Adrenal Crisis - A Guide for EMT Students

1. DEFINITION

• Tintinalli's Emergency Medicine, p. 1499
• Sabiston Textbook of Surgery, p. 1563

2. CAUSES

Underlying Conditions (Who is at risk?)

• Autoimmune adrenalitis (most common cause in developed countries)
• Tuberculosis or fungal infection destroying the glands
• Bilateral adrenal hemorrhage (Waterhouse-Friderichsen syndrome - classically from meningococcal sepsis)
• HIV/AIDS-related adrenal destruction
• Adrenal metastases

• Pituitary tumors, apoplexy (sudden hemorrhage), or surgical removal
• Traumatic brain injury / severe head trauma
• Autoimmune hypophysitis
• Radiation to the pituitary

• Abrupt withdrawal or missed doses of chronic corticosteroid therapy - this is by far the most common trigger EMTs will see. Any patient on long-term prednisone, dexamethasone, or similar drugs is at risk.

Crisis Precipitants (Triggers - what pushes a vulnerable patient into crisis?)

• Infection - the most common trigger, especially gastrointestinal infections
• Severe physical illness, trauma, or burns
• Major surgery
• Extreme physical exertion
• Acute cardiovascular event (MI, stroke)
• Missed or vomited steroid doses
• Certain medications (checkpoint inhibitors, etomidate, ketoconazole)

EMT Pearl: Always ask patients who look "sick but you can't explain why" if they take steroids or have a steroid emergency card/bracelet.

• Tintinalli's Emergency Medicine, p. 1499
• Harrison's Principles of Internal Medicine 22E (2025), p. 1285

3. SIGNS & SYMPTOMS

Cardinal Signs of Acute Crisis

Differentiating Primary vs. Secondary (helpful in-hospital, less critical in the field)

The "Great Mimic" Warning

• Septic shock
• Acute abdomen / surgical emergency
• Neurological emergency (confusion, coma)

If a patient has unexplained shock that does not respond to fluids and you cannot find another cause - think adrenal crisis. - Tintinalli's Emergency Medicine, p. 1500

4. CLINICAL ASSESSMENT (Prehospital Focus for EMTs)

Scene Size-Up & Dispatch Clues

• Patient found unresponsive, hypotensive, with vomiting/abdominal pain
• History of Addison's disease, pituitary disease, or chronic steroid use
• Steroid alert card, medic-alert bracelet, or home emergency injection kit

Primary Survey (ABCDE)

• Hypotension (often systolic < 90 mmHg) - the hallmark finding
• Tachycardia
• Poor perfusion: pale/mottled skin, delayed capillary refill, weak rapid pulse
• Look for signs of dehydration

• GCS - assess level of consciousness
• Blood glucose (capillary/fingerstick) - hypoglycemia is common and immediately treatable
• Pupils

• Look for medic-alert bracelets/necklaces, wallet cards, steroid emergency card
• Look for hyperpigmentation (bronze skin, dark mucous membranes)
• Look for evidence of steroid use (cushingoid appearance, steroid inhalers/tablets at scene)

Key History Questions (SAMPLE - from patient, bystanders, or medical alert)

• Known Addison's disease or adrenal insufficiency?
• Currently taking corticosteroids (prednisone, hydrocortisone, dexamethasone, etc.)?
• Missed any doses recently? Vomited their morning medication?
• Recent illness, infection, injury, or surgery?
• Do they carry an emergency hydrocortisone injection kit?

Red Flags Pointing to Adrenal Crisis

• Unexplained hypotension not responding to IV fluids
• Hypoglycemia in a non-diabetic
• History of chronic steroid use + acute illness
• Altered mental status with no other clear cause
• Abdominal pain + hypotension without obvious surgical cause

5. MANAGEMENT

The EMT Priorities: ABCs + Early Recognition + Rapid Transport

The Golden Rule: Do not delay treatment waiting for lab confirmation. Treat based on clinical suspicion.

