Immediate steroid therapy
›Glucocorticoids
›Hydrocortisone preferred
›Hydrocortisone IV 100 mg bolus now
›Continue 200 mg per 24 hours
›Hydrocortisone IV 50 mg q6h
›Alternative infusion 8.3 mg/hour
›Taper to oral as clinically improving
›Transition when hemodynamically stable and tolerating PO
›Dexamethasone alternative when cortisol testing planned
›Dexamethasone IV 4 mg
›Minimal cortisol assay interference
›Convert to hydrocortisone after diagnostic sampling if needed
›Evidence and guidance
›Immediate parenteral hydrocortisone standard of care Class I expert consensus
›Do not delay steroids for confirmatory testing ACEP Level C
›Volume resuscitation
›Isotonic crystalloid
›0.9% sodium chloride 1 L rapid bolus adult
›Repeat bolus guided by MAP and perfusion
›Typical early total 20 to 30 mL/kg
›Dextrose containing fluid if hypoglycemia risk
›D5 0.9% sodium chloride after initial bolus when needed
›Hemodynamic reassessment
›MAP response within 10 to 20 minutes
›Lactate trend within 2 to 4 hours if elevated
›Vasopressors if persistent shock
›Norepinephrine infusion
›Initiate 0.05 to 0.1 microg/kg/min
›Titrate q2 to 5 minutes to MAP target
›Typical range 0.05 to 1.0 microg/kg/min
›Central line preferred
›Peripheral acceptable short term with frequent checks
›Vasopressin adjunct
›Vasopressin 0.03 units/min
›Add when norepinephrine escalating
›Steroid effect expectation
›Improved vasopressor responsiveness within hours
›Dextrose therapy
›Symptomatic or glucose < 3.0 mmol/L
›Dextrose IV bolus
›D10W 150 mL
›Recheck glucose in 10 to 15 minutes
›Repeat as needed
›Recurrent hypoglycemia
›D10W infusion
›Initiate 50 to 100 mL/hour
›Titrate to glucose target
›Oral carbohydrate when safe
Electrolyte and acid base management
›Hyperkalemia pathway
›ECG changes or potassium 6.0 mmol/L or higher
›Calcium gluconate IV 10% 10 mL over 2 to 5 minutes
›Repeat in 5 to 10 minutes if persistent ECG changes
›Insulin glucose shift
›Regular insulin IV 10 units
›Dextrose support if glucose < 7.0 mmol/L
›D10W 250 mL over 15 to 30 minutes
›Recheck glucose q30 to 60 minutes for 3 hours
›Beta agonist shift
›Salbutamol nebulized 10 to 20 mg
›Avoid as monotherapy in severe hyperkalemia
›Potassium removal
›Loop diuretic if volume replete and renal function adequate
›Dialysis consultation if refractory or severe renal failure
›Mineralocorticoid replacement timing
›Hydrocortisone at stress dose provides mineralocorticoid activity
›Fludrocortisone usually deferred until hydrocortisone tapered below stress dosing
›Hyponatremia considerations
›Hypovolemic hyponatremia correction
›0.9% sodium chloride primary therapy
›Avoid rapid correction
›Sodium rise goal 4 to 6 mmol/L in first 24 hours
›Severe symptomatic hyponatremia
›Hypertonic saline per institutional protocol
›ICU level monitoring
Treat precipitating cause
›Infection management
›Empiric antibiotics if sepsis suspected
›Admin within 1 hour for septic shock Class I
›Source tailored regimen per local antibiogram
›Source control pathway
›Urinary obstruction
›Abscess or perforation
›Stress dose education reinforcement for known adrenal insufficiency
›Sick day dosing plan
›Double or triple oral dose during febrile illness
›Parenteral dosing if vomiting or unable to tolerate PO
Consultation and escalation
›Endocrinology
›New diagnosis suspected
›Difficulty tapering vasopressors or steroids
›ICU or critical care
›Persistent shock
›Multi organ dysfunction
›Neurosurgery and ophthalmology
›Suspected pituitary apoplexy with neuro ophthalmic findings