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Clinical practice

Adrenal Crisis Information


COVID-19 adrenal crisis information


Diagnostic measures should never delay treatment and if adrenal crisis is suspected, treatment should be initiated WITHOUT DELAY. Short-term administration of high doses of glucocorticoids is never harmful but failure to treat adrenal crisis can result in the death of the patient.

Management of adrenal crisis summary


If you suspect established or developing adrenal crisis in a patient:

Please immediately inject 100mg hydrocortisone i.v. or i.m. followed by rapid rehydration with i.v. administration of 0.9% saline solution (or equivalent). 

Please maintain the patient on hydrocortisone at a dose of 200mg hydrocortisone per 24 hours (preferably by continuous i.v. infusion, alternatively by i.v. or i.m. injection of 50mg hydrocortisone every 6 hours) until clinical recovery and further guidance by an endocrinologist.

Adrenal crisis can be a manifestation of previously undiagnosed adrenal failure. Patients taking exogenous glucocorticoids across any route (oral, intra-articular, intra-muscular, inhaled, nasal and topical preparations) being used to treat a variety of medical conditions, can cause adrenal insufficiency by suppressing the hypothalamo-pituitary-adrenal axis. The Society for Endocrinology has endorsed a joint guidance document written together with Specialist Pharmacy Services.

Adrenal crisis can also occur in patients with known adrenal insufficiency if existing cortisol replacement does not meet the increased need for cortisol, e.g. due to illness with fever, persistent vomiting or diarrhoea, trauma or childbirth. Preparation for invasive diagnostic procedures such as colonoscopy and surgery requiring general anaesthesia are further risk factors for adrenal crises.

To prevent adrenal crisis in all these situations, hydrocortisone needs to be administered and maintained as per above.

Do not hesitate to give high doses of hydrocortisone to a pregnant woman; hydrocortisone 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 death of mother and/or loss of the child.

Children can be given i.v. or i.m. hydrocortisone as follows:

  • Infants up to 1 year - 25mg
  • children 1 to 5 years -  50mg
  • children 6 to 12 years - 100mg

These doses can be repeated three or four times in 24 hours depending upon the condition being treated and the patient's response.

Download the BSPED Paediatric Steroid Treatment Card for full guidance.

NHS Steroid Emergency card

The new card can be ordered through the usual NHS ordering mechanisms:

  • Secondary Care: Xerox online portal 
    You may need to raise a Non-Catalogue Requisition in Oracle, selecting supplier as XEROX, and we can process the requisition by raising the order with NHS Forms. Cost is £3.94 excluding VAT for 100 cards. 1 unit is 100 cards.
  • Primary Care: PCSE online portal 
  • Private sector: email: for registration form

Patients can also download a pdf version if they wish. Some patients are also uploading the pdf version as the lock screen on their mobile phones, to show health care professionals in a medical emergency.

Read the guidance on the prevention and emergency management of adult patients with adrenal insufficiency that accompanies the NHS Steroid Emergency Card. 

Download NHS Steroid Emergency Card

This card and its associated guidance is intended for use by adults (16+).

BSPED Paediatric Steroid Treatment Card 

The BSPED Paediatric Steroid Treatment Card provides a succinct steroid management plan for illnesses, emergency injections and blood sugar & electrolyte correction. Please encourage your patients to download and use this card. BSPED is keen to encourage uniform practice and improve the care of children and young people with adrenal insufficiency. If you have any queries regarding the card please contact the BSPED Clinical Committee 

Summary guidance:

Give IV or IM hydrocortisone

  • Infants up to 1 year - 25mg
  • children 1 to 5 years -  50mg
  • children 6 to 12 years - 100mg


Download Paediatric Steroid Treatment Card


Queries about the blue steroid card and London Respiratory Network Card

The new NHS Steroid Emergency Card is a prompt to healthcare professionals when patients are admitted in crisis/as an emergency or when undergoing surgery/procedure, to ensure steroid treatment is given appropriately and promptly. The card clearly outlines first management steps in an emergency. In addition, the card contains a QR code that links to further specialist advice.

The blue Steroid Treatment Card and the London Respiratory Network Card are unaffected by the introduction of the NHS Steroid Emergency Card. Patients should keep these if advised by their medical team whilst implementation of the new steroid emergency card takes place.

Related links for patient information

Steroid replacement therapy Information for patients (University of Leeds) 

Hydrocortisone Sick Day Rules - The Pituitary Foundation

Keeping safe with adrenal insufficiency - The Pituitary Foundation

Newly Diagnosed - Sick Day Rules - Addison's Disease Self-Help Group

Sick Day Rules figure


Contact for more information.