An adrenal crisis is a sudden, life‑threatening failure to meet the body’s cortisol needs during stress. It causes a rapid fall in blood pressure and low blood sugar, and it can lead to collapse if not treated straight away.
It links closely to adrenal insufficiency and Addison’s disease, but it also follows steroid withdrawal or pituitary problems. Cortisol normally helps keep blood pressure, inflammation and metabolism steady; its sudden loss undermines these systems.
Immediate treatment is vital. Care starts with urgent hydrocortisone injection and IV fluids, so clinicians should not wait for blood tests before acting. In the UK, call 999 for severe symptoms and tell A&E staff about steroid therapy.
Carrying emergency hydrocortisone and a steroid card can save time and lives. Prompt recognition and swift treatment are the key messages for patients and carers.
Key Takeaways
- Recognise rapid weakness, low blood pressure and fainting as red flags.
- Treatment must begin immediately with hydrocortisone and fluids.
- It often stems from adrenal insufficiency, steroid withdrawal or pituitary causes.
- In the UK, phone 999 for severe signs and inform A&E about steroid use.
- Carry emergency medication and a steroid identification card at all times.
What is an adrenal crisis
A life‑threatening decline in cortisol can trigger low blood pressure and shock within hours. This event is the most severe form of adrenal insufficiency, where the body cannot mount the hormone response needed for stress.
How it relates to adrenal insufficiency and Addison’s disease
Primary disease — known as addison disease — means damage to the adrenal glands themselves. That can cause chronic hormone shortage and, in up to about half of cases, a first presentation with a sudden collapse.
Secondary or tertiary insufficiency arises from loss of ACTH drive or hypothalamic problems. These forms still risk a crisis because cortisol remains inadequate when stress occurs.
Why it is a medical emergency in the UK
Rapid deterioration can lead to hypovolaemic shock, seizures, coma and death without prompt steroid injection and IV fluids. Early signs may be vague, so delay and misdiagnosis happen.
- Action point: if severe symptoms suggest an adrenal crisis, phone 999 and tell ambulance or A&E staff about steroid treatment.
- Diagnosis: is often confirmed after stabilisation, but treatment must start on clinical suspicion.
What the adrenal glands do and why cortisol matters
Above each kidney sit paired glands that release hormones vital for energy, blood pressure and fluid balance. These small organs produce two key crisis‑related hormones: cortisol and aldosterone.
Cortisol and the body’s response to stress
Cortisol helps keep blood vessels responsive so blood pressure stays steady during illness or injury. It also supports glucose availability and limits excessive inflammation by calming cytokine activity.
When cortisol falls, vascular tone drops and inflammation rises. That change reduces the body’s ability to cope with infection, surgery or severe injury.
Aldosterone, sodium balance and blood pressure
Aldosterone controls sodium and water retention. Loss of this hormone causes salt and fluid loss, which raises the risk of dehydration and low blood pressure.
In primary problems both cortisol and aldosterone may be low, producing low sodium (and sometimes high potassium) with symptoms such as dizziness, weakness and faintness.
If illness, vomiting, diarrhoea or surgery occur, limited hormone reserves can be quickly overwhelmed. This link between physiology and real‑world triggers explains why prompt treatment matters for preventing severe collapse.
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How an adrenal crisis develops in the body
When cortisol supply stops, a swift cascade of changes begins that can overwhelm the body in a few hours. Cortisol has a short half‑life (about 70–120 minutes), so blood levels may fall rapidly and symptoms can progress within hours.
Rapid cortisol loss and worsening within hours
The rapid spiral starts when steroid production or replacement falls short. Within a few hours the body loses the hormone that keeps many stress responses in check.
Inflammation, low blood pressure and shock
Low cortisol removes inhibition on inflammatory cytokines. A cytokine surge causes fever, pain and profound lethargy and makes the person feel severely unwell.
Vascular reactivity falls and fluid balance is disturbed. Reduced responsiveness of blood vessels plus sodium and water loss lowers blood pressure and can lead to shock if untreated.