• Tintinalli's Emergency Medicine, p. 1501; ISMP Canada Safety Bulletin, 2025

Step-by-Step Prehospital Management

• Ensure patent airway; consider positioning
• Apply supplemental oxygen (SpO2 target ≥ 94%)
• Be prepared to support ventilation in obtunded patients

• Establish large-bore IV access (2 lines if possible)
• Normal saline (0.9% NaCl) is the fluid of choice - aggressive resuscitation
• If hypoglycemic: administer dextrose-containing saline (D5NS) or dextrose bolus per protocol
• Target: begin correcting hypotension
• Typical hospital protocol: 2-3 liters NS in the first 6 hours

• Obtain capillary blood glucose immediately
• Hypoglycemia is common and rapidly correctable in the field
• Give IV dextrose (D50W 25g in adults, or D10W in pediatrics) per protocol if glucose is low

EMT Note: Basic EMTs typically cannot administer hydrocortisone. Your role is to recognize the crisis, treat hypoglycemia, administer IV fluids, and transport rapidly. Some patients carry their own hydrocortisone auto-injector (like Solu-Cortef) and may self-administer or need assistance.

• Only used AFTER steroid therapy has been given
• Norepinephrine, dopamine, or phenylephrine if shock persists despite fluids + steroids
• Vasopressors are relatively ineffective without adequate cortisol replacement because cortisol is required for catecholamine sensitivity

• Continuous cardiac monitoring (ECG changes from hyperkalemia)
• Repeat vital signs every 5 minutes in unstable patients
• Blood glucose monitoring

• If infection suspected: alert receiving hospital for antibiotics
• Identify and communicate any known triggers to receiving team

• All confirmed or suspected adrenal crisis patients require ICU admission
• Pre-notify the receiving facility - this is a time-critical emergency

If Patient Has a Home Emergency Injection Kit

6. SUMMARY - ADRENAL CRISIS AT A GLANCE

SUSPECT IT when:
  → Unexplained hypotension/shock
  → Known steroid user + acutely ill
  → Steroid medic-alert card or bracelet
  → Hypoglycemia without clear cause

ASSESS:
  → ABCDE + fingerstick glucose
  → Scene clues (medications, alert cards)
  → Hyperpigmentation? (primary AI)

TREAT (prehospital):
  1. Airway + O2
  2. IV Normal Saline (aggressive)
  3. Dextrose if hypoglycemic
  4. Hydrocortisone 100 mg IV/IM (if in scope)
  5. Rapid transport → ICU
  6. Pre-notify hospital

DO NOT:
  → Wait for labs before treating
  → Give vasopressors before steroids
  → Forget to look for the precipitating cause

Key References

• Tintinalli's Emergency Medicine: A Comprehensive Study Guide, Table 230-4, pp. 1499-1501
• Sabiston Textbook of Surgery, pp. 1563-1564
• Bailey and Love's Short Practice of Surgery (28th Ed.), p. 1330
• Harrison's Principles of Internal Medicine 22E (2025), p. 1285
• ISMP Canada Safety Bulletin: Adrenal Crisis Management, Oct 2025
• EMCrit IBCC: Adrenal Crisis & Steroid Pharmacology, Sept 2025

Note for EMT Scope of Practice: Corticosteroid administration is typically within the Paramedic or AEMT scope. Basic EMTs should focus on recognition, airway management, IV fluid therapy, dextrose for hypoglycemia, and rapid transport with early notification. Always follow your local medical director's protocols and standing orders.

Pathophysiology of Adrenal Crisis

Step 1 - Normal HPA Axis: The Foundation

STRESS / STRESSOR
       ↓
Hypothalamus → releases Corticotropin-Releasing Hormone (CRH)
       ↓
Anterior Pituitary → releases ACTH (adrenocorticotropic hormone)
       ↓
Adrenal Cortex → produces CORTISOL + ALDOSTERONE
       ↓
Negative feedback back to hypothalamus & pituitary (keeps levels in check)

Step 2 - What Cortisol Normally Does (Why Its Absence is Lethal)

A. Glucose Homeostasis

• Stimulates gluconeogenesis (making new glucose in the liver from amino acids and glycerol)
• Promotes glycogenolysis (breaking down liver glycogen into glucose)
• Inhibits peripheral glucose uptake, inducing mild insulin resistance
• Net result: keeps blood glucose elevated during stress

