Emergency Info for AI and AVP-D (DI)

Adrenal Insufficiency and Adrenal Crisis

An adrenal crisis is a medical emergency. If you suspect you, or someone else, is experiencing an adrenal crisis you should call 999 and state that you / they are having an adrenal crisis.

The below information relates to adrenal insufficiency and adrenal crisis. Click here for our emergency information for AVP deficiency.

What is an adrenal crisis?

Adrenal crisis is a life-threatening situation where the level of cortisol in your body has dropped too low.

Common causes of adrenal crisis are:

• Sudden onset of diarrhoea and / or vomiting,
• A rise in body temperature to above 38 °C
• A Significant accident or injury
• Sometimes, intense psychological stress, such as bereavements or witnessing trauma, can lead to adrenal crisis

Signs of an adrenal crisis

Signs of low cortisol and adrenal crisis include:

• Headache
• Nausea
• Irritable / restless
• Clumsiness
• Fatigue
• Pale skin (if you have darker skin this may look ashen or grey)
• Muscle aches
• Weakness
• Shivery / cold
• Spasms
• Dizziness (especially on standing)
• Stomach pain / diarrhoea
• Vomiting
• Reduced / loss of consciousness
• Seizures

It’s important to note that you may not have all of these symptoms. For more information on signs of adrenal crisis, see our Adrenal Crisis Signs Table.

If you have more than one of these symptoms at the same time, your cortisol levels are likely to be too low for your current illness or stressful situation.

Similarly, if you find symptoms start to accumulate, (e.g. headache, followed by nausea, then feel shivery cold, with leg aches and fatigue) this may also indicate inadequate cortisol levels. Taking extra cortisol by mouth, as outlined in the Sick Day Rules Table, at this time can often prevent a full-blown adrenal crisis.

Signs of Adrenal Crisis

A helpful table covering possible signs of adrenal crisis and what to do in each situation

What to do if you’re having an adrenal crisis

If you are having an adrenal crisis you should call 999 and state that you are having an adrenal crisis / Addisonian crisis and describe the symptoms that you are experiencing (e.g. vomiting, diarrhoea, dehydration, injury/shock).

Whilst you wait for the ambulance you should administer your emergency hydrocortisone injection. If you are unsure if what you are experiencing is an adrenal crisis then you should still administer your emergency injection.

How to administer an emergency hydrocortisone injection (pre-mixed and powder)

Step 1: Ensure you have all the equipment listed. Clean the injection site (mid-upper thigh) and wash your hands if possible.

Equipment:

• 1 x drawing up needle (green)
• 1 x injection needle (blue)
• 1 x 2 ml syringe

and

• 1 x ampoule (glass bottle) of hydrocortisone (for pre-mixed solution version)

OR (for powder version)

• 1 x ampoule (glass bottle) of water
• 1 x ampoule (glass bottle) of powder

Step 2: Open the plastic packets on the needles and syringe and attach the green ‘drawing up’ needle to the syringe

Step 3: Make sure all the liquid is at the bottom of the ampoule. If using the pre-mixed version, this will be liquid hydrocortisone. If using the powder version, this will be water.

Hold the ampoule with the blue dot facing backwards. Break the top off the ampoule by ‘snapping’ the blue dot backwards. You can use a tissue to hold the ampoule to avoid cuts.

Step 4: Take the cap off the green needle. Place the tip of the needle into the open ampoule (this can be tipped without losing the liquid). Pull back the plunger to draw the liquid up into the syringe.

Step 5: For powder version only (if using pre-mixed solution, skip to step 6).

Hold the powder ampoule on a flat surface. Push the needle through the rubber top and push the plunger of the syringe down to inject water into the powder ampoule. Keep the plunger down and remove the needle. Mix the powder and water with a swirling motion for a few seconds. Re-insert the needle into the ampoule and draw up the mixed liquid, same as in step 4.

Step 6: Hold the filled syringe with the needle facing up. Remove the green ‘drawing up’ needle and place it in a sharps bin, if one is available. Now attach the blue ‘injection’ needle. Gently tap the syringe to make sure there are no air bubbles in the liquid. If there are air bubbles, you can push the plunger down a little bit to push them out.

Step 7: Hold the barrel of the syringe between the thumb and forefinger of your dominant hand. Take off the needle cover and use the other hand to support the skin at the injection site. Hold the needle at a 90 degree angle to the injection site. Push the needle into the skin of the mid-upper thigh, using a smooth, steady push.

Step 8: Smoothly push down the plunger until all the liquid has been injected into the leg. Carefully remove the needle and apply gentle pressure to the injection site with a cotton swab or tissue.

Step 9: Place any used equipment (including needles, syringes and ampoules) into a sharps container, if one is available. Make sure the ambulance has been called and stay with the person until they arrive.

You can also watch this video on how to administer an emergency injection.

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People with adrenal insufficiency should always make sure they have an emergency hydrocortisone injection kit on their person, including when out and about, at work and on holiday. For more information on what this kit should include, see our overview of emergency hydrocortisone injection packs.

Sick Day Rules

During normal health and life, when you become ill or suffer injuries the body produces increased levels of cortisol to help us survive those stresses. Now that you are unable to produce your own cortisol, you need to be aware of when to provide an increased cortisol level during stressful times or during ill health. The amount of increase needed, the way the cortisol is given and the length of time the increase is needed will vary depending on the situation you are in.

Following the Sick Day Rules is important to prevent adrenal crisis. If you do not take enough cortisol in response to stress or illness, you may progress to an adrenal crisis.

Steroid Sick Day Rules

See our website page for more information on the Sick Day Rules

Read more

Download our Sick Day Rules Table

You can download this table of the steroid Sick Day Rules, to take with you on the go

Download now

AVP Deficiency (Diabetes Insipidus)

The following provides emergency information relating to AVP deficiency.

Sick Day Rules

You can download our Desmopressin Sick Day Rules table, which covers illness and emergency situations for people taking desmopressin.

Desmopressin Sick Day Rules

What you need to know about changing your desmo dose during times of illness or stress

You should seek medical attention if any of the following happen:

• You have missed or cannot take your desmopressin and have little or no access to fluids
• You have taken your desmopressin as normal but have then had a large intake of fluid
• You have vomiting (more than once) and / or diarrhoea

Your healthcare team should seek advice from an endocrinologist experienced in AVP-D (DI).

You may want to share this link to the Society for Endocrinology Emergency Care Guidance for the Emergency Management of Severe Symptomatic Hyponatraemia in Adult Patients with your clinician.

See below for more information on possible emergency situations.