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Symptom
dx.
Clinical Reference
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Adrenal Insufficiency (Addisonian Crisis)
Cardiovascular Presentations
Abdominal aortic aneurysm
Acute coronary syndrome (NSTEMI)
Acute coronary syndrome (STEMI)
Acute decompensated heart failure
Acute limb ischemia
Acute mesenteric ischemia
Aortic dissection
Aortic stenosis
Atrial fibrillation and flutter
Bradyarrhythmia and heart block
Cardiac arrest
Deep vein thrombosis
Myocarditis
Pericarditis
Pulmonary embolism
Stable angina
Superficial thrombophlebitis
Superior vena cava syndrome
Supraventricular tachycardia
Syncope (cardiogenic)
Unstable angina
Ventricular tachycardia
Respiratory Presentations
Acute bronchitis
Acute respiratory failure
Aspiration pneumonia
Asthma exacerbation
Bronchiolitis
Community-acquired pneumonia
COVID-19 pneumonia
COPD exacerbation
Croup
Croup (laryngotracheobronchitis)
Epiglottitis
Hemothorax
Hospital-acquired pneumonia
Pleural effusion
Pneumothorax (traumatic)
Pulmonary contusion
Spontaneous pneumothorax
Neurological Presentations
Bell's palsy
Benign paroxysmal positional vertigo
Brain abscess
Cauda equina syndrome
Cervical radiculopathy
Concussion (mild traumatic brain injury)
Encephalitis
Guillain-Barré syndrome
Hemorrhagic stroke (intracerebral)
Ischemic stroke
Lumbar radiculopathy
Malignant spinal cord compression
Migraine
Peripheral neuropathy (acute)
Retropharyngeal abscess
Schizophrenia (acute exacerbation)
Seizure (breakthrough:known epilepsy)
Seizure (first-time)
Spinal cord injury
Status epilepticus
Subarachnoid hemorrhage
Tension headache
Transient ischemic attack
Traumatic brain injury (moderate-severe)
Vestibular neuritis
Viral meningitis
Gastrointestinal Presentations
Acute appendicitis
Acute cholecystitis
Acute diverticulitis
Acute pancreatitis
Anal fissure
Choledocholithiasis and cholangitis
Clostridioides difficile colitis
Gastritis
Gastroenteritis (viral and bacterial)
Gastroesophageal reflux disease
Incarcerated or strangulated hernia
Inflammatory bowel disease flare
Large bowel obstruction
Lower GI hemorrhage
Peptic ulcer disease
Perforated viscus
Small bowel obstruction
Upper GI hemorrhage
Genitourinary and Reproductive Presentations
Acute prostatitis
Acute urinary retention
Ectopic pregnancy
Epididymitis
Orchitis
Ovarian torsion
Paraphimosis
Pelvic inflammatory disease
Priapism
Pyelonephritis
Renal laceration
Ruptured ovarian cyst
Testicular torsion
Tubo-ovarian abscess
Urinary tract infection (uncomplicated)
Urolithiasis (renal colic)
Vaginal bleeding (non-pregnant)
Infectious Disease Presentations
Acute sinusitis
Acute tonsillitis
Acute upper respiratory infection
Animal bite
Bacterial meningitis
Cellulitis
Conjunctivitis (bacterial)
Dental abscess
Endocarditis
Febrile neutropenia
Fournier gangrene
Hand-foot-mouth disease
Hepatitis (acute)
Herpes zoster
HIV-related illness
Human bite
Impetigo
Infected diabetic foot ulcer
Infectious mononucleosis
Influenza
Necrotizing fasciitis
Osteomyelitis
Otitis externa
Parasitic infection
Periorbital cellulitis
Peritonsillar abscess
Scabies
Sepsis
Septic arthritis
Spontaneous bacterial peritonitis
Tick-borne illness (Lyme disease)
Tinea infection
Tuberculosis
Viral exanthem
Wound infection
Trauma Presentations
Achilles tendon rupture
ACL and mceniscus tear
Ankle fracture
Ankle sprain
Burn
Calcaneus fracture
Cervical spine fracture
Clavicle fracture
Dental avulsion
Distal radius fracture
Drowning
Elbow fracture and dislocation
Electrical injury
Facial bone fracture
Facial laceration
Femur fracture
Fingertip amputation
Forearm fracture (radius and ulna)
Frostbite
Hand:finger laceration