Metabolic effects include less gluconeogenesis, so low blood sugar may occur, especially with vomiting or poor intake. In primary problems, loss of mineralocorticoid action adds further sodium and water loss.
“Rapid replacement with parenteral steroid and IV fluids counters this chain reaction and is the cornerstone of emergency care.”
- Key effects: fast cortisol loss, cytokine rise, falling blood pressure, metabolic collapse.
- Immediate action: steroid replacement and fluid resuscitation to halt progression to shock.
Early warning signs and symptoms to spot quickly
In many cases, nausea and abdominal pain herald more serious decline in the hours that follow. Early recognition of warning signs helps speed treatment and avoid collapse.
Gastrointestinal patterns
Nausea, vomiting and abdominal pain are common first symptoms. Repeated vomiting or diarrhoea prevents oral medication absorption and speeds dehydration, which worsens low blood pressure.
Severe fatigue, weakness and dizziness
Extreme tiredness and marked weakness often follow gut symptoms. Dizziness and faintness signal falling blood pressure and need urgent assessment rather than rest alone.
Fever, dehydration and reduced consciousness
Fever may reflect infection or a cytokine response when cortisol is low. Confusion, reduced alertness or progression to coma represent severe physiological failure and require immediate emergency care.
- Look for clusters: gut upset + severe weakness/dizziness + fever.
- Do not ignore sudden confusion or inability to keep medication down.
| Symptom | Why it matters | Action |
|---|---|---|
| Nausea & vomiting | Stops oral steroids; increases dehydration | Seek urgent medical advice; use parenteral steroid if available |
| Extreme fatigue & weakness | May indicate falling blood pressure | Measure pulse and BP; contact emergency services if severe |
| Fever & confusion | Suggests infection or inflammatory surge | Hospital assessment and IV fluids/steroids |
Red-flag symptoms that require calling 999 immediately
Certain sudden symptoms require people in the UK to call 999 without delay. The NHS states this is an emergency when severe signs appear and rapid treatment may save life.
Severe vomiting or diarrhoea with inability to keep medication down
If oral replacement cannot be kept down due to vomiting, call 999. Repeated vomiting or diarrhoea prevents steroid absorption and quickly leads to dehydration and worsening low blood pressure.
Collapse, extreme drowsiness, coma or signs of shock
Collapse means sudden fainting or inability to stand. Signs of shock include pale, cold clammy skin, very fast or shallow breathing, severe dizziness, profound weakness and fainting.
Coma or markedly reduced consciousness is not a wait‑and‑see problem. It can progress rapidly and needs immediate ambulance care.
“If severe or worsening symptoms suggest a crisis, call 999 first, then give emergency hydrocortisone if trained and available.”
- Call 999 for severe vomiting that stops oral meds, persistent dehydration or collapse.
- Carers should act when the person cannot speak or is confused; do not wait for consent.
- Paramedics and A&E teams will prioritise rapid hydrocortisone and IV fluids if a crisis is suspected.
| Situation | Why urgent | Immediate action |
|---|---|---|
| Unable to keep oral medication (vomiting) | Oral steroids fail; dehydration risk | Phone 999; prepare emergency injection if trained |
| Collapse or fainting | May reflect falling blood pressure | Call 999; keep person flat and warm until help arrives |
| Signs of shock or coma | Circulatory failure or severely reduced consciousness | Phone 999; inform ambulance about steroid therapy |
Common causes of adrenal crisis
Several underlying disorders can leave hormone production too low to meet stress demands. These causes fall into three clear groups that clinicians and patients should recognise.
Primary adrenal insufficiency from gland damage
Primary insufficiency usually follows direct damage to the adrenal gland, often autoimmune disease such as Addison’s in the UK. This causes low cortisol and commonly low aldosterone, which raises the risk of low blood pressure and salt loss.
