Browse categories and answer follow-up questions to refine your symptom profile.
Approach to the Critical Patient
Immediate priorities
First 5 minutes
Airway risk
Depressed mental status
Refractory shock
Breathing support
High flow oxygen for hypoxemia
Ventilation if fatigue or hypercapnia
Circulation
Two large bore IV or IO
Cardiac monitor and defibrillation pads
Point of care glucose within minutes
Time critical therapy
Hydrocortisone immediately if suspected
Do not delay steroids for labs
Shock recognition and triggers
Adrenal crisis phenotype
Hypotension or shock
SBP < 90 mmHg
MAP < 65 mmHg
Vasopressor requirement
Volume depletion
Tachycardia
Poor capillary refill
Oliguria
Metabolic features
Hypoglycemia
Hyponatremia
Hyperkalemia
High risk context
Known adrenal insufficiency
Chronic glucocorticoid use with recent reduction
Recent surgery or severe infection
Monitoring and targets
Resuscitation targets
MAP target 65 mmHg
Higher target for chronic hypertension
Lactate clearance trend if elevated
Urine output target 0.5 mL/kg/hour
Foley if shock or strict I and O
Glucose target 4.0 to 10.0 mmol/L
Dextrose support if recurrent hypoglycemia
Electrolyte safety
Potassium trend and ECG changes
Sodium correction rate safety
Key concepts
Core pathophysiology
Absolute or relative cortisol deficiency
Reduced vascular tone and catecholamine responsiveness
Impaired gluconeogenesis and glycogenolysis
Mineralocorticoid deficiency in primary adrenal insufficiency
Renal sodium wasting
Hyperkalemia and metabolic acidosis
Precipitating stress with inadequate stress dose steroids
Infection
Surgery
Trauma
History
Presentation patterns
Typical presentation
Shock with nonspecific symptoms
Weakness and fatigue
Nausea and vomiting
Abdominal pain
Altered mental status
Hypoglycemia driven
Hyponatremia driven
Fever
Triggering infection
Crisis itself
Risk factors and triggers
Predisposing context
Known primary adrenal insufficiency
Addison disease
Congenital adrenal hyperplasia
Known secondary or tertiary adrenal insufficiency
Pituitary disease or surgery
Chronic exogenous steroid exposure
Recent stressors
Sepsis or gastroenteritis
Surgery or anesthesia
Trauma
Medication and adherence
Glucocorticoid details
Daily dose and timing
Missed doses
Recent taper or discontinuation
Stress dosing plan
Sick day dosing use
Parenteral emergency kit availability
Drug interactions
Enzyme inducers reducing steroid effect
Opioids or sedatives masking symptoms
Mineralocorticoid details
Fludrocortisone use
Recent interruption
Salt craving history
Etiology clues
Primary adrenal insufficiency clues
Hyperpigmentation
New or worsening
Salt craving
Autoimmune history
Thyroid disease
Type 1 diabetes
Secondary adrenal insufficiency clues
Recent pituitary symptoms
Headache
Visual changes
Postpartum hemorrhage history
No hyperpigmentation history
Physical Exam
Vital sign patterns
Hemodynamic findings
Hypotension
Orthostatic component
Refractory to fluids
Tachycardia
Fever
Respiratory findings
Tachypnea
Metabolic acidosis compensation
Volume status and perfusion
Hypovolemia features
Dry mucous membranes
Decreased skin turgor
Flat neck veins
Poor perfusion features
Cool extremities
Delayed capillary refill
Mottling
Focused exam clues
Primary adrenal insufficiency signs
Hyperpigmentation
Buccal mucosa
Palmar creases
Vitiligo
Secondary adrenal insufficiency signs
No hyperpigmentation
Other pituitary hormone deficiency features
Precipitating cause signs
Infection source findings
Abdominal tenderness
Meningismus
PITFALLS
Common misses
Sepsis assumption with delayed steroids
Normal potassium in secondary adrenal insufficiency
Relative adrenal insufficiency in critical illness without classic stigmata
Differential Diagnosis
Life threatening mimics
Shock differentials
Septic shock ICD-10 R57.2
Anaphylaxis ICD-10 T78.2
Cardiogenic shock ICD-10 R57.0
Massive pulmonary embolism ICD-10 I26
Hemorrhagic shock ICD-10 R57.1
Metabolic differentials
Diabetic ketoacidosis ICD-10 E10.10 E11.10
Hyperosmolar hyperglycemic state ICD-10 E11.00
Hypoglycemia non-diabetic ICD-10 E16.2
Myxedema coma ICD-10 E03.5
Adrenal related entities