Heat exhaustion
Heat stroke
Hip fracture
Humeral shaft fracture
Knee dislocation
Knee sprain
Lightning injury
Mandible fracture
Metacarpal fracture
Metatarsal fracture
Muscle strain
Nasal fracture
Non-accidental trauma
Orbital fracture
Patella fracture
Phalanx fracture (finger)
Proximal humerus fracture
Pulmonary contusion
Rib fracture
Rotator cuff tear (acute traumatic)
Scalp laceration
Scaphoid fracture
Shoulder dislocation
Skull fracture
Splenic laceration
Sternal fracture
Supracondylar pediatric fracture
Tendon laceration (hand:wrist)
Thoracic and lumbar spine fracture
Tibia:fibula fracture
Tibial plateau fracture
Toe fracture
Traumatic epistaxis
Traumatic hyphema
Toxicologic Presentations
Acetaminophen toxicity
Alcohol intoxication
Alcohol withdrawal
Anticholinergic toxicity
Anticoagulant overdose
Benzodiazepine overdose
Benzodiazepine:sedative overdose
Beta-blocker and calcium channel blocker toxicity
Carbon monoxide poisoning
Caustic ingestion
Digoxin toxicity
Drug eruption
Foreign body ingestion
Opioid intoxication
Opioid overdose
Opioid withdrawal
Organophosphate
Salicylate toxicity
Serotonin syndrome
Stimulant intoxication (cocaine, methamphetamine)
Tricyclic antidepressant overdose
Psychiatric Presentations
Acute anxiety
Acute psychosis
Agitation:behavioral emergency
Bipolar disorder
Conversion disorder
Major depressive episode
Neuroleptic malignant syndrome
Suicidal ideation and attempt
Musculoskeletal and Rheumatologic Presentations
Acute low back pain (mechanical)
Bursitis
Cervical radiculopathy
Costochondritis
Gout (acute)
Lumbar radiculopathy
Pseudogout
Tendinitis
Dermatology Presentations
Acute eczema (Eczema acute flare)
Allergic contact dermatitis
Erythema multiforme
Henoch-Schönlein purpura
Pressure injury
Psoriasis (acute flare)
Stevens-Johnson syndrome
Toxic epidermal necrolysis
Urticaria (acute)
Environmental and Exposure Presentations
Envenomation (snake, spider, insect)
High-altitude illness
Hypothermia
Hematologic and Oncologic Presentations
Acute chest syndrome
Coagulopathy
Hyperviscosity syndrome
Sickle cell crisis (vaso-occlusive)
Symptomatic anemia
Thrombocytopenia (severe)
Tumor lysis syndrome
Pediatric-Specific Presentations
Bronchiolitis
Croup
Emergency delivery
Febrile seizure
Kawasaki disease
Neonatal jaundice
Neonatal sepsis
Nursemaid's elbow
Pediatric fever 0 to 28 days
Pediatric fever 29 to 60 days
Pediatric fever 61 to 90 days
Pyloric stenosis
Slipped capital femoral epiphysis
Intussusception
Endocrine and Metabolic Presentations
Adrenal crisis
Diabetic ketoacidosis
Hypercalcemia
Hyperosmolar hyperglycemic state
Hypertensive emergency
Hypertensive urgency
Hypoglycemia
Myasthenia gravis crisis
Myxedema coma
Severe hyperkalemia
Severe hyponatremia
Thyroid storm
ENT and Maxillofacial Presentations
Acute laryngitis
Acute otitis media
Acute pharyngitis
Cerumen impaction
Epistaxis (anterior)
Nasal foreign body
Otitis externa
Tympanic membrane perforation
Ophthalmologic Presentations
Acute angle-closure glaucoma
Central retinal artery occlusion
Chemical eye injury
Corneal abrasion
Corneal ulcer
Globe rupture
Ocular foreign body
Orbital cellulitis
Retinal detachment
Obstetric Presentations
Hyperemesis gravidarum
Painful vaginal bleeding in pregnancy
Placenta previa
Placental abruption
Preeclampsia:eclampsia
Preterm labor
Threatened:inevitable:incomplete abortion
Systemic and Miscellaneous Presentations
Anaphylaxis
Angioedema
Cannabis-induced hyperemesis
Adrenal Insufficiency (Addisonian Crisis)
POCUS
Procedures
Calculators
Resuscitation
ECG Guide
Back
Clinical Assessment Checklist
Browse categories and answer follow-up questions to refine your symptom profile.