Secondary and tertiary insufficiency linked to ACTH problems
Problems higher in the brain reduce ACTH drive from the pituitary or hypothalamus. Aldosterone tends to remain nearer normal, but cortisol falls and the person still faces significant risk during stress.
Sudden steroid withdrawal and suppressed function
Long-term glucocorticoid therapy suppresses natural production. Abrupt stopping of systemic steroids can precipitate emergency collapse.
Note: suppression may follow oral, injected, inhaled or topical steroids; all can affect the HPA axis.
Practical point: the immediate cause is failure of hormone production; separate triggers such as infection or surgery often push someone into trouble. People with known insufficiency or recent steroid use should view themselves as at increased risk and seek early advice when unwell.
Triggers that can precipitate an adrenal crisis
In over 90% of episodes a clear precipitant exists. Recognising common triggers helps with timely management and may prevent collapse.
Infections, especially gastrointestinal illness
Infection is the single most frequent trigger. Gastrointestinal illness causes fluid loss and may stop oral medication being absorbed.
Key point: vomiting or diarrhoea rapidly raises risk and often needs parenteral steroid and fluids without delay.
Procedures, injury and pregnancy
Surgery, dental work, major injury and labour sharply increase demand. Patients need planned “stress‑dose” cover before, during and after procedures.
Stress, exercise and extreme weather
Emotional stress, intense exercise or prolonged heat or cold can push requirements up. Individual thresholds vary, so personalised plans matter.
Medicines that change steroid levels
Certain medicines (for example rifampicin or strong CYP3A4 inducers) speed hydrocortisone breakdown. Abrupt steroid withdrawal is a major hazard.
- Action: follow sick‑day rules, carry emergency injection supplies and escalate early to services if illness or injury reduces oral intake.
Who is most at risk
History and existing autoimmune disease often identify those most likely to need emergency steroid care. Recognition helps people and clinicians plan ahead and act quickly if severe symptoms develop.
People with Addison’s disease and other autoimmune conditions
People with primary adrenal insufficiency, especially addison disease, face higher risk because loss of mineralocorticoid function raises dehydration and low blood pressure risk. In the UK about 8,400 people have addison disease, often alongside other autoimmune conditions.
Common associated conditions include type 1 diabetes and thyroid disease, which can complicate illness management and mask warning signs.
Those with prior episodes and recurrence risk
A previous emergency increases susceptibility to further episodes. Patients should learn their early symptom pattern so they act at first signs rather than waiting.
Older adults and missed recognition
Older people may show subtler signs. Higher baseline blood pressure can hide relative hypotension, delaying treatment and raising risk of severe outcomes.
- High‑risk checklist: medical alert ID, an emergency steroid plan shared with family, and up‑to‑date repeat prescriptions.
- Remember: undiagnosed insufficiency can first present as emergency; severe symptoms always need urgent assessment.
What to do immediately if an adrenal crisis is suspected
Acting without delay can prevent life‑threatening drops in blood pressure and consciousness. On suspicion, call 999 and begin the emergency response while arranging transport to hospital.
Do not delay treatment while awaiting tests
Blood should be drawn for cortisol, ACTH and electrolytes, but care must not wait for results. Immediate parenteral steroid and IV fluids take priority over diagnostic delay.
When a hydrocortisone injection is needed
If oral medication cannot be kept down because of vomiting or diarrhoea, give parenteral hydrocortisone without hesitation. Hospital dosing usually starts with 100 mg IV; if IV access is delayed an IM injection is appropriate.
At home: an IM injection is indicated when vomiting, rapid worsening weakness or confusion occur and no IV route exists. Trained carers should use the person’s emergency kit if available.
Information to share with paramedics and A&E teams
Tell crews the patient has adrenal insufficiency or recent steroid therapy, when symptoms began, and the time of the last replacement dose.
Also provide a steroid emergency card, a medication list, allergies and the injection kit. This speeds correct treatment and avoids duplication.
Quick action checklist
- Recognise suspected crisis and call 999.
- Administer emergency hydrocortisone injection if trained and available.
- Do not delay escalation; draw blood but treat first.
- Bring steroid card, medication list and injection kit to paramedics/A&E.
| Step | Why | Immediate action |
|---|---|---|
| Initial recognition | Fast fall in blood pressure or consciousness requires urgent support | Call 999; start emergency plan |
| Parenteral steroid given | Replaces missing cortisol quickly to stabilise circulation | 100 mg IV hydrocortisone or IM if IV delayed |
| Information transfer | Guides A&E treatment and avoids repeat dosing errors | Provide card, medication list, time of last dose and note if injection given |
How clinicians diagnose adrenal crisis and adrenal insufficiency
Initial assessment relies on urgent blood tests that guide immediate care and later investigation. Clinicians draw serum samples for cortisol and ACTH and request a basic metabolic panel to assess electrolytes and glucose.
Key blood tests and why they matter
Cortisol helps decide whether hormone replacement is needed now. Low values support the diagnosis of adrenal insufficiency; a level below about 3 µg/dL is strongly suggestive, while values above 13–15 µg/dL argue against it.
ACTH helps classify primary versus pituitary causes. Basic metabolic tests check sodium, potassium and glucose to judge severity and guide safe resuscitation.
Electrolyte patterns and clinical importance
Typical findings include low sodium and, in primary disease, high potassium. These changes increase the risk of hypotension and need careful correction during fluid resuscitation.
Hypoglycaemia may occur, especially in children or after poor intake, so bedside glucose is routine.
Confirming the underlying condition after stabilisation
After the patient stabilises, clinicians perform confirmatory tests such as the synacthen (ACTH stimulation) test and arrange endocrine follow‑up. In UK A&E practice, treatment is pragmatic: give parenteral steroid if a crisis is suspected without waiting for results, then confirm the formal diagnosis later.
| Investigation | What it shows | Immediate action |
|---|---|---|
| Serum cortisol | Low level supports insufficiency | Start hydrocortisone if clinical suspicion |
| ACTH | High in primary, low/normal in secondary | Classify cause; plan endocrine follow‑up |
| Metabolic panel (Na, K, glucose) | Hyponatraemia; hyperkalaemia in primary; low glucose | Guide fluids, electrolytes and dextrose if needed |
How an adrenal crisis is treated in hospital
Emergency care focuses on rapid steroid replacement and restoring circulation. On arrival the team gains IV access, checks observations and gives immediate parenteral therapy to stop further harm.
Immediate parenteral hydrocortisone dosing and timing
Initial management uses a 100 mg IV bolus of hydrocortisone (or IM if no IV access). This is followed by either a continuous infusion of about 200 mg over 24 hours or 50 mg IV/IM every six hours.
Prompt administration of the correct doses avoids ongoing low hormone effects and stabilises physiology while investigations proceed.
IV fluid resuscitation with 0.9% saline for hypovolaemia
Restoring volume uses 0.9% saline to support blood pressure. Often clinicians give about 1 litre in the first hour, then adjust the rate according to observations and urine output.
Correcting low blood sugar with dextrose when needed
Bedside glucose testing guides treatment. If hypoglycaemia exists, IV dextrose is given promptly because correcting low blood glucose can be lifesaving and improves alertness.
Managing the trigger, such as treating infection
Teams search for and treat triggers in parallel. For suspected infection, antibiotics start early while samples are taken. Other causes, such as recent surgery or missed oral doses, are managed alongside steroid and fluid therapy.
Key steps on arrival:
- Urgent assessment, IV access and blood tests.
- 100 mg hydrocortisone bolus, then maintenance doses.
- Saline resuscitation to restore circulating volume and support blood pressure.
- IV dextrose for low glucose and targeted care for any infection.
With prompt treatment, the risk of lasting organ damage from prolonged low blood pressure falls markedly. For related sepsis timing resources see sepsis timing information.
Monitoring during emergency treatment
Frequent bedside checks guide clinicians as steroid and fluid therapy change the patient’s physiology rapidly. Continuous observation in the first hours reduces risks and directs ongoing treatment.
Blood pressure, heart rhythm and signs of organ effects
Staff monitor blood pressure trends, pulse and heart rhythm continuously. They watch urine output, mental state and skin perfusion for early signs of organ under‑perfusion.
Changes can happen fast: once steroids and fluids work, circulation may recover quickly or swing the other way, so nurses record observations at short intervals.
Managing sodium correction safely
Correction of sodium must be cautious. Rapid rises (more than ~10 mEq in 24 hours) risk osmotic demyelination, especially when cortisol replacement causes water diuresis and lowers vasopressin.
Repeat blood tests guide fluid choice and rate. Electrolytes and glucose are checked often to tailor IV saline, dextrose and any other fluids.
| What is monitored | Why it matters | How often |
|---|---|---|
| Blood pressure and pulse | Stability of circulation and response to fluids | Minutes to hourly in first hours |
| Heart rhythm | Arrhythmias from electrolyte shifts or low perfusion | Continuous ECG monitoring if unstable |
| Sodium and glucose | Guide safe correction and energy support | 4–8 hourly or sooner as change occurs |
Certain co‑existing problems such as infection or kidney impairment require closer monitoring and tailored fluids. Monitoring is part of treatment, not separate from it, and helps avoid complications while recovery progresses.
Recovery, aftercare and medication adjustments
The days after stabilisation focus on safe tapering of stress doses back to the patient’s usual replacement regimen. Hydrocortisone given in emergency is reduced stepwise to avoid sudden hormone gaps and to allow careful clinical assessment.
Tapering stress doses and returning to usual steroid replacement
Tapering usually begins once circulation and sodium balance are stable. The goal is to return to the prior maintenance dose over a few days to a week while checking symptoms and observations.
When mineralocorticoid replacement may be needed in primary insufficiency
When daily hydrocortisone falls below about 50 mg, fludrocortisone is often reintroduced for primary insufficiency. Typical fludrocortisone doses run 50–200 mcg/day and correct salt and blood pressure problems.
Follow-up with endocrinology and GP care in the UK
Endocrinology review is arranged after discharge and the GP manages repeat prescriptions and local monitoring. Aftercare covers the trigger review, sick‑day rules, injection technique and ensuring the emergency kit is complete.
Recovery may include lingering fatigue and a gradual return to normal activity; pacing and a written plan shared with family and recorded in notes help prevent future episodes.
| Item | Purpose | Typical timing |
|---|---|---|
| Hydrocortisone taper | Return to baseline replacement | Days to a week |
| Fludrocortisone restart | Restore mineralocorticoid effect | When HC ≤50 mg/day |
| Endocrine follow‑up | Adjust doses and prevention plan | Within weeks of discharge |
Preventing future adrenal crises
A clear plan for illness, travel and procedures helps prevent sudden deterioration and keeps hospital visits to a minimum.
Sick‑day rules and stress‑dose planning
Sick‑day rules mean promptly increasing usual replacement during fever, vomiting, diarrhoea or acute infection. Typical advice is to double or triple oral doses while unwell and to contact a clinician if oral intake fails.
If vomiting persists or severe weakness appears, give a parenteral injection and seek urgent care without delay.
Carrying spare medication and travel planning
Keep spare tablets in a separate bag, check repeat prescriptions before bank holidays, and carry a note from the GP for airport security. Plan for time zone changes and store emergency supplies in carry‑on luggage.
Training for intramuscular hydrocortisone at home
Patients and a partner or close friend should receive hands‑on training to give an IM injection. Practice reduces hesitation and can save time when rapid injection is needed.
Medical alert jewellery and informing others
Wear medical alert jewellery and carry a steroid emergency card so responders know to give hydrocortisone and fluids quickly. Tell family, employers, school or university staff about red flags and when to call 999.
