A fictional 48-year-old who recently stopped long-term glucocorticoids presents with vomiting, profound weakness, hypotension and hyponatraemia.
Frame the danger first.
- Consider adrenal crisis with otherwise unexplained hypotension or shock, especially with steroid exposure or known adrenal insufficiency.
- Look for vomiting, abdominal symptoms, weakness, confusion, hyponatraemia, hyperkalaemia or hypoglycaemia.
- A normal or non-specific early assessment does not exclude evolving crisis in a high-risk patient.
Act, escalate, reassess.
- Do not delay emergency glucocorticoid treatment for diagnostic testing when adrenal crisis is suspected.
- Begin ABCDE resuscitation and protocol-directed isotonic fluid replacement, accounting for cardiac and renal comorbidity.
- Take useful pretreatment bloods only if this causes no delay, and monitor glucose and electrolytes closely.
- Treat the precipitant and involve endocrinology and critical care according to severity and response.
Red flags that change pace.
- Persistent shock, reduced consciousness or severe hypoglycaemia
- Major sodium or potassium disturbance, pregnancy or pituitary disease with possible diabetes insipidus
- Failure to improve promptly after initial emergency treatment
What makes care less safe.
- Waiting for a cortisol result before treating a convincing crisis
- Missing adrenal suppression from non-oral or recently withdrawn glucocorticoids
- Failing to identify infection, vomiting or another precipitant
Say the concern plainly.
Suspected adrenal crisis with steroid/adrenal history [summary], blood pressure [trend], glucose/electrolytes [results] and precipitant [known/uncertain]. Emergency treatment began at [time]; response is [summary]. I need endocrine/critical-care review.