Primary adrenal insufficiency
Addisonian crisis ICD-10 E27.2
Primary adrenocortical insufficiency ICD-10 E27.1
SNOMED CT Addisonian crisis disorder
Secondary adrenal insufficiency
Pituitary apoplexy ICD-10 E23.6
Hypopituitarism ICD-10 E23.0
Adrenal hemorrhage
Anticoagulation associated adrenal hemorrhage
Sepsis associated adrenal hemorrhage
Differentiating clues
Features supporting adrenal crisis
Refractory hypotension despite fluids and catecholamines
Hyponatremia with or without hyperkalemia
Hypoglycemia in non-diabetic patient
Hyperpigmentation history suggesting primary disease
Laboratory Tests
Core resuscitation labs
Initial lab bundle
Basic metabolic panel
Sodium and potassium
Bicarbonate and anion gap
Glucose
Repeat q30 to 60 min until stable
Venous blood gas
pH
Lactate
CBC
Eosinophilia supportive but nonspecific
Creatinine and urea
Prerenal azotemia pattern
Endocrine specific labs
Adrenal axis sampling before steroids if feasible
Serum cortisol
Random cortisol interpretation depends on illness severity
Very low cortisol supports diagnosis
Plasma ACTH
High ACTH suggests primary adrenal insufficiency
Low or inappropriately normal ACTH suggests secondary or tertiary
Renin and aldosterone
Primary adrenal insufficiency evaluation
Not time critical for ED stabilization
Precipitant and complication labs
Infection evaluation
Blood cultures before antibiotics if possible
Do not delay antibiotics in septic shock
Urinalysis and urine culture
Chest imaging correlation
Hyperkalemia evaluation
Magnesium and phosphate
Repeat potassium after therapy
Coagulopathy and hemorrhage risk
INR and aPTT if adrenal hemorrhage concern
Type and screen if hemorrhage or surgery
PITFALLS
Interpretation limitations
Cortisol may be misleading after exogenous steroids
Dexamethasone least assay interfering for cortisol measurement
Hyponatremia may reflect SIADH or volume depletion in other illnesses
Diagnostic Tests
Scoring Systems
Diagnostic approach aids
High suspicion pathway
Known adrenal insufficiency plus shock
Immediate steroids without confirmatory testing
Random cortisol in critical illness
Very low random cortisol strongly supportive
Intermediate values indeterminate
High values make adrenal crisis less likely but not impossible
ACTH stimulation test role
Best for stable patients
Limited ED value in unstable shock
MRI
Pituitary evaluation
MRI sella for suspected pituitary apoplexy
Severe headache with visual symptoms
Ophthalmoplegia
MRI timing
After stabilization
Urgent endocrine and neurosurgery coordination
CT
Adrenal imaging
CT abdomen for suspected adrenal hemorrhage
Anticoagulation
Recent sepsis or trauma
CT findings considerations
Bilateral adrenal enlargement or hemorrhage
Alternative intraabdominal source evaluation
Brain imaging
CT head for altered mental status with focal deficits
Pituitary apoplexy screening if MRI delayed
Ultrasound
Shock ultrasound integration
RUSH style assessment
IVC size and collapsibility for volume status
Cardiac function and pericardial effusion
Lung ultrasound for pulmonary edema or pneumonia
Limitations
Adrenal glands not reliably visualized in adults
Does not rule out adrenal hemorrhage
Disposition
Level of care
ICU admission criteria
Vasopressor requirement
Persistent hypotension after 30 mL/kg crystalloid equivalent
Severe electrolyte disturbance
Potassium 6.0 mmol/L or ECG changes
Sodium < 120 mmol/L with symptoms
Recurrent hypoglycemia
Altered mental status
Ward admission and monitoring
Inpatient admission criteria
Suspected adrenal crisis improved after initial therapy
Ongoing IV steroids requirement
Need for precipitant treatment
Monitoring needs
Electrolytes q4 to 6 hours initially
Glucose q2 to 4 hours initially
Fluid balance and urine output trend
Discharge rare pathway
ED discharge criteria
Clear alternative diagnosis without adrenal crisis
Mild stress dosing need without shock
Reliable follow up within 24 to 72 hours
Discharge prerequisites for known adrenal insufficiency
Patient education reinforced
Emergency injection kit access confirmed
Endocrinology follow up arranged
Treatment
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
