⚡ Adrenocortical crisis is a life-threatening emergency in infants and young children, caused by acute adrenal insufficiency. It is frequently triggered by stress (infection, trauma, surgery) in a child with underlying adrenal dysfunction (e.g., Congenital Adrenal Hyperplasia). Because symptoms such as vomiting, lethargy, and seizures are non-specific, the condition is often misdiagnosed as sepsis or febrile convulsions. 👉 Early recognition and immediate treatment with IV hydrocortisone and fluids is lifesaving.

Adrenal Crisis (Paediatric) – Emergency Card🚨
⚠️ Suspect if: vomiting, lethargy, hypotension, hypoglycaemia ± seizures, hyponatraemia ± hyperkalaemia, known CAH/adrenal insufficiency 💡 Think: sepsis mimic → treat both if unsure 🔴 Immediate (ABCDE) – O₂, monitoring, senior help 💉 Hydrocortisone IM/IV STAT <1 yr → 25 mg \| 1–5 yrs → 50 mg \| >6 yrs → 100 mg 💧 IV 0.9% NaCl 10–20 mL/kg bolus → reassess 🍬 Hypoglycaemia: 10% dextrose 2 mL/kg IV 🩺 Monitor: ECG, BP, glucose, U&Es, urine output 🔁 Ongoing: hydrocortisone 50–100 mg/m²/day IV + fluids ± glucose + treat cause (e.g. sepsis) ❗ Key rules: Do NOT delay steroids for tests Give IM if no IV access Fludrocortisone NOT needed acutely Send cortisol/ACTH if possible (but don’t wait) 🧠 Exam trigger: hypoglycaemia + hyponatraemia + shock → adrenal crisis

Adrenal Crisis (Paediatric) – Emergency Card🚨

⚠️ Suspect if: vomiting, lethargy, hypotension, hypoglycaemia ± seizures, hyponatraemia ± hyperkalaemia, known CAH/adrenal insufficiency
💡 Think: sepsis mimic → treat both if unsure
🔴 Immediate (ABCDE) – O₂, monitoring, senior help
💉 Hydrocortisone IM/IV STAT <1 yr → 25 mg | 1–5 yrs → 50 mg | >6 yrs → 100 mg
💧 IV 0.9% NaCl 10–20 mL/kg bolus → reassess
🍬 Hypoglycaemia: 10% dextrose 2 mL/kg IV
🩺 Monitor: ECG, BP, glucose, U&Es, urine output
🔁 Ongoing: hydrocortisone 50–100 mg/m²/day IV + fluids ± glucose + treat cause (e.g. sepsis)
❗ Key rules:
- Do NOT delay steroids for tests
- Give IM if no IV access
- Fludrocortisone NOT needed acutely
- Send cortisol/ACTH if possible (but don’t wait)
🧠 Exam trigger: hypoglycaemia + hyponatraemia + shock → adrenal crisis

🌟 Common Causes of Adrenocortical Crisis in Babies

Congenital Adrenal Hyperplasia (CAH): Most common cause in neonates; enzyme defects impair cortisol ± aldosterone synthesis, leading to salt-wasting crisis.
Severe Infections: Sepsis, gastroenteritis, or meningitis can precipitate crisis in infants with borderline adrenal reserve.
Surgery or Major Trauma: Physiological stress can overwhelm adrenal output.
Inadequate Corticosteroid Replacement: Missed doses, abrupt steroid withdrawal, or underdosing in children with known adrenal insufficiency.
Adrenal Hemorrhage/Waterhouse-Friderichsen Syndrome: Classically due to meningococcal sepsis.
Hypoglycemia: From inadequate cortisol-mediated gluconeogenesis.

🔎 Symptoms and Signs

🤢 Nausea, Vomiting, Abdominal Pain – early non-specific features, often mistaken for gastroenteritis.
😴 Lethargy, Weakness – due to cortisol deficiency and electrolyte derangements.
⬇️ Hypotension / Shock – refractory to fluids alone; hallmark of crisis.
💧 Hyponatremia (Na loss) and 🔺 Hyperkalemia (K retention) from aldosterone deficiency.
🩸 Hypoglycemia – especially in neonates, presenting as jitteriness or seizures.
🧠 Seizures – commonly due to severe hyponatremia, often mislabelled as “febrile convulsions.”

🧪 Key Investigations (Do not delay treatment)

Serum cortisol: may be low or inappropriately normal in an unwell child (interpret with caution).
ACTH Stimulation Test: Definitive, but performed later once stable.
Electrolytes: Hyponatremia, hyperkalemia, metabolic acidosis.
Blood Glucose: Hypoglycemia is common in infants.
17-Hydroxyprogesterone: Elevated in CAH (confirmatory).
Genetic Testing: For congenital adrenal enzyme defects.

🚑 Emergency Management (Do not wait for results)

🔴 ABCDE approach – high-flow O₂, monitoring, senior help early.
💉 Hydrocortisone IM/IV immediately (do NOT delay)
- <1 year: 25 mg stat
- 1–5 years: 50 mg stat
- >6 years: 100 mg stat
Then continue:
- 50–100 mg/m²/day IV (continuous infusion or 6-hourly doses)
💧 IV 0.9% sodium chloride 10–20 mL/kg bolus → reassess frequently (Add glucose early if hypoglycaemia or risk present)
🍬 Treat hypoglycaemia: 10% dextrose 2 mL/kg IV bolus → infusion
📈 Monitoring: BP, electrolytes, glucose, urine output
⚠️ Do NOT delay steroids for investigations
❌ Fludrocortisone not required acutely (start later if needed)

💡 Clinical Pearls

🍼 In neonates, salt-wasting CAH often presents at 1–3 weeks with vomiting, poor feeding, weight loss, and shock.
💊 Children on long-term steroids require “stress doses” during illness, surgery, or trauma to prevent crisis.
🧠 Always consider adrenal crisis in an infant with seizures + hyponatremia + hypoglycemia.
📢 Do not delay hydrocortisone for tests if the child is unstable-treat first, investigate later.

Adrenal crisis is fundamentally a failure of stress physiology, where cