Adrenal Crisis: What to Do First?

5 minute read
Adrenal crisis is a true medical emergency where treatment must begin immediately.

In patients with known Addison’s disease, recognising the classic combination of hypotension, hyponatraemia, hyperkalaemia and hypoglycaemia can be lifesaving.

For exam questions, the key is knowing what to do first — and what must never delay steroid treatment.

Here’s a high-yield adrenal crisis question with the common exam trap explained.

 Clinical Case

A 40-year-old with known Addison's disease presents with vomiting, profound hypotension and confusion during a urinary tract infection. Sodium low, potassium high, glucose low.

What should you do?
A. IV hydrocortisone 100 mg plus IV fluids
B. IV fludrocortisone
C. IV antibiotics before any steroid
D. IV dextrose alone
E. Short Synacthen test before treating
 Correct Answer
A. IV hydrocortisone 100 mg plus IV fluids

An adrenal crisis is treated with immediate IV/IM hydrocortisone 100 mg and aggressive IV fluids (saline, with dextrose for hypoglycaemia). Treatment must not wait for biochemical confirmation. At high dose, hydrocortisone provides sufficient mineralocorticoid effect, so fludrocortisone is not needed acutely.
 Why the other options are wrong

B. Fludrocortisone is not required in the acute phase.

C. The infection should be treated, but withholding steroid until antibiotics are given is dangerous — the crisis itself is what kills.

D. Dextrose corrects the sugar but not the cortisol deficiency.

E. Diagnostic testing is done after resuscitation, never before.
 Exam Trap

Delaying steroids to do a Short Synacthen test. Treat first, confirm later.

  Reference 

Society for Endocrinology — Emergency management of adrenal crisis.

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