Suspected adrenal crisis
A streamlined, differential-led presentation for rapid clinical review.
Twenty-second review
- Adrenal crisis causes cortisol deficiency with impaired vascular response, volume depletion, hypoglycemia, and often sodium or potassium disturbance, commonly triggered by illness or missed steroids.
- Refractory hypotension, vomiting, severe weakness, abdominal pain, altered LOC, hypoglycemia, or known adrenal insufficiency with illness is high risk.
- Keep gastroenteritis or hypoglycemia in the differential; overlapping or concurrent illness remains possible.
- For suspected adrenal crisis, trends and combinations of findings are more informative than one isolated vital sign.
Compare the clinical patterns
The repeated material is grouped inside each possibility. Open only the condition you need.
Septic shockTime-sensitive high-risk possibility
HPI
Clarify known adrenal insufficiency; steroid use or missed dose; vomiting, pain or infection.
Signs & symptoms
Similar physiology may coexist and cannot be excluded prehospital.
Focused exam
Assess respiratory pattern, hydration, perfusion, temperature, neurologic status, and medication-delivery devices; Repeat glucose and clinical observations after treatment or during transport.
Brief pathophysiology
Septic shock may cause suspected adrenal crisis through a time-sensitive process capable of rapid physiological deterioration.
What the trend may show
No single vital sign diagnoses sepsis. New tachypnea, abnormal temperature, tachycardia, or falling pressure—especially with altered mentation or poor perfusion—supports organ dysfunction and urgency.
Respiratory rate (breaths/min)
May rise earlyTachypnea is included in NEWS2 and can precede overt hypotension.
Temperature (°C)
High or lowAbsence of fever does not exclude sepsis; hypothermia is concerning.
Heart rate (bpm)
Often risesTachycardia is common but may be blunted by age or medication.
Blood pressure (mmHg)
May fallRelative hypotension and trend matter; profound hypotension can be late.
Front-load in the triage report
- Septic shock: Similar physiology may coexist and cannot be excluded prehospital.
- Known adrenal insufficiency?
- Steroid use or missed dose?
Severe electrolyte disturbanceTime-sensitive high-risk possibility
HPI
Clarify steroid use or missed dose; vomiting, pain or infection; blood pressure and perfusion.
Signs & symptoms
Similar physiology may coexist and cannot be excluded prehospital.
Focused exam
Repeat glucose and clinical observations after treatment or during transport; Assess hydration, skin pigmentation when relevant, abdomen, infection source, steroid use, emergency kit, perfusion, and mental status.
Brief pathophysiology
Severe electrolyte disturbance may cause suspected adrenal crisis through a time-sensitive process capable of rapid physiological deterioration.
What the trend may show
Vital signs are nonspecific in electrolyte or dialysis emergencies. Rhythm/ECG and the patient’s fluid status are essential; do not infer potassium level from vital signs.
Heart rate (bpm)
Rate / rhythm may changeBradycardia or tachyarrhythmia may occur, but ECG findings are more informative.
Blood pressure (mmHg)
High or lowVolume overload, dehydration, and dialysis timing can move pressure in either direction.
Respiratory rate (breaths/min)
May riseTachypnea may reflect acidosis or pulmonary edema.
Oxygen saturation (SpO₂)
May fallLow saturation supports pulmonary edema or another respiratory complication.
Front-load in the triage report
- Severe electrolyte disturbance: Similar physiology may coexist and cannot be excluded prehospital.
- Steroid use or missed dose?
- Vomiting, pain or infection?
Adrenal insufficiency decompensationCommon presentation pattern
HPI
Clarify known adrenal insufficiency; steroid use or missed dose; vomiting, pain or infection.
Signs & symptoms
Illness, missed steroid, vomiting, weakness, and hypotension may fit.
Focused exam
Assess respiratory pattern, hydration, perfusion, temperature, neurologic status, and medication-delivery devices; Repeat glucose and clinical observations after treatment or during transport.
Brief pathophysiology
Adrenal insufficiency decompensation may explain the presenting symptoms through a common clinical mechanism, while serial assessment checks for complications or an alternate cause.
What the trend may show
Adrenal crisis commonly produces hypotension and may cause hypoglycemia; fever or hypothermia can reflect the trigger or severe illness.
