Adrenal Crisis in the Field
Objective: Recognize adrenal crisis: shock from too little cortisol, the stress hormone. Use the medication list and the vital signs. Check sugar, give fluid, and give the steroid your protocol allows.
Why this matters
These patients can look like a routine stomach illness. The bottle may say hydrocortisone, prednisone, or adrenal insufficiency. That last phrase means the body does not make enough cortisol. Crews sometimes treat the nausea and leave an adult with low blood pressure at home. Adrenal crisis is shock plus that missing hormone. Give the steroid your protocol names. It replaces the hormone. Also give fluid and treat low sugar. Some systems use dexamethasone when hydrocortisone is not carried. Your protocol owns the drug. Do not call this a simple stomach illness.
- Ask about daily steroids, Addison disease, adrenal insufficiency, a steroid course they just stopped, pituitary disease, or fever plus a rash that does not fade when pressed. Addison disease means the adrenal glands do not work. That rash can be a meningococcal infection with bleeding into the adrenals. The hospital name is Waterhouse-Friderichsen.
- Check sugar. Low sugar is common. Give fluid for shock. Give the steroid if your protocol includes one. Many ambulances do not carry hydrocortisone.
- Infection, injury, and vomiting are typical triggers. Go to an emergency department. Do not wait it out at home.
Clinical sequence
- Look for shock first. Check sugar. Get a 12-lead if it will not delay care. If they have a fever, look for pinpoint spots that do not fade when pressed.
- Get vascular access. Give isotonic fluid, the shock fluid your protocol names. Treat low sugar.
- Give the steroid your protocol names. Use hydrocortisone if you carry it. If you do not, use the dexamethasone or methylprednisolone your system lists for this problem.
- Do not hold the fluid while you wait for the steroid to work. Do not hold the steroid because the blood pressure might come up on its own.
- Tell the hospital three things: known adrenal insufficiency, low blood pressure, and whether you gave a steroid or do not carry one.
Teaching points
- The medication list is the clue. Believe hydrocortisone, fludrocortisone, prednisone, or “I take steroids for my adrenals.”
- Nausea medicine does not treat this shock. Ondansetron may help vomiting. It does not replace the missing hormone.
- Dexamethasone and hydrocortisone are not the same. Hydrocortisone also helps the body hold salt. Dexamethasone does not. Use the steroid your protocol stocks. See the steroids lesson.
- Children. Some children are born with adrenal glands that do not work. That is congenital adrenal hyperplasia. It can show up as shock. Check sugar, give fluid, give the steroid your protocol allows, and go to a pediatric emergency department.
- Adrenal crisis is possible.
- Say the sugar you measured.
- Fluid and the steroid follow protocol.
- Do not call this a simple stomach illness.
Common errors
- Giving ondansetron, getting a signature, and leaving a patient with Addison disease and low blood pressure at home.
- Waiting on scene for a hospital cortisol level.
- Giving the steroid and forgetting to check the sugar.
Practice
One-minute check
A 34-year-old takes hydrocortisone at home, has been vomiting for 18 hours, and now has a blood pressure of 76/40 and a sugar of 58. Say the order of treatment and the radio report. What will you not call this?
Related: Dexamethasone & Field Steroids, Shock Categories.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; your protocol still decides care
- AHA 2025 Part 10: Special Circumstances — endocrine / shock support remains ABCs, glucose, and cause-specific therapy
- Endocrine Society primary adrenal insufficiency guidance — crisis = fluids plus glucocorticoid; EMS uses whatever steroid the protocol stocks
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.