Approach to the Critical Patient
Immediate priorities
Recognize adrenal crisis early
▶
Hypotension or hypovolemic shock plus one or more
▶
Nausea or vomiting
Severe fatigue
Fever without clear source
Impaired consciousness
Shock out of proportion to trigger severity
▶
Refractory to fluids alone
Refractory to conventional vasopressors until glucocorticoid given
Treatment must never be delayed for diagnostic workup
▶
Hydrocortisone 100 mg IV bolus immediately
Draw cortisol and ACTH before treatment only if no delay
Airway and breathing threats
▶
Depressed mental status
▶
Obtundation
Seizure or coma
If unable to protect airway, definitive airway control
▶
Rapid sequence intubation preparation
Avoid etomidate as induction agent
Circulation threats
▶
Distributive and hypovolemic shock
▶
SBP < 100 mmHg or >= 20 mmHg below baseline
Tachycardia and poor perfusion
If shock present, 1 L 0.9% saline in first hour
▶
Aggressive crystalloid resuscitation
Reassess after each bolus
Reversible cardiomyopathy from cortisol deficiency
▶
Decreased myocardial contractility
Improves with glucocorticoid replacement
Time critical actions
First-hour bundle
▶
Hydrocortisone 100 mg IV or IM bolus
▶
Do not wait for confirmatory testing
IM route if no IV access
Point-of-care glucose immediately
▶
Dextrose 0.5 to 1 g/kg if hypoglycemic
D50 or D10 infusion
Cardiac monitoring for hyperkalemia
▶
Peaked T waves
Widened QRS
Escalation and consults
Escalation triggers
▶
Persistent hypotension after hydrocortisone and fluids
▶
Investigate alternative shock cause
ICU level care
Altered mental status or severe electrolyte derangement
▶
High-dependency monitoring
Frequent neuro checks
Consultation triggers
▶
Endocrinology for all new diagnoses
▶
Recurrent crises
Etiologic workup planning
Critical care for refractory shock
▶
Vasopressor titration
Mechanical ventilation needs
History
Presenting symptoms
Core syndrome
▶
Fatigue (50% to 95%)
▶
Chronic and progressive
Worse with stress
Nausea and vomiting (20% to 62%)
▶
Impairs oral medication absorption
Common crisis precipitant
Anorexia and weight loss (43% to 73%)
▶
Unintentional
Months-long course
Cardinal features
▶
Orthostatic dizziness or syncope
▶
Orthostatic hypotension 68% in primary AI
Salt cravings from aldosterone deficiency
Abdominal pain
▶
May mimic acute abdomen
Peritoneal-like irritation
Skin darkening
▶
Hyperpigmentation 74% in primary AI
Buccal mucosa and palmar creases
Precipitants and triggers
Recent stressors
▶
Infection especially GI illness
▶
Vomiting and diarrhea
Dehydration
Surgery, trauma, or dental procedure
▶
Physiologic stress demand
Inadequate stress dosing
Recent steroid taper or discontinuation
▶
Below physiological replacement dose
Nonadherence to replacement
Medication history
Critical medication review
▶
Glucocorticoid use any route
▶
Oral, inhaled, topical, intra-articular
Most common cause of AI overall
ACTH-suppressing or enzyme-inhibiting drugs
▶
Opioids suppress ACTH
Ketoconazole, metyrapone, etomidate, mitotane
CYP3A4 inducers accelerating cortisol metabolism
▶
Rifampin and phenytoin
Carbamazepine and phenobarbital
Immune checkpoint inhibitors
▶
Hypophysitis or adrenalitis
Risk under 1%
Iatrogenic precipitant caution
