National Adrenal Diseases Foundation

Information for Emergency Response Personnel

The ER physician is faced with a major decision when a very sick person comes to the emergency room. If it is an injury or known disease it can be addressed immediately. But if it is a rapidly escalating illness it may be caused by sepsis or adrenal fatigue. There are many common symptoms. While adrenal fatigue requires steroid replacement to stabilize the patient, this treatment may be counterproductive for sepsis.

A British Medical Journal, editorial 9 October 2012 entitled “How To Avoid Precipitating An Acute Adrenal Crisis" Noted that fifteen percent of Addisonian patients die in the emergency room. After reading this article the Addisonian will know how critical it is to identify themselves as having Addison's disease.

Patients with adrenal insufficiency are at risk of developing life threatening adrenal crisis if steroids are reduced or stopped, or if glucocorticoid treatment is not increased during periods of increased stress (for example, illness, trauma, or surgery). The features of acute adrenal crisis include hypotension (particularly postural hypotension), shock, and hyponatraemia in 90% of patients. Hyperkalaemia is also a feature in 65% of patients. Fatal but avoidable Addisonian crisis is the second most common cause of death in patients with known Addison’s disease, accounting for 15% of deaths in patients with this disease. (Emphasis added.) Early treatment with parenteral hydrocortisone and intravenous rehydration with fluids are essential measures to avoid mortality. Why is this not always achieved?

The Addison’s Disease Self Help Group (www.addisons.org.uk/), a charity that informs and support patients with Addison’s disease, has received numerous reports of doctors and nursing staff refusing requests for or delaying hydrocortisone administration in patient with Addison’s disease who present unwell to healthcare services. One member of the group, a junior doctor with Addison’s disease, reported a delay of more than 24 hours before being given steroids while she was an inpatient even though she told healthcare staff that she needed hydrocortisone.“

Deaths associated with inadequate steroid administration during surgery, for patients who require steroid replacement or need high doses of steroids that result in adrenal suppression, are common. This is despite guidelines for the perioperative management of these patients being available on the websites of the Society for Endocrinology (www.endocrinology.org/), the Addison’s Disease Self Help Group, and the Pituitary Foundation. In the US go to the National Adrenal Diseases Foundation.


Comments on British Medical Journal Editorial

  1. Increased Risk of Adrenal Insufficiency Following Etomidate Exposure in Critically Injured Patients—Invited Critique - Exposure to etomidate is a modifiable risk factor for the development of AI in this sample of critically injured patients. The use of etomidate for procedural sedation and rapid-sequence intubation in this patient population should be reevaluated.
  2. Scott D Mackenzie responded that Guidance is needed on inhaled glucocorticoids and acute adrenal crises.

Emergency Response Guidelines

  1. NADF Emergency Response Guidelines - Specific Instructions from NADF to Emergency Personnel is Addison's Disease possible.
  2. Royal College of Emergency Medicine Alert for patients with Addison Disease This is an alert for Emergency Room Professionals to be aware of the frequency of Addisonian deaths in emergency rooms.
  3. Eight percent of patients diagnosed with Addison disease require annual hospital treatment for adrenal crisis.

Important Guidelines for Addisonian Patients

This would suggest two important steps that need to be taken since there are far more patients with Adrenal crisis each year than newly diagnosed patients.

  1. It is essential that all Addisonian patients carry information to notify ER personnel that they have the disease. This includes medic alert bracelets, DOT yellow dot emblems on left rear car window with a yellow packet includeing picture and instructions in the glove box, and making sure they tell the ER personnel that they have the disease. It is also essential that ER personnel be attuned to patients who provide this information.
  2. For the longer term there needs to be procedures to differentiate between sepsis and adrenal deficiency. If the person has adrenal deficiency, that disease should be treated first, and then focus on the patient's other issues. See NADF Emergency Response Guidelines - Specific Instructions from NADF to Emergency Personnel if any hint that Addison's Disease is possible.

These procedures are especially important since many Addisonian are not diagnosed until they go to the emergency room in an Adrenal Crisis.