Caring for a steroid-dependent patient in adrenal crisis

Diagnostic measures should never delay treatment, and if an adrenal crisis is suspected, treatment should be initiated without delay.

Adrenal crisis requires time-critical treatment with parenteral steroids and intravenous (IV) fluids.

Here we provide more information, in line with the standalone Steroid Dependent patient JRCALC guidelines:

  1. Immediately inject 100mg hydrocortisone IV or IM followed by rapid rehydration with IV administration of 0.9% saline solution (or equivalent). There is no toxic dose for hydrocortisone, but advanced hypocortisolemia may rapidly prove fatal. If there is any doubt about previous steroid administration, it is better to administer further hydrocortisone.
  2. Stabilise the patient with normal saline (intravenously) and injected hydrocortisone before transportation.
  3. Keep the patient lying down - they may become profoundly hypotensive when sitting upright. Where the patient cannot be transported flat on a stretcher, they must not be moved until full circulatory volume has been restored with IV fluids and they have received injected hydrocortisone.
  4. When handing over to the emergency department team, convey, if possible, the cause of the adrenal crisis and also that the patient needs hospital assessment/ management.
  5. Maintain the patient on hydrocortisone until clinical recovery and further guidance by an endocrinologist.

Do not hesitate to give high doses of hydrocortisone to a pregnant woman; it is inactivated in the placenta and does not affect the unborn baby. However, failure to treat a pregnant woman with adrenal insufficiency can result in the death of the mother and/or loss of the child.

Note: Lower hydrocortisone doses/saline infusion rates are appropriate for children. 

Visit the Society of Endocrinology website for more details.

We have created a poster for you to share with your ambulance trust or service, advertising our Adrenal Crisis Management training.

Download our poster

Time-critical Medication

Patients with undiagnosed or established primary or secondary adrenal insufficiency, as well as those who are at risk of developing tertiary adrenal insufficiency, are all at risk of adrenal crisis.

This is a life-threatening emergency resulting from a lack of cortisol, the major glucocorticoid.

Critically, the patient's daily medication is also time-critical.

To help share this message with your colleagues or to learn more, click below to download and print the Royal College of Emergency Medicine (RCEM) and the Association of Ambulance Chief Executives (AACE) resources.

Review the RCEM Safety Flash from June 2025, on Glucocorticoid Steroid Dependency.

RCEM Safety Flash

Time Critical Medications Poster

AACE & RCEM (Feb 2024)

Time Critical Medication Self-Administration in Emergency Departments

RCEM Advisory Statement, March 2025

Paramedic Training in Adrenal Crisis Management

Make our Paramedic Training Sessions on managing adrenal crisis part of your continuous professional development (CPD). 

Our FREE (subsidised by the charity) online educational sessions on adrenal insufficiency, including Addison's, are set in the context of the JRCALC guidelines for emergency management.

Each session is complemented by members’ own experiences, so alongside the theory, you hear real-life accounts from people living with adrenal insufficiency.

Explore upcoming training events

Course feedback

Thank you to the paramedics who kindly got in touch to let us know how they found the sessions and for your time in attending these sessions.

Incredibly engaging, information was pitched at the right level and showed a good understanding of the ambulance service and what we need to know. Personal experiences made it even more tangible and realistic to us. The feedback from staff who attended the sessions has been overwhelmingly positive.

Absolutely brilliant. I learnt so much. Having professional and personal experience was great and really aided my understanding. Just wanted to say a HUGE THANK YOU. It was truly awesome! I have never seen a group so engaged in a session before! The feedback has been enormously positive from everyone.

A very well-presented session, efficient yet human, about a subject I knew too little about. Lots of useful, practical information.

This really helped develop my understanding of the disease and how ambulance crews can assess and treat people with it.

If you have attended one of our training courses, please complete our feedback form to let us know what you thought about the content and presentation, and any improvements we could make.   

It should just take you a couple of minutes. Thank you!

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