▶
Levothyroxine started in undiagnosed AI
▶
Increases cortisol clearance
Can precipitate crisis
Risk factors and collateral
Personal risk factors
▶
Prior adrenal crisis as strongest predictor
▶
Recurrent crisis tendency
Higher comorbidity burden
Age over 65 years or adolescence transition
▶
Care transition gaps
Reduced reserve
Family and autoimmune history
▶
Autoimmune polyendocrine syndromes
▶
Type 1 diabetes
Autoimmune thyroid disease
Other autoimmune associations
▶
Vitiligo
Pernicious anemia
Collateral and adherence
▶
Medication compliance confirmation
▶
Nonadherence as common precipitant
Medical alert identification or steroid card
Self-injection capability
▶
Patient ability to self-inject hydrocortisone
Caregiver availability
Physical Exam
Vital signs and general
Hemodynamic snapshot
▶
Hypotension
▶
SBP < 100 mmHg
Greater than or equal to 20 mmHg below baseline
Orthostatic changes and tachycardia
▶
Postural drop
Compensatory tachycardia
Fever
▶
May be from infection precipitant
May occur without infectious source
General appearance
▶
Dehydration
▶
Poor skin turgor
Dry mucous membranes
Cachexia
▶
Chronic weight loss
Muscle wasting
Targeted organ exam
Skin findings
▶
Hyperpigmentation in primary AI only
▶
Palmar creases and buccal mucosa
Scars, areolae, and axillae
Absence does not exclude AI
▶
Secondary AI lacks hyperpigmentation
Glucocorticoid-induced AI lacks hyperpigmentation
Abdomen
▶
Tenderness
▶
Diffuse or epigastric
Guarding can mimic surgical abdomen
Bowel sounds and distension
▶
Ileus possible
Non-specific findings
Neurologic
▶
Altered mental status
▶
Lethargy to coma
Confusion and delirium
Hypoglycemia contribution
▶
Diaphoresis
Focal deficits possible
PITFALLS
Common exam traps
▶
Anchoring on acute abdomen
▶
Avoid unnecessary laparotomy
Consider crisis when shock disproportionate
Attributing shock solely to sepsis
▶
Adrenal crisis may coexist with sepsis
Treat empirically when suspected
Differential Diagnosis
Life-threatening mimics
Shock states
▶
Septic shock
▶
Most important mimic
May coexist with adrenal crisis
Hypovolemic shock
▶
GI losses or hemorrhage
Responds to volume alone
Cardiogenic shock
▶
Acute heart failure
Crisis itself causes reversible cardiomyopathy
Other emergencies
▶
Anaphylaxis
▶
Hypotension with GI symptoms
Urticaria and angioedema
Diabetic ketoacidosis
▶
Nausea, vomiting, abdominal pain
Anion-gap acidosis and ketones
Endocrine and abdominal mimics
Endocrine
▶
Myxedema coma
▶
Hypothyroidism with hypotension
Altered mental status
Hypoglycemia from other causes
▶
Insulinoma
Liver failure
Abdominal
▶
Acute surgical abdomen
▶
Appendicitis or perforation
ICD-10 R10.0 acute abdomen
Differentiating clue
▶
Shock refractory to fluids and vasopressors
Rapid response to glucocorticoid
Coding and classification
Diagnostic codes
▶
Primary adrenocortical insufficiency
▶
ICD-10 E27.1
Addison disease
Adrenal crisis
▶
ICD-10 E27.2
Addisonian crisis
Drug-induced adrenocortical insufficiency
▶
ICD-10 E27.3
Glucocorticoid-induced AI
Laboratory Tests
Core diagnostic labs
Draw before treatment if no delay
▶
Serum cortisol
▶
Random in crisis
Under 5 µg/dl strongly suggests AI
Plasma ACTH
▶
Elevated over 2x upper limit in primary AI
