Unexplained shock, vomiting, hyponatraemia, hyperkalaemia or hypoglycaemia in someone at risk (steroid use, Addison's, pituitary disease): give hydrocortisone 100 mg IV immediately after a random cortisol, without waiting for results, plus 1 L isotonic fluid in the first hour.
At the bedside
Timed steps- 1
Who
SuspectLong-term or recently stopped glucocorticoids (including inhaled/topical high dose), known Addison's or hypopituitarism, post-partum haemorrhage (Sheehan's), adrenal haemorrhage on anticoagulants or in meningococcaemia, TB or HIV adrenalitis, checkpoint inhibitors, etomidate.
- 2
Treat now
0 minDraw random cortisol (+ ACTH if possible), then hydrocortisone 100 mg IV/IM bolus. Do not wait for results or a stimulation test.
- 3
Fluids
0-1 h1 L 0.9% saline (or 5% dextrose in saline if hypoglycaemic) within the first hour, then guided by haemodynamics.
- 4
Continue
24 hHydrocortisone 200 mg/24 h as continuous infusion or 50 mg IV every 6 h; taper to oral maintenance over 1-3 days once the trigger is controlled.
- 5
Prevent
LaterSick-day rules (double oral dose during febrile illness), steroid card, IM hydrocortisone emergency kit; treat the trigger (infection, surgery, missed doses).
Adrenal crisis
Hydrocortisone
- Dose
- 100 mg bolus, then 200 mg/24 h infusion or 50 mg 6-hourly
Children: 50 mg/m² (approx. 2 mg/kg, max 100 mg) bolus.
Suspected adrenal crisis
Step 1 of ~6
Random cortisol ± ACTH
Based on Bornstein SR, Allolio B, Arlt W, et al. Educational use; follow local protocol.
Evidence
- Endocrine Society 2016: immediate parenteral hydrocortisone 100 mg, then 200 mg/24 h; fluid resuscitation with isotonic saline.
🇮🇳 India notes
- Over-the-counter steroid use (including adulterated ayurvedic/herbal preparations) and tuberculous adrenalitis are important Indian causes; Sheehan's syndrome still occurs.
References
Test yourself
Module quiz · score 70% to complete the module
Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.