do NOT delay treatment for result (Bornstein JCEM 2016 ESE)

Differentiates primary vs secondary AI (Bornstein JCEM 2016 ESE)

Distributive vs hypovolemic shock pattern; sepsis precipitant (Bornstein JCEM 2016 ESE)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningcrisis_suspected_no_steroid_yet — ESE 2016
    Shock + hyponatremia +/- hyperkalemia +/- hypoglycemia +/- AI history with no hydrocortisone given (Bornstein JCEM 2016 ESE)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghyperkalemia_ECG_changes — ESE 2016
    K >6.5 with peaked T, wide QRS, or arrhythmia (Bornstein JCEM 2016 ESE)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningpregnancy_AC — ESE 2016
    Adrenal crisis in pregnancy any trimester (Bornstein JCEM 2016 ESE)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererefractory_hypotension_despite_steroid — ESE 2016
    MAP <65 despite hydrocortisone bolus + 30 mL/kg crystalloid (Bornstein JCEM 2016 ESE)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_hyponatremia_lt_125 — ESE 2016
    Sodium <125 with neuro symptoms (Bornstein JCEM 2016 ESE)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecheckpoint_inhibitor_hypophysitis — ESE 2016
    New AC pattern in patient on PD-1/PD-L1/CTLA-4 inhibitor (Rushworth Endocr Rev 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateconcomitant_hypothyroidism_warning — ESE 2016
    Concomitant hypothyroidism low FT4 / elevated TSH at presentation (Bornstein JCEM 2016 ESE)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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RED_FLAGSrequiredDrives severity classification
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Recommended regimen

Adrenal crisis acute — stress-dose hydrocortisone + fluids + treat trigger (Bornstein JCEM 2016 ESE)
axis: adrenal_crisis_acutestep 1 - Stage 1 — Empirical hydrocortisone — do NOT delay for cortisol/ACTH (Bornstein JCEM 2016 ESE)
Selected step "Stage 1 — Empirical hydrocortisone — do NOT delay for cortisol/ACTH (Bornstein JCEM 2016 ESE)" — Crisis suspected: shock + hyponatremia ± hyperkalemia ± hypoglycemia in AI substrate (Bornstein JCEM 2016 ESE; Rushworth Endocr Rev 2019)
  • hydrocortisone
    first line
    glucocorticoid_short_acting
    Adult: 100 mg IV/IM bolus STAT, then 50 mg IV q6h OR 200 mg/24h continuous infusion. Pediatric: <1y 25 mg, 1–5y 50 mg, ≥6y 100 mg IV/IM bolus, then 100 mg/m²/day infusion (or 25–50 mg q6h) • IV • q6h or continuous infusion
    triggers: adrenal_crisis_suspected
    Endocrine Society 2016 + UK SfE 2020 — replaces cortisol AND mineralocorticoid effect at high dose; single most important intervention; mortality if delayed
    rxcui 5492
  • dexamethasone
    second line
    glucocorticoid_long_acting
    Adult 4 mg IV bolus (only if hydrocortisone unavailable AND ACTH stim test pending) • IV • single dose
    triggers: hydrocortisone_unavailable, preserve_diagnostic_window
    Does not cross-react with cortisol assay; bridge until hydrocortisone arrives; lacks mineralocorticoid effect (Bornstein JCEM 2016 ESE)
    rxcui 3264

ed playbook — drug actions (6)

  1. 1. hydrocortisone IV STAT
    Adult 100 mg IV bolus; peds <1y 25 mg / 1–5y 50 mg / ≥6y 100 mg • IV • STAT
    trigger: Crisis suspected (Bornstein JCEM 2016 ESE)
    Do not wait for cortisol (Bornstein JCEM 2016 ESE; NICE 2018 AI)
  2. 2. 0.9% NaCl bolus
    1 L over 1h adult; peds 20 mL/kg • IV • over 1h
    trigger: Hypotension/volume depletion (Bornstein JCEM 2016 ESE)
    Volume + Na repletion (Bornstein JCEM 2016 ESE)
  3. 3. D50 if hypoglycemic
    25 g D50 IV push • IV • PRN
    trigger: Glucose <70 (Bornstein JCEM 2016 ESE)
    Common in AC (Bornstein JCEM 2016 ESE; Hahner JCEM 2015)
  4. 4. hydrocortisone maintenance
    50 mg IV q6h OR 200 mg/24h infusion after bolus • IV • q6h or continuous
    trigger: Continuous coverage (Bornstein JCEM 2016 ESE)
    Maintain stress dose (Bornstein JCEM 2016 ESE)
  5. 5. broad-spectrum antibiotics
    Per source; e.g., ceftriaxone 2g IV ± vancomycin • IV • per agent
    trigger: qSOFA ≥2 or evident infection (Hahner JCEM 2015)
    Infection #1 precipitant (Hahner JCEM 2015; Rushworth Endocr Rev 2019)
  6. 6. norepinephrine
    0.05–0.5 mcg/kg/min titrated • IV • continuous
    trigger: MAP <65 despite 30 mL/kg + steroid (Bornstein JCEM 2016 ESE)
    Distributive component (Bornstein JCEM 2016 ESE; Rushworth Endocr Rev 2019)