Low or low-normal in secondary or tertiary
DHEAS
▶
Low in all forms of AI
Adjunct support
Electrolytes and metabolic
Basic metabolic panel
▶
Hyponatremia
▶
Present in 84% of undiagnosed AI
Cortisol and aldosterone deficiency
Hyperkalemia
▶
34% in primary AI only
Mineralocorticoid deficiency
Hypoglycemia and prerenal markers
▶
Low glucose
Elevated creatinine and BUN
Hematology
▶
Complete blood count
▶
Eosinophilia and lymphocytosis
Mild normocytic anemia
Adjunct and etiologic labs
Hormonal axis
▶
Aldosterone and renin
▶
Low aldosterone with high renin in primary AI
Confirms mineralocorticoid deficiency
Additional chemistry
▶
Mild hypercalcemia possible
TSH may be elevated
Etiologic workup once stable
▶
21-hydroxylase antibodies
▶
Autoimmune adrenalitis
Addison disease confirmation
Targeted testing
▶
Very long-chain fatty acids for adrenoleukodystrophy in males
17-hydroxyprogesterone for congenital adrenal hyperplasia
Diagnostic Tests
Scoring Systems
Adrenal crisis clinical definition
▶
Hypotension or hypovolemic shock
▶
SBP < 100 mmHg
Marked orthostatic drop
Plus one or more features
▶
Nausea or vomiting
Fever or impaired consciousness
Distinguishing principle
▶
Shock disproportionate to trigger
Refractory until glucocorticoid given
Cosyntropin stimulation test
▶
Gold standard in stable patients
▶
250 µg cosyntropin IV or IM
Cortisol at 0 and 60 minutes
Interpretation
▶
Peak cortisol under 18 µg/dl confirms AI
Newer assays use 15 to 17 µg/dl thresholds
Performance and limits
▶
Sensitivity 64% and specificity 93% for secondary AI
Normal result does not exclude recent-onset secondary AI
Not needed when unequivocal
▶
Low baseline cortisol with elevated ACTH
Primary AI already established
MRI
Pituitary MRI
▶
Indications for suspected secondary AI
▶
Pituitary tumor or hemorrhage
Hypophysitis or infiltrative disease
Findings
▶
Sellar or suprasellar mass
Empty sella or stalk thickening
Timing
▶
After stabilization
Not required for acute diagnosis
CT
CT abdomen and adrenals
▶
Indication when etiology unclear
▶
After labs in primary AI
Not required for acute crisis diagnosis
Findings
▶
Adrenal enlargement from infection, hemorrhage, or metastases
Calcification from TB or prior hemorrhage
Acute hemorrhage consideration
▶
Waterhouse-Friderichsen syndrome
Bilateral adrenal hemorrhage
Ultrasound
Point-of-care ultrasound
▶
Volume status assessment
▶
IVC collapse with hypovolemia
Guides fluid resuscitation
Cardiac evaluation
▶
Gross LV function for reversible cardiomyopathy
Pericardial effusion screen
Shock differential support
▶
Excludes obstructive causes
Integrate with clinical exam
Disposition
Level of care
Admit all adrenal crisis patients
▶
ICU or high-dependency unit
▶
Hemodynamic monitoring
Frequent electrolyte checks
ICU indications
▶
Persistent hypotension despite treatment
Altered mental status or severe electrolyte derangement
Observation candidates
▶
Incipient crisis
▶
Symptomatic AI without frank hypotension
Rapid response to stress-dose steroids
Reassessment cadence
▶
Serial vitals
Repeat electrolytes
Consults and follow-up
Copy
Specialist involvement
▶
Endocrinology consultation
▶
All new diagnoses and recurrent crises
HPA axis recovery not achieved within 1 year
