Adrenal Crisis in the Field
Objective: Recognize adrenal / Addisonian crisis from the medication list and shock picture, check glucose, give fluids, and get the steroid on board if your protocol allows it.
Why This Is Hard
They look like every other gastroenteritis. The bottle says hydrocortisone or prednisone or “adrenal insufficiency.” Crews treat nausea and leave a hypotensive steroid-dependent adult on the couch. Endocrine emergency teaching and NASEMSO-style pathways: adrenal crisis is shock plus missing cortisol. The steroid is the missing hormone. Fluids and glucose still matter. Dexamethasone can cover in some EMS systems if hydrocortisone is not on the truck — protocol owns the drug.
- Ask: steroid-dependent, Addison’s, adrenal insufficiency, recent steroid burst that stopped, pituitary history, meningococcemia/Waterhouse-Friderichsen picture.
- Glucose. Hypoglycemia is common. Fluids for shock. The steroid is not optional if you carry it.
- Infection, trauma, and vomiting are typical triggers. Destination is an ED, not a wait-and-see.
Street Sequence
- Shock assessment. Glucose. 12-lead if it will not delay. Expose for petechiae if fever.
- Access. Isotonic fluids. Treat hypoglycemia.
- Steroid per protocol (hydrocortisone if carried; otherwise the dexamethasone / methylprednisolone your system lists for this indication).
- Do not withhold fluids because you are “waiting for the steroid to work.” Do not withhold steroid because the BP “might come up.”
- Notify: “known adrenal insufficiency, hypotensive, steroid given/not carried.”
Field Rules (Education)
- The list is the diagnosis: hydrocortisone, fludrocortisone, prednisone, “I take steroids for my adrenals.” Believe it.
- Steroid is the missing drug in this shock category. Ondansetron does not replace cortisol.
- Dexamethasone vs hydrocortisone: hydrocortisone has mineralocorticoid effect; dex is glucocorticoid only. Use what protocol stocks. See the steroids lesson.
- Kids: congenital adrenal hyperplasia can present in shock. Same idea: glucose, fluids, steroid, pediatric ED.
- Adrenal crisis on the table
- Glucose is __
- Fluids and steroid per protocol
- Not treating this as simple gastroenteritis
Field Pitfalls
- Ondansetron, a signature, and a refusal in a hypotensive Addison’s patient.
- Waiting for a hospital cortisol level.
- Giving the steroid and skipping glucose.
Practice
60-second drill
34-year-old, hydrocortisone at home, vomiting 18 hours, BP 76/40, glu 58. Order of drugs and the radio sentence. What do 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; protocol still wins
- 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
Street decisions from this lesson only. After you check, the key is highlighted. Education practice — not a certification exam.