Emergency Department Evaluation and Management of Patients With Adrenal Insufficiency

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Publication Date: October 2025 (Volume 27, Number 10)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-B CME credits. CME expires 10/01/2028.

Authors

Peer Reviewers

Abstract

Adrenal insufficiency is a challenging condition to diagnose and manage in the emergency department, and adrenal crisis remains a significant cause of morbidity and potential mortality. Rapid recognition of adrenal insufficiency and adrenal crisis is essential to ensure that life-saving therapy is initiated without delay. This issue provides a review of the etiology and pathophysiology of adrenal insufficiency and focuses on emergency department evaluation and treatment of this condition. The current literature was reviewed to provide an up-to-date guide and the best practices related to management of these diagnoses, as well as strategies for patient education and prevention.

Case Presentations

In the middle of a norovirus outbreak, a 4-year-old girl with congenital adrenal hyperplasia presents to the ED with vomiting…

• The girl’s mother said she started vomiting a few hours ago, twice at home and once during triage. She is well-appearing, with signs of mild dehydration.
• Her vital signs are: temperature, 37°C; heart rate, 132 beats/min; blood pressure, 92/58 mm Hg; and respiratory rate, 24 breatahs/min.
• You have seen 2 other pediatric patients today with similar presentations who did not have congenital adrenal hyperplasia. They both responded well to oral dissolving tablet (ODT) ondansetron and were able to be discharged. Given her medical history, does your patient need additional workup and treatment, or can you proceed with ODT medication and a trial of oral rehydration?

Your next patient, a 38-year-old woman, presents with weight loss, fatigue, and flu-like symptoms…

• This patient seems to have the same virus as most of the patients that have been coming in, but chart review shows she has had more than 10 visits over the last 6 months to local EDs, urgent cares, and her primary care provider for vague complaints such as fatigue.
• Her vital signs are: temperature, 37.1°C; heart rate, 86 beats/min; blood pressure, 98/60 mm Hg; and respiratory rate, 18 breaths/min.
• She appears very tanned, and when you inquire, she says she went on vacation 5 months ago, but her tan never went away. She also notes she has been craving salty foods. You review her chart again and note she has had labs drawn a few times in the last 6 months, and she has consistently had low sodium levels, mildly elevated potassium, and glucose levels in the 60s.
• What tests should you order to further evaluate for adrenal insufficiency? What should the disposition be for this patient?

A 67-year-old man has come in to the ED for shortness of breath….

• He appears to be in mild distress. His vital signs reveal a temperature of 39°C, heart rate of 98 beats/min, blood pressure of 91/55 mm Hg, and respiratory rate of 28 breaths/min.
• Examination reveals focal crackles in his right lower lung. Chest x-ray confirms your suspicion for right lower lobe pneumonia. The patient says that he is due for the daily prednisone he takes for polymyalgia rheumatica.
• After administration of IV crystalloid fluids for his hypotension, his blood pressure has not improved. What should you do about the patient’s daily corticosteroid dose?

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.