"In hypocortisolism, there is hypoglycemia." - Costanzo Physiology, 7th Ed., p. 438

B. Vascular Tone & Blood Pressure ("Permissive Effect")

• Cortisol up-regulates alpha-1 adrenergic receptors on vascular smooth muscle
• This makes blood vessels sensitive to catecholamines (norepinephrine, epinephrine)
• Without this permissive effect, even high circulating catecholamines cannot maintain vasoconstriction

"Glucocorticoids exert a permissive and enhancing effect on catecholamine signaling by sensitizing arterial smooth muscle cells to beta-adrenergic stimulation... Cardiac contractility and peripheral vascular tone are thus maintained, explaining why the hemodynamic collapse that accompanies acute adrenal insufficiency can be remedied by glucocorticoid administration." - Sabiston Textbook of Surgery, p. 1560

C. ADH (Anti-Diuretic Hormone) Regulation

• Cortisol normally suppresses ADH release
• Low cortisol → ADH rises → kidneys retain free water → dilutes sodium in blood

D. Immune & Inflammatory Modulation

• Cortisol suppresses excessive inflammatory cascades
• Without cortisol, the inflammatory response goes unchecked
• This contributes to fever, vasodilation, and organ dysfunction

Step 3 - What Aldosterone Normally Does

• Promotes Na+ reabsorption from urine back into blood
• In exchange, secretes K+ and H+ into urine
• Net effect: retains sodium and water → maintains intravascular volume and blood pressure

"Aldosterone deficiency results in salt losses and clinical hypovolemia. The hypovolemia may further stimulate ADH release. Finally, the aldosterone deficiency may also cause hyperkalemia." - Symptom to Diagnosis, 4th Ed., p. 7286-7287

Step 4 - The Pathophysiological Cascade of Adrenal Crisis

TRIGGER (infection, missed steroids, trauma, surgery...)
              ↓
  Demand for cortisol EXCEEDS supply
              ↓
    ┌─────────────────────────────────────────┐
    │         CORTISOL DEFICIENCY             │
    └─────────────────────────────────────────┘
          ↓               ↓               ↓
  Gluconeogenesis     Catecholamine    ADH suppression
     FAILS            sensitization      LOST
          ↓           LOST                ↓
    HYPOGLYCEMIA    Arterioles don't   Free water retained
                    vasoconstrict          ↓
                          ↓           HYPONATREMIA
                   Vasodilatation
                          ↓
    ┌─────────────────────────────────────────┐
    │      ALDOSTERONE DEFICIENCY             │
    │       (primary AI only)                 │
    └─────────────────────────────────────────┘
          ↓               ↓               ↓
    Na+ wasted        K+ retained     H+ retained
    in urine              ↓               ↓
          ↓          HYPERKALEMIA   METABOLIC
    HYPOVOLEMIA       (can cause      ACIDOSIS
          ↓           arrhythmia)
    More hypotension
          ↓
    ──────────────────────────────────────
    COMPOUND SHOCK:
    Distributive (no vascular tone) +
    Hypovolemic (no volume) +
    Cardiogenic (poor cardiac output)
    → REFRACTORY to IV fluids alone
    → REFRACTORY to vasopressors alone
    ──────────────────────────────────────

Step 5 - Why Crisis Becomes Lethal Without Treatment

1. Cardiovascular collapse - vasodilation + hypovolemia combine into profound shock that does not respond to IV fluids or vasopressors because cortisol is absent
2. Hypoglycemia - brain glucose supply fails → seizures, coma, death
3. Electrolyte catastrophe - severe hyponatremia causes cerebral edema; severe hyperkalemia causes fatal arrhythmias
4. Metabolic acidosis - from tissue hypoxia (shock) + H+ retention (aldosterone loss)
5. Renal shutdown - from severe hypovolemia/shock → acute kidney injury + azotemia (rising creatinine/BUN)

Step 6 - Primary vs. Secondary: Pathophysiology Differences

"Adrenal crisis is usually seen in patients with Addison disease because of mineralocorticoid deficiency but can also present in patients with secondary or tertiary adrenal insufficiency who undergo severe physiologic stress." - Rosen's Emergency Medicine, p. 2577