Persistent shock evaluation
▶
Investigate alternative causes
Confirm adequate hydrocortisone and fluids
Discharge prerequisites
▶
Hemodynamic stability
▶
Normalized blood pressure
Tolerating oral intake and medication
Education and equipment
▶
Emergency hydrocortisone injection kit
Steroid card and medical alert identification
Treatment
Immediate stabilization
Glucocorticoid first
▶
Hydrocortisone 100 mg IV bolus immediately
▶
IM if no IV access
Do not delay for labs
Rationale
▶
Restores vascular tone
Reverses vasopressor refractoriness
Fluid resuscitation
▶
0.9% normal saline
▶
1 L in the first hour
Titrate to hemodynamics and electrolytes
Hypoglycemia correction
▶
Dextrose 0.5 to 1 g/kg
D50 or D10 infusion
Ongoing glucocorticoid
Hydrocortisone maintenance dosing
▶
200 mg per 24 hours
▶
Continuous IV infusion preferred
Or 50 mg IV every 6 hours
Day 2 onward
▶
Reduce to 100 mg per day after 24 hours
Guided by clinical response
Oral transition once stable
▶
Start at 2 to 3x usual dose when tolerating PO
Taper to maintenance over 2 to 3 days
Alternatives if hydrocortisone unavailable
▶
Prednisolone
▶
25 mg bolus then 50 mg per day
Less mineralocorticoid activity
Dexamethasone
▶
4 mg per day
Least preferred and no mineralocorticoid effect
Mineralocorticoid and adjuncts
Mineralocorticoid replacement
▶
Not needed during crisis
▶
High-dose hydrocortisone provides mineralocorticoid activity
Avoids overcorrection
Resume fludrocortisone on maintenance
▶
0.05 to 0.3 mg daily for primary AI
Once on oral hydrocortisone
Treat the precipitant
▶
Infection
▶
Empiric antibiotics when source suspected
Source control
Other triggers
▶
Surgical management if indicated
Correct dehydration and electrolytes
Sick-day rules
Outpatient dose adjustment for known AI
▶
Fever 38°C
▶
Double oral hydrocortisone dose
Continue until recovery
Fever 39°C
▶
Triple oral hydrocortisone dose
Monitor closely
Vomiting or unable to take PO
▶
IM hydrocortisone 100 mg
Present to emergency department
Special Populations
Pregnancy
Pregnancy considerations
▶
Increased glucocorticoid requirement
▶
Higher demand in third trimester
Stress-dose at labor and delivery
Preferred agents
▶
Hydrocortisone preferred
Avoid dexamethasone which crosses placenta
Crisis management unchanged
▶
Hydrocortisone 100 mg IV bolus
Aggressive saline resuscitation
Fludrocortisone in primary AI
▶
Continue maintenance
Monitor blood pressure and potassium
Geriatric
Older adult features
▶
Atypical presentation
▶
Confusion or delirium predominant
Falls and functional decline
Higher crisis risk
▶
Age over 65 years a risk factor
Polypharmacy and CYP3A4 interactions
Comorbidity caution
▶
Cardiac tolerance of fluid resuscitation
Monitor for fluid overload
Disposition bias
▶
Lower threshold for admission
Limited home supports
Pediatrics
Pediatric differences
▶
Common etiologies
▶
Congenital adrenal hyperplasia
Autoimmune adrenalitis
Weight-based hydrocortisone
▶
50 mg/m2 IV bolus or 2 mg/kg
Then 50 to 100 mg/m2 per day divided
Hypoglycemia prominent
▶
Dextrose 0.5 to 1 g/kg
Check glucose immediately
Fluid resuscitation
▶
20 ml/kg 0.9% saline bolus
Repeat to restore perfusion
Background
Epidemiology
Burden and presentation
▶
Crisis as first manifestation