Blood pressure (mmHg)
Often lowHypotension may be profound and fluid-resistant.
MAP (mmHg)
Often lowLow MAP supports impaired perfusion.
Blood glucose (mmol/L)
May fallHypoglycemia is especially important in children but may occur in adults.
Heart rate (bpm)
Often risesTachycardia commonly accompanies volume depletion and shock.
Front-load in the triage report
- Illness, missed steroid, vomiting, weakness, and hypotension may fit.
- Known adrenal insufficiency?
- Steroid use or missed dose?
GastroenteritisImportant alternative presentation
HPI
Clarify known adrenal insufficiency; steroid use or missed dose; vomiting, pain or infection.
Signs & symptoms
Common symptoms may obscure the endocrine cause.
Focused exam
Assess respiratory pattern, hydration, perfusion, temperature, neurologic status, and medication-delivery devices; Repeat glucose and clinical observations after treatment or during transport.
Brief pathophysiology
Gastroenteritis can resemble suspected adrenal crisis through overlapping symptoms or referred physiology despite a different primary mechanism.
What the trend may show
Volume loss may first appear as tachycardia or postural symptoms; hypotension is a later sign. Fever or blood loss changes the likely cause and risk.
Heart rate (bpm)
May riseTachycardia may reflect volume depletion, fever, or distress.
Blood pressure (mmHg)
May fallRelative or orthostatic change can precede resting hypotension.
Pulse pressure (mmHg)
May narrowReduced stroke volume can narrow pulse pressure as depletion worsens.
Temperature (°C)
VariableFever supports infection; hypothermia may occur in severe illness.
Front-load in the triage report
- Common symptoms may obscure the endocrine cause.
- Known adrenal insufficiency?
- Steroid use or missed dose?
HypoglycemiaImportant alternative presentation
HPI
Clarify steroid use or missed dose; vomiting, pain or infection; blood pressure and perfusion.
Signs & symptoms
Common symptoms may obscure the endocrine cause.
Focused exam
Repeat glucose and clinical observations after treatment or during transport; Assess hydration, skin pigmentation when relevant, abdomen, infection source, steroid use, emergency kit, perfusion, and mental status.
Brief pathophysiology
Hypoglycemia can resemble suspected adrenal crisis through overlapping symptoms or referred physiology despite a different primary mechanism.
What the trend may show
Confirm low capillary glucose and reassess after treatment. Adrenergic signs may be absent in recurrent hypoglycemia or blunted by medications.
Blood glucose (mmol/L)
< 4.0 mmol/LBCEHS defines hypoglycemia as blood glucose below 4.0 mmol/L.
Heart rate (bpm)
May riseAdrenergic activation commonly produces tachycardia, but this is not universal.
Blood pressure (mmHg)
Often preservedBlood pressure is not a reliable discriminator; hypotension suggests another or additional process.
Temperature (°C)
May fallHypothermia can accompany prolonged or severe hypoglycemia.
Front-load in the triage report
- Common symptoms may obscure the endocrine cause.
- Steroid use or missed dose?
- Vomiting, pain or infection?
Findings that should escalate concern
- Shock
- Hypoglycemia
- Severe electrolyte concern
- Altered LOC
- Refractory hypotension, vomiting, severe weakness, abdominal pain, altered LOC, hypoglycemia, or known adrenal insufficiency with illness is high risk.
- Septic shock or severe electrolyte disturbance: Similar physiology may coexist and cannot be excluded prehospital.
Medication recognition
Continue the clinical pathway
Clinical and academic sources
Curated clinical guidance and peer-reviewed evidence supporting this presentation. Current BCEHS guidance, medical direction, and local policy remain authoritative for practice.
BCEHS Handbook — specific CPGs
Supporting clinical and academic evidence
- CEDIS Presenting Complaint List updateCanadian Association of Emergency Physicians
Presenting-complaint terminology and categorization context. It does not establish a prehospital “top 100” ranking.
- Clinical Practice GuidelinesDiabetes Canada
Canadian evidence-based guidance for diabetes, hypoglycemia, hyperglycemia, and related emergencies.
- Adrenal insufficiencyNature Reviews Disease Primers · 2021
Adrenal-crisis physiology, triggers, hypotension, electrolyte and glucose abnormalities, and emergency therapy.