Step 7 - Why Vasopressors Alone Don't Work (Critical EMT Concept)

• The catecholamine receptors on blood vessels are down-regulated without cortisol's "permissive" effect
• You can push as much vasopressor as you want, but the vessel walls won't respond adequately
• Only after hydrocortisone is given do vasopressors begin to work

Summary Diagram: What Each Hormone Loss Causes

References

• Costanzo Physiology, 7th Ed., pp. 437-438 - Actions of glucocorticoids
• Sabiston Textbook of Surgery, p. 1560 - Cortisol permissive effect on catecholamines
• Rosen's Emergency Medicine, pp. 2576-2578 - HPA axis diagram and pathophysiology
• Symptom to Diagnosis, 4th Ed., pp. 7265-7286 - Aldosterone deficiency mechanism
• StatPearls - Adrenal Crisis (Updated Feb 2025) - Glucocorticoid effects on glucose homeostasis
• Medscape - Adrenal Crisis Pathophysiology - Cortisol, aldosterone, and vascular tone

Adrenal Crisis - Simplified Pathophysiology

The Big Picture (One Sentence)

Think of It Like This - A Simple Analogy

• The engine (your heart and blood vessels) can still run without oil for a short time
• But under stress (infection, injury, missed medication), the engine seizes up completely
• No matter how hard you press the accelerator (vasopressors), the engine won't respond
• The only fix is to add the oil back (give hydrocortisone)

The Two Hormones That Fail

The Pathophysiology - Step by Step

1. The Trigger Hits

2. Blood Pressure Collapses (The Most Dangerous Part)

Normal: Adrenaline → arteries tighten → Blood pressure maintained ✓

Crisis:  Adrenaline → arteries DO NOT respond → vasodilation → BP crashes ✗

3. Blood Sugar Drops (Hypoglycemia)

• Telling the liver to make new glucose (gluconeogenesis)
• Breaking down glycogen stores

4. Salt and Water Are Lost (Volume Depletion)

5. The Compound Crash

      Cortisol deficiency          Aldosterone deficiency
             │                              │
    ┌────────┴────────┐            ┌────────┴────────┐
    │                 │            │                 │
 No vascular     No glucose     Salt lost        K+ builds up
 tone            made           in urine              │
    │                 │            │            Arrhythmia
 Vasodilation    HYPOGLYCEMIA  HYPOVOLEMIA      risk
    │                              │
    └──────────────┬───────────────┘
                   │
          REFRACTORY SHOCK
          (blood pressure crashes
           and won't come back up
           with fluids alone)
                   │
           If untreated → DEATH

Why Treatment Works

The key point: giving hydrocortisone is not just replacing a hormone - it is literally restoring the ability of blood vessels to maintain blood pressure. That is why steroids must come before or alongside vasopressors, not after.

One-Line Summary Per Mechanism

• No cortisol + stress = vessels go limp → shock
• No cortisol = liver stops making glucose → hypoglycemia
• No aldosterone = kidneys dump salt → dehydration + low BP + high potassium
• All three at once = life-threatening emergency

What is Adrenal Crisis?

In Simple Terms

• Keep your blood pressure up
• Maintain blood sugar
• Help your body cope with any kind of stress (illness, injury, surgery)

The Key Points

A One-Sentence Definition

Adrenal crisis is an acute, life-threatening state of severe cortisol deficiency in which the body can no longer maintain blood pressure, blood sugar, or fluid balance - resulting in refractory shock and death if not treated immediately.

Who Is at Risk?