▶
Up to 50% of primary AI present in crisis
Frequently undiagnosed at presentation
Causes of primary AI
▶
Autoimmune adrenalitis most common in developed countries
Tuberculosis leading cause in developing countries
Glucocorticoid-induced AI
▶
Most common form overall
Crisis may be first manifestation
Pathophysiology
Mechanisms of cortisol deficiency
▶
Primary AI
▶
Cortisol, aldosterone, and androgen deficiency
Hyperpigmentation, hyperkalemia, salt wasting
Secondary AI
▶
Cortisol deficiency only with preserved aldosterone
No hyperpigmentation or hyperkalemia
Hemodynamic consequences
▶
Loss of vascular tone and catecholamine sensitivity
Reduced myocardial contractility
Etiologic categories
▶
Autoimmune and infiltrative
▶
Autoimmune polyendocrine syndromes
Adrenal metastases and infiltration
Vascular and pituitary
▶
Adrenal hemorrhage in Waterhouse-Friderichsen syndrome
Sheehan syndrome and hypophysitis
Therapeutic Considerations
Treatment principles
▶
Glucocorticoid before confirmation
▶
Empiric treatment when suspected
Mortality benefit of early hydrocortisone
Stress dosing concept
▶
Replace physiologic surge during illness
Prevents recurrent crisis
Prevention as treatment
▶
Patient education
▶
Sick-day rules
Self-injection technique
Equipment and identification
▶
Emergency hydrocortisone kit
Medical alert identification
Monitoring for recovery
▶
Glucocorticoid-induced AI
▶
Periodic morning cortisol after holding steroid 24 hours
Assess HPA axis recovery
Maintenance follow-up
▶
Endocrinology within 1 to 2 weeks
Reinforce education at every visit
Patient Discharge Instructions
copy discharge instructions
Copy
Adrenal insufficiency home care
▶
Take steroid medication exactly as prescribed every day
Never stop steroids suddenly
Carry your emergency hydrocortisone injection kit at all times
Wear medical alert identification
Sick-day rules
▶
Double your dose if you have a fever of 38°C
Triple your dose if you have a fever of 39°C
Use the emergency injection and come to the ER if you cannot keep pills down
Drink electrolyte-containing fluids when ill
Return to ER immediately for
▶
Persistent vomiting or diarrhea stopping your medication
Fever not responding to stress dosing
Dizziness, fainting, or near-fainting
Confusion or severe drowsiness
Any symptoms resembling a prior crisis
Follow-up
▶
See endocrinology within 1 to 2 weeks
Annual influenza vaccine
Pneumococcal vaccine if over 60 years
Ensure a caregiver can also give your injection
References
Guidelines and key sources
Society guidelines
▶
Endocrine Society primary adrenal insufficiency guideline
ESE and Endocrine Society glucocorticoid-induced AI joint guideline 2024
Bornstein primary adrenal insufficiency clinical practice guideline 2016
Landmark reviews
▶
Rushworth Adrenal Crisis NEJM 2019
Vaidya Adrenal Insufficiency in Adults JAMA 2025
Husebye Adrenal Insufficiency Lancet 2021
Coding standards
▶
ICD-10 E27.1 primary adrenocortical insufficiency
ICD-10 E27.2 Addisonian crisis
ICD-10 E27.3 drug-induced adrenocortical insufficiency
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.
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Management Protocols
Adrenal Insufficiency (Addisonian Crisis)