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Shock / trauma / unconscious / unresponsive / altered mental status

SHOCK / TRAUMA / Unconscious / Unresponsive / Altered Mental Status / Hypotension /
Hypoglycemia / Abdominal Complaints (non traumatic) / Seizures / Syncope
Acute Adrenal Insufficiency or Addisonian Crisis

Assessment
Identify if the patient is at risk for acute adrenal insufficiency or Addisonian crisis by either the presence
of a medical alert bracelet, designation in patient records or other family or medical confirmation.
If the patient is confirmed to have a disease (such as congenital adrenal hyperplasia or chronic use of
systemic steroids) that could lead to acute adrenal insufficiency or Addisonian crisis, then the
administration of steroids (hydrocortisone sodium succinate (Solu-Cortef), methylprednisolone (Solu-
Medrol), or dexamethasone (Decadron)) is life-saving and necessary for reversing cardiovascular shock.
Signs and symptoms of patients in acute adrenal crisis include pallor, dizziness, headache,
weakness/lethargy, abdominal pain, vomiting/nausea, hypoglycemia, hyponatremia, hyperkalemia,
hypotension, shock, and heart failure.
For patients confirmed to have a disease that could lead to acute adrenal insufficiency or Addisonian
crisis but who are not in a state of compensated or decompensated shock, administration of steroids may
prevent the progression to shock, heart failure and possible death. The early signs and symptoms may
include: pallor, dizziness, headache, weakness or lethargy, abdominal pain, nausea or vomiting, and
hypoglycemia. These symptoms are not specific for acute adrenal insufficiency or Addisonian crisis,
therefore when in doubt contact online medical control for further orders.
Dosing of steroids is as indicated below with hydrocortisone being the preferred medication if available:
Adult patients:
Administer hydrocortisone sodium succinate (Solu-Cortef) 100mg IM/IO/IV Push
Or
Administer methylprednisolone (Solu-Medrol) 125mg IM/IO/IV Push
Or
Administer dexamethasone (Decadron) 4 or 5 mg IM/IO/IV Push
Pediatric patients:
Administer hydrocortisone sodium succinate (Solu-Cortef) 2mg/kg IM/IO/IV push (to maximum
100mg)
Or
Administer methylprednisolone (Solu-Medrol) 2mg/kg IM/IO/IV Push (to maximum 125mg)
Or
Administer dexamethasone (Decadron) 4 or 5 mg IM/IO/IV Push
1. Patient is identified as being at risk for acute adrenal insufficiency or Addisonian crisis by presence of a medical alert bracelet/identification, patient records, family or medical confirmation or is identified as having a disease (such as Congenital Adrenal Hyperplasia or chronic systemic steroid use) that could lead to acute adrenal insufficiency or Addisonian crisis. 2. Communication of information obtained in step 1 is made with EMT-IV, Paramedic, and/or Medical 3. Oxygen 100% at 12 - 15 Lpm NRB and airway maintenance appropriate to patient’s condition. 4. Consider spinal stabilization appropriate to patient’s condition. 5. Obtain and record an oral or axillary temperature if possible. 6. Glucose check. 7. Maintain body temperature above 97 degrees F. 8. If the patient or family or ambulance does not have hydrocortisone, methylprednisolone or dexamethasone, then call into medical control and the local emergency department and advise that the patient needs this medication as soon as possible after arrival. 9. EMT STOP Ø

10. IV NS bolus (20mL/kg) (Pediatrics 20 mL/kg)
11. Administer Dextrose 50% if appropriate.
12. Begin maintenance IVF with D5NS, or may substitute NS for IVF.
13. EMT-IV STOP Ø

14. EKG monitor
15. Oxygen saturation
16. Administer Hydrocortisone 2mg/kg up to a maximum of 100mg IM/IO/IV Push, Methylprednisolone
2mg/kg up to a maximum of 125mg IM/IO/IV Push, or Dexamethasone 4 or 5mg IM/IO/IV Push
(Pediatrics: Hydrocortisone 2mg/kg IM/IO/IV Push (up to maximum 100mg, Methylprednisolone
2mg/kg IM/IO/IV Push (up to maximum 125mg, or Dexamethasone 4 or 5 mg IM/IO/IV Push)
15. Repeat fluid bolus as necessary.
16. Recheck glucose and treat as necessary.
17. Maintenance IVF with D5NS, or may substitute NS for IVF.
18. PARAMEDIC STOP Ø

Treatment - Protocol
Administer hydrocortisone, methylprednisolone, or dexamethasone as soon as possible after identifying that the patient is at risk for adrenal insufficiency. Administer fluid bolus 20 mL/kg up to two times after administration of steroids and contact medical control if patient continues with hypotension. Monitor EKG for signs of hyperkalemia which can be present in patients with adrenal crisis. Treat as necessary. If no hydrocortisone, methylprednisolone, or dexamethasone is available during transport, then alert the emergency department/medical control that a patient with adrenal crisis is en route and ask that hydrocortisone, methylprednisolone, or dexamethasone is ready to administer on patient arrival. Below are additions to be included in the Pharmacology Section of the Tennessee Emergency
Medical Services Protocol Guidelines.

100 mg IM/IO/IV Push
Peds- 2mg/kg IM/IO/IV Push (up to maximum 100mg)
Respiratory
Peds- contact medical control
Distress
(Asthma/COPD)
Protocol
Dosage: Acute
Peds- 2mg/kg IM/IO/IV Push (up to maximum 125mg)
Insufficiency or
Addisonian Crisis
Protocol
Drug: Dexamethasone
Trade Names
4 or 5 mg IM/IO/IV Push
Peds- 4 or 5 mg IM/IO/IV Push

Source: http://www.r2ems.com/cms/documents/documents/TN%20State%20CAH%20Protocol.pdf