1. Known Addison's disease patients - their adrenal glands don't work at all; any illness or missed dose can tip them into crisis
2. Chronic steroid users (prednisone, dexamethasone, etc.) - long-term steroids suppress the HPA axis; if they stop suddenly or get sick without increasing their dose, crisis can occur
3. Acute adrenal destruction - bilateral adrenal hemorrhage (Waterhouse-Friderichsen syndrome from severe meningococcal sepsis), or traumatic brain injury affecting the pituitary

How to Remember It

• Blood vessels go limp → shock
• Liver stops making glucose → hypoglycemia
• Kidneys dump salt → dehydration

Definition of Adrenal Crisis

Definitions from Authoritative Sources

"Adrenal crisis is a life-threatening state caused by insufficient levels of cortisol. It can result from acute destruction of the hypothalamic-pituitary axis or the adrenal glands, or from acute stressors in the setting of underlying primary or secondary adrenal insufficiency." — Tintinalli's Emergency Medicine

"Acute adrenal insufficiency, or adrenal crisis, is a life-threatening condition that typically occurs in individuals with already marginal adrenocortical function who are subjected to a significant acute physiologic stressor, such as infection or trauma." — Sabiston Textbook of Surgery

"Acute adrenal insufficiency, also termed adrenal crisis, usually occurs after a prolonged period of nonspecific complaints and is more frequently observed in patients with primary adrenal insufficiency, due to the loss of both glucocorticoid and mineralocorticoid secretion." — Harrison's Principles of Internal Medicine, 22nd Edition (2025)

Breaking Down the Definition

In One Simple Sentence for EMT Students

Adrenal crisis is a medical emergency where the adrenal glands suddenly fail to produce enough cortisol, causing the body to go into a life-threatening shock that will not respond to fluids or vasopressors alone - only hydrocortisone can reverse it.

Causes of Adrenal Crisis

How to Think About It

1. The underlying condition - what made the adrenal glands vulnerable in the first place
2. The trigger/precipitant - what pushed the vulnerable patient into full crisis

LAYER 1 - Underlying Conditions (Who Is Already at Risk?)

A. Primary Adrenal Insufficiency (Adrenal Gland Itself Is Destroyed)

B. Secondary Adrenal Insufficiency (Pituitary Fails - No ACTH Signal)

C. Tertiary Adrenal Insufficiency - Most Common Cause EMTs Will Encounter

EMT Pearl: Any patient who takes or recently stopped taking oral steroids is at risk. Always ask about steroid use.

LAYER 2 - Precipitating Triggers (What Pushes Into Crisis?)

Most Common Triggers

Medications That Can Trigger Crisis

Summary - Causes at a Glance

ADRENAL CRISIS CAUSES
│
├── UNDERLYING CONDITIONS (make patient vulnerable)
│   ├── PRIMARY (adrenal gland destroyed)
│   │   ├── Autoimmune (Addison's) ← most common in West
│   │   ├── Tuberculosis ← most common worldwide
│   │   ├── Bilateral adrenal hemorrhage (Waterhouse-Friderichsen)
│   │   ├── HIV/AIDS, fungal infection, cancer metastases
│   │   └── Surgery (bilateral adrenalectomy)
│   │
│   ├── SECONDARY (pituitary fails → no ACTH)
│   │   ├── Pituitary tumor/apoplexy
│   │   ├── Traumatic brain injury
│   │   └── Cranial radiation, surgery
│   │
│   └── TERTIARY (HPA axis suppressed) ← MOST COMMON
│       └── Long-term corticosteroid use / abrupt withdrawal
│
└── TRIGGERS (push vulnerable patient into crisis)
    ├── Infection (especially GI) ← #1 trigger
    ├── Missed/vomited steroid dose
    ├── Surgery or trauma
    ├── Burns, extreme stress
    └── Drugs (etomidate, ketoconazole, rifampicin)

Simple summary: In HIV/AIDS patients, the immune system is too weak to fight off these normally manageable infections. CMV, MAC, and fungi then spread through the body and physically destroy the adrenal glands - leading to primary adrenal insufficiency and eventually adrenal crisis.

Signs & Symptoms of Adrenal Crisis

First - Know the Difference

Sign = something you can observe or measure (objective) Symptom = something the patient tells you they feel (subjective)

The Most Important Warning

• Septic shock
• Acute abdomen / surgical emergency
• Neurological emergency
• Simple gastroenteritis

SYMPTOMS (What the Patient Reports)

General / Whole Body

Cardiovascular

Gastrointestinal (very common - often leads to misdiagnosis)

EMT Pearl: Abdominal pain + hypotension in a steroid user = think adrenal crisis until proven otherwise.