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Refractory hypotension / shock (Bornstein JCEM 2016 ESE); Hyponatremia + hyperkalemia constellation (Bornstein JCEM 2016 ESE; Rushworth Endocr Rev 2019); Unexplained hypoglycemia (Bornstein JCEM 2016 ESE).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Adrenal crisis** (endo.adrenal-crisis.core.v1).
Phenotype framing: Phenotype: known AI precipitated, new presentation primary AI, iatrogenic steroid withdrawal, Waterhouse-Friderichsen, checkpoint-inhibitor hypophysitis (Bornstein JCEM 2016 ESE; Rushworth Endocr Rev 2019)
Scope: Recognize adrenal crisis pattern: shock + hyponatremia +/- hyperkalemia +/- hypoglycemia in Addisonian/steroid-treated patient (Bornstein JCEM 2016 ESE; Rushworth Endocr Rev 2019)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Adrenal crisis acute — stress-dose hydrocortisone + fluids + treat trigger (Bornstein JCEM 2016 ESE)** — step "Stage 1 — Empirical hydrocortisone — do NOT delay for cortisol/ACTH (Bornstein JCEM 2016 ESE)".
1. hydrocortisone Adult: 100 mg IV/IM bolus STAT, then 50 mg IV q6h OR 200 mg/24h continuous infusion. Pediatric: <1y 25 mg, 1–5y 50 mg, ≥6y 100 mg IV/IM bolus, then 100 mg/m²/day infusion (or 25–50 mg q6h) IV q6h or continuous infusion (glucocorticoid_short_acting, first line) — Endocrine Society 2016 + UK SfE 2020 — replaces cortisol AND mineralocorticoid effect at high dose; single most important intervention; mortality if delayed
2. dexamethasone Adult 4 mg IV bolus (only if hydrocortisone unavailable AND ACTH stim test pending) IV single dose (glucocorticoid_long_acting, second line) — Does not cross-react with cortisol assay; bridge until hydrocortisone arrives; lacks mineralocorticoid effect (Bornstein JCEM 2016 ESE)

Setting playbook (ed) — Recognize crisis pattern, give STAT empirical hydrocortisone, fluids, identify precipitant, transfer to ICU (Bornstein JCEM 2016 ESE)
3. hydrocortisone IV STAT Adult 100 mg IV bolus; peds <1y 25 mg / 1–5y 50 mg / ≥6y 100 mg IV STAT — Crisis suspected (Bornstein JCEM 2016 ESE) (Do not wait for cortisol (Bornstein JCEM 2016 ESE; NICE 2018 AI))
4. 0.9% NaCl bolus 1 L over 1h adult; peds 20 mL/kg IV over 1h — Hypotension/volume depletion (Bornstein JCEM 2016 ESE) (Volume + Na repletion (Bornstein JCEM 2016 ESE))
5. D50 if hypoglycemic 25 g D50 IV push IV PRN — Glucose <70 (Bornstein JCEM 2016 ESE) (Common in AC (Bornstein JCEM 2016 ESE; Hahner JCEM 2015))
6. hydrocortisone maintenance 50 mg IV q6h OR 200 mg/24h infusion after bolus IV q6h or continuous — Continuous coverage (Bornstein JCEM 2016 ESE) (Maintain stress dose (Bornstein JCEM 2016 ESE))
7. broad-spectrum antibiotics Per source; e.g., ceftriaxone 2g IV ± vancomycin IV per agent — qSOFA ≥2 or evident infection (Hahner JCEM 2015) (Infection #1 precipitant (Hahner JCEM 2015; Rushworth Endocr Rev 2019))
8. norepinephrine 0.05–0.5 mcg/kg/min titrated IV continuous — MAP <65 despite 30 mL/kg + steroid (Bornstein JCEM 2016 ESE) (Distributive component (Bornstein JCEM 2016 ESE; Rushworth Endocr Rev 2019))