Prevention works best as a system: reliable medication access + clear education + practiced escalation steps.
Living with Addison’s disease or adrenal insufficiency in the UK
Recognising subtle changes in strength or mood can prevent escalation to emergency care. Daily life usually centres on reliable dosing, pacing activities and spotting when usual tiredness becomes worrying.
Recognising fatigue patterns and associated conditions
People learn their baseline fatigue and note when it deepens or coincides with other symptoms. One clear red flag is new dizziness, persistent vomiting or confusion.
Co‑existing conditions such as diabetes or thyroid disease may mask low blood sugar or alter symptom patterns, so joint management with other teams helps avoid misinterpretation.
When to seek urgent help versus routine advice
Routine advice covers mild symptoms with stable oral intake — contact the GP or endocrine clinic for dose guidance and repeat prescriptions.
Urgent action is needed for persistent vomiting, collapse, worsening weakness or confusion: phone 999 and tell responders about steroid treatment.
Personal plans should be reviewed regularly with specialists. Good long‑term care reduces risk but does not remove it; preparedness remains essential for all people with these conditions.
| Area | Practical tip | When to act |
|---|---|---|
| Medication routine | Set alarms; keep spare supply with GP repeat | Missed doses for >24 hours or vomiting |
| Co‑existing conditions | Share records with diabetes or thyroid teams | New hypoglycaemia or confusing symptoms |
| Travel & work | Carry emergency card and injection kit; plan time zones | Severe illness away from home or inability to take oral meds |
Outlook and potential complications
Serious outcomes can follow rapidly when circulation, salts and glucose go badly out of balance.
Major risks: seizures, arrhythmias, coma and death
Seizures may happen with severe low blood sugar or sodium shifts. Arrhythmias follow large electrolyte swings and reduced perfusion of the heart.
Coma and death result when circulation fails and organs lose oxygen.
Why prolonged low blood pressure causes irreversible harm
Prolonged hypotension reduces oxygen delivery to the brain, heart and kidneys. After many hours this can cause lasting organ damage and long‑term disability.
Early restoration of circulation helps prevent these irreversible effects and lowers the risk of ongoing problems.
Frequency, mortality and the benefit of prompt treatment
Among people with long‑term hormone deficiency, emergency episodes occur in roughly 6–8% per year. Reported mortality reaches about 6% in some series.
With rapid hydrocortisone and fluid treatment in UK services, outcomes improve substantially and most episodes are survivable when acted upon quickly.
- Treat every suspected crisis as time‑critical — deterioration can occur within hours.
- Review prevention plans after any near‑miss or hospital admission.
| Measure | Typical figure | Note |
|---|---|---|
| Annual event rate | 6–8% | Among affected people |
| Mortality | Up to ~6% | Varies with promptness of treatment |
| Key intervention | Hydrocortisone + fluids | Reduces irreversible effects |
Conclusion
,
When the body cannot mount enough cortisol during stress, collapse can follow very quickly. This life‑threatening emergency needs immediate parenteral hydrocortisone and IV 0.9% saline; add dextrose if glucose is low. Do not delay treatment to wait for blood tests.
Recognise key red flags: severe vomiting that prevents oral medication, marked weakness or fainting, altered consciousness and signs of shock. Gastrointestinal illness is a common trigger because it causes dehydration and stops tablets being absorbed.
In hospital, treatment centres on prompt hydrocortisone, fluid resuscitation and management of the trigger while monitoring sodium and glucose. Early therapy stabilises circulation before diagnostic confirmation and reduces the risk of lasting harm.
Prevention depends on practical measures: follow sick‑day rules, carry spare medication and a steroid emergency kit, learn injection technique, and wear medical ID. In the UK, phone 999 for severe signs and give an emergency injection if trained and available.
Many people live well with Addison’s disease and other insufficiency disorders when clear plans, training and regular review are in place. Still, immediate action saves lives when severe symptoms occur.