Neurological

Musculoskeletal

SIGNS (What You Observe and Measure)

Vital Signs - The Most Critical Findings

Skin Findings

Neurological Signs

Cardiovascular Signs

Progression of Symptoms (Early to Late)

EARLY                          MIDDLE                        LATE / CRITICAL
─────────                      ──────                        ───────────────
Fatigue                    →   Nausea/vomiting          →   Severe hypotension
Weakness                   →   Abdominal pain           →   Altered consciousness
Dizziness                  →   Worsening weakness       →   Coma
Anorexia                   →   Confusion begins         →   Seizures
Salt craving               →   Hypoglycemia             →   Cardiovascular collapse
                           →   Fever                    →   DEATH if untreated

Primary vs. Secondary - Signs That Differ

Quick Memory Tool for EMT Students

"The 5 H's of Adrenal Crisis"

What to Look For on Scene (Prehospital)

LOOK:       Medic-alert bracelet/necklace
            Steroid emergency card in wallet
            Bronze/dark skin, pale/mottled skin
            Altered mental status

FEEL:       Weak thready pulse
            Cool clammy skin

MEASURE:    BP → low, often < 90 systolic
            HR → fast
            BGL → low (hypoglycemia)
            SpO2 → may be low in severe shock

ASK:        "Do you take steroids?"
            "Do you have Addison's disease?"
            "Have you missed any doses?"
            "Have you been vomiting or had diarrhea?"

Signs & Symptoms of Adrenal Crisis

(Emergency-Focused - What You Will Actually See)

The One Thing to Remember First

Most patients will look like they are in septic shock with no obvious cause. The clue is their history - steroids, Addison's disease, or a missed dose.

What You Will Find in an Emergency

1. Severe Hypotension (Most Critical Finding)

• Systolic BP often below 90 mmHg
• Does not respond to IV fluids alone
• Patient may be in obvious shock - pale, mottled, cold and clammy skin
• Weak, rapid, thready pulse

2. Tachycardia

• Heart rate fast and weak
• The heart is racing to compensate for the collapsing blood pressure

3. Altered Mental Status

• Ranges from confusion and disorientation → lethargy → unresponsive
• Caused by the brain being starved of both blood and glucose simultaneously

4. Nausea, Vomiting & Abdominal Pain

• Very common - present in most crisis patients
• Abdominal pain can be severe, mimicking an acute abdomen
• Vomiting makes everything worse - patient loses more fluids and cannot keep oral medications down

5. Hypoglycemia (Low Blood Sugar)

• Check fingerstick glucose immediately on every patient
• Patient may be sweating, shaking, confused, or unconscious
• One of the most immediately treatable findings in the field

6. Extreme Weakness and Fatigue

• Patient feels too weak to stand or sit up
• Often described as "the worst they have ever felt"
• May have collapsed or be found on the floor

7. Fever

• Present even without obvious infection
• Loss of cortisol removes the body's natural anti-inflammatory control

8. Bronze Skin Hyperpigmentation (Primary Addison's only)

• Darkening of skin, lips, gums, and palmar creases
• This is a scene clue - if you see it, adrenal crisis jumps to the top of your list

All Together - At a Glance

The Emergency Memory Rule

Unexplained SHOCK  +  History of STEROIDS or ADDISON'S
           =  Adrenal Crisis until proven otherwise

Bottom line for EMTs: You will arrive to find a patient in shock - cold, hypotensive, tachycardic, confused, and vomiting - with no obvious cause. The moment you see a medic-alert bracelet, steroid medications at the scene, or a history of Addison's disease, treat it as adrenal crisis immediately.

Assessment of Adrenal Crisis

EMT Prehospital Assessment Guide

The Golden Rule of Assessment

You will rarely diagnose adrenal crisis with certainty in the field. Your job is to SUSPECT it, assess systematically, and act fast.

STEP 1 - Scene Size-Up (Before You Touch the Patient)

LOOK FOR:
✔ Steroid medications (prednisone, dexamethasone, hydrocortisone tablets)
✔ Medic-alert bracelet or necklace ("Addison's disease" / "steroid dependent")
✔ Steroid emergency card in wallet or on fridge
✔ Emergency hydrocortisone injection kit at home
✔ Patient found collapsed or unable to get up
✔ Signs of recent vomiting or diarrhea

If you see any of these - adrenal crisis is immediately on your differential list.

STEP 2 - Primary Survey (ABCDE)

Life threats first - find and fix as you go

A - Airway

B - Breathing

C - Circulation

D - Disability (Neurological)

E - Exposure

STEP 3 - History (SAMPLE)

Ask the patient, family, or bystanders

The 3 Most Important History Questions for Adrenal Crisis

1. "Do you take steroids or have you recently stopped taking them?"
2. "Have you been diagnosed with Addison's disease?"
3. "Have you missed any doses due to vomiting, illness, or forgetting?"

STEP 4 - Secondary Survey

Head-to-toe check for additional clues

STEP 5 - Vital Signs (Reassess Every 5 Minutes in Unstable Patients)

STEP 6 - Red Flags That Demand Immediate Action

ANY ONE of these = treat as adrenal crisis NOW:

⚠ Unexplained hypotension not responding to fluids
⚠ Known steroid user who is acutely ill or collapsed
⚠ Medic-alert device saying "Addison's" or "steroid dependent"
⚠ Hypoglycemia with no history of diabetes
⚠ Severe abdominal pain + shock + steroid history
⚠ Altered mental status with no clear neurological cause
⚠ Bronze hyperpigmentation + collapse

Complete Assessment Summary

SCENE SIZE-UP
→ Steroid meds? Medic-alert? Emergency kit? Vomit?

PRIMARY SURVEY (ABCDE)
→ A: Airway open?
→ B: Breathing rate & SpO2
→ C: BP (low?), HR (fast?), perfusion (poor?)
→ D: GCS, AVPU, BLOOD GLUCOSE (mandatory)
→ E: Hyperpigmentation? Cushingoid? Medic-alert?

HISTORY (SAMPLE)
→ Taking steroids? Missed dose? Addison's?
→ Recent illness, vomiting, surgery, trauma?

VITAL SIGNS
→ BP, HR, RR, SpO2, Temp, BGL - every 5 min if unstable

RED FLAGS
→ Unexplained shock + steroid history = ADRENAL CRISIS

Final Assessment Principle for EMTs: You do not need to confirm the diagnosis - you need to recognize the pattern. Shock + steroid history + no obvious cause = act immediately, notify the hospital early, and transport fast.

Assessment of Adrenal Crisis - EMT Quick Guide

The Mindset Before You Start

You will not diagnose adrenal crisis in the field. You will suspect it based on the pattern: unexplained shock + history of steroids or Addison's disease.

1. Scene Size-Up

• Steroid medications nearby (prednisone, hydrocortisone, dexamethasone)
• Medic-alert bracelet or necklace
• Steroid emergency card
• Home hydrocortisone injection kit
• Signs of vomiting or diarrhea
• Patient found collapsed and unable to get up

2. Primary Survey - ABCDE

Fingerstick blood glucose is mandatory in every suspected adrenal crisis patient.

3. History - SAMPLE

4. Vital Signs - Every 5 Minutes if Unstable

5. Red Flags - Act Immediately if Any Present

⚠ Unexplained shock not responding to fluids
⚠ Known steroid user who is acutely unwell
⚠ Medic-alert device for Addison's or steroid dependence
⚠ Hypoglycemia with no diabetes history
⚠ Severe abdominal pain + shock + steroid history
⚠ Altered mental status with no clear cause
⚠ Bronze skin + collapse

At a Glance - Assessment Flow

SCENE → clues (meds, medic-alert, vomit)
   ↓
ABCDE → airway, breathing, BP, HR, GCS, BGL
   ↓
SAMPLE → steroids? Addison's? Missed dose? Recent illness?
   ↓
VITALS → BP low, HR fast, BGL low, temp up
   ↓
PATTERN RECOGNIZED:
Unexplained shock + steroid/Addison's history
= ADRENAL CRISIS → treat immediately + transport

One rule to remember: Any patient in unexplained shock who takes steroids or has Addison's disease is in adrenal crisis until proven otherwise.