Non-pharmacologic actions:
- Cardiac monitor + IV access x 2 (Bornstein JCEM 2016 ESE)
- Hyperkalemia ECG check; treat with Ca + insulin/D50 if K >6.5 with ECG changes (Bornstein JCEM 2016 ESE)
- Foley + strict I/Os (Bornstein JCEM 2016 ESE)
- Treat precipitant sepsis bundle, ACS workup (Hahner JCEM 2015; Rushworth Endocr Rev 2019)

AVOID / contraindication checks:
- Never_start_levothyroxine_before_hydrocortisone (Bornstein JCEM 2016 ESE)
- Do_not_delay_steroid_for_diagnostic_cortisol (Bornstein JCEM 2016 ESE; NICE 2018 AI)
- Fludrocortisone_unnecessary_at_HC_ge_50_mg_per_day (Bornstein JCEM 2016 ESE)
- Dexamethasone_only_if_HC_unavailable (Bornstein JCEM 2016 ESE)
- Correct_Na_max_8_mEq_per_24h_to_prevent_ODS (Bornstein JCEM 2016 ESE)

Monitoring

Regimen monitoring:
- BP q15min until stable (Bornstein JCEM 2016 ESE)
- BMP q4h x first 24h (Bornstein JCEM 2016 ESE)
- glucose q1-2h until stable (Bornstein JCEM 2016 ESE; Hahner JCEM 2015)
- sodium correction <8 mEq per 24h (Bornstein JCEM 2016 ESE)
- continuous telemetry (Bornstein JCEM 2016 ESE)
- mental status q2h (Bornstein JCEM 2016 ESE)
- ECG with K abnormalities (Bornstein JCEM 2016 ESE)

Setting (ed) monitoring:
- BP q15 min x 1h then q1h (Bornstein JCEM 2016 ESE)
- POC glucose q1h x 4h (Bornstein JCEM 2016 ESE)
- BMP q4h (Bornstein JCEM 2016 ESE)
- Continuous telemetry (Bornstein JCEM 2016 ESE)

Follow-up plan: Endocrine within 1 week; sick-day rules education; emergency hydrocortisone IM kit; medical alert ID; etiology workup completion; family screening if autoimmune (Bornstein JCEM 2016 ESE; Hahner JCEM 2015; NICE 2018 AI)
- Close-out criterion: sick-day rules taught; emergency kit prescribed; follow-up scheduled (Bornstein JCEM 2016 ESE; Hahner JCEM 2015; NICE 2018 AI)

Monitoring phase: Continuous telemetry, hourly vitals, q4h electrolytes + glucose, strict I/Os, mental status q2h, Na correction <8 mEq/L/24h ceiling (Bornstein JCEM 2016 ESE; NICE 2018 AI)

Disposition

Current setting: ed — Recognize crisis pattern, give STAT empirical hydrocortisone, fluids, identify precipitant, transfer to ICU (Bornstein JCEM 2016 ESE)

Disposition criteria:
- ICU for shock, AMS, or refractory electrolyte abnormalities (Bornstein JCEM 2016 ESE)
- Step-down/ward only after BP stable on q6h IV HC, no pressors, electrolytes correcting (Bornstein JCEM 2016 ESE)

Escalation triggers (move to higher acuity):
- Refractory hypotension despite fluids + steroid + pressors → ICU (Bornstein JCEM 2016 ESE)
- AMS / seizure → ICU + CT brain (Bornstein JCEM 2016 ESE)
- Hyperkalemia with ECG changes → ICU + emergency K Rx (Bornstein JCEM 2016 ESE)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Shock + hyponatremia +/- hyperkalemia +/- hypoglycemia +/- AI history with no hydrocortisone given (Bornstein JCEM 2016 ESE)
- [LIFE_THREATENING] K >6.5 with peaked T, wide QRS, or arrhythmia (Bornstein JCEM 2016 ESE)
- [LIFE_THREATENING] Adrenal crisis in pregnancy any trimester (Bornstein JCEM 2016 ESE)

Citations

- 2016 Endocrine Society AI Guideline (Bornstein JCEM 2016) + NICE 2018 Adrenal Insufficiency + Rushworth Endocr Rev 2019 + Hahner JCEM 2015 + 2020 UK Society for Endocrinology Emergency Guidance [PMID:26760044](https://pubmed.ncbi.nlm.nih.gov/26760044/)
- Cited evidence (PMID 31461595) [PMID:31461595](https://pubmed.ncbi.nlm.nih.gov/31461595/)

Last reconciled with current guidelines: 2026-05-22.
References
  • 2016 Endocrine Society AI Guideline (Bornstein JCEM 2016) + NICE 2018 Adrenal Insufficiency + Rushworth Endocr Rev 2019 + Hahner JCEM 2015 + 2020 UK Society for Endocrinology Emergency Guidance — PMID:26760044
  • Cited evidence (PMID 31461595) — PMID:31461595