Fluids and hemodynamics
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
Hypoglycemia management
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
Special Populations
Pregnancy
Pregnancy considerations
Maternal physiology
Increased cortisol binding globulin altering total cortisol
Hypotension may be late sign
Steroid therapy safety
Hydrocortisone preferred
Stress dosing required for labor and delivery
Obstetric coordination
Fetal monitoring if viable gestation and maternal instability
Obstetric consult for delivery planning
Geriatric
Older adult considerations
Atypical presentation
Delirium predominant
Minimal fever despite infection
Fluid resuscitation risks
Heart failure exacerbation
Frequent lung ultrasound or exam reassessment
Medication risks
Higher delirium risk with hypoglycemia
Higher arrhythmia risk with hyperkalemia
Pediatrics
Pediatric considerations
Weight based steroids
Hydrocortisone IV 50 to 100 mg/m2 bolus
Continue 50 to 100 mg/m2 per 24 hours divided q6h
Glucose vulnerability
Early dextrose containing fluids often needed
Frequent glucose checks
Congenital adrenal hyperplasia
Salt wasting crisis risk
Hyperkalemia and hyponatremia prominent
Fluid dosing
Isotonic bolus 20 mL/kg
Repeat based on perfusion
Background
Epidemiology
Frequency and risk
Adrenal crisis incidence higher in known adrenal insufficiency during intercurrent illness
Infection and gastroenteritis common precipitants
Mortality risk driven by delayed steroid administration and shock severity
Pathophysiology
Cortisol deficiency effects
Reduced vascular responsiveness
Decreased alpha adrenergic receptor expression and signaling
Reduced catecholamine synthesis support
Metabolic vulnerability
Impaired gluconeogenesis
Reduced glycogen stores mobilization
Immune modulation changes
Excess inflammatory response in infection
Aldosterone deficiency effects in primary disease
Sodium wasting
Hypovolemia and hypotension
Potassium retention
Hyperkalemia
Hydrogen ion retention
Non anion gap metabolic acidosis
Therapeutic Considerations
Steroid selection principles
Hydrocortisone provides glucocorticoid and mineralocorticoid activity at stress doses
Dexamethasone preserves cortisol testing utility
Timing principles
Steroids early improves vasopressor responsiveness
Fluids correct hypovolemia and improve sodium
Taper principles
High dose IV for 24 to 48 hours typical
Transition to oral stress dosing then baseline regimen with endocrinology guidance
Patient Discharge Instructions
Copy discharge instructions
Adrenal insufficiency sick day plan
Home steroid plan
Take prescribed steroid exactly as directed
Do not stop steroids suddenly
Illness stress dosing
Fever or significant illness requires increased steroid dosing per your plan
Vomiting or inability to keep pills down requires injection and urgent medical care
Emergency injection kit
Keep injectable steroid kit available at all times if prescribed
Family or friends training on injection use
Medical alert identification
Wear medical alert bracelet or carry card for adrenal insufficiency
Return to ED now
Fainting or severe dizziness
Persistent vomiting or inability to drink fluids
Confusion or unusual sleepiness
Severe weakness
Fever with worsening symptoms
Severe abdominal pain
Follow up
Endocrinology follow up within 1 to 2 weeks
Review sick day rules and emergency dosing plan
References
Clinical guidelines and key sources
Guideline sources
Endocrine Society clinical practice guideline for primary adrenal insufficiency stress dosing and adrenal crisis management
Society for Endocrinology adrenal crisis guidance for emergency hydrocortisone and fluids
Surviving Sepsis Campaign recommendations for early antibiotics and vasopressor targets in septic shock
Evidence and reviews
Evidence summaries
Reviews on adrenal crisis recognition and outcomes in known adrenal insufficiency cohorts
Critical care literature on steroid effects on vasopressor responsiveness in shock physiology
Diagnostic endocrinology references for ACTH stimulation testing interpretation limits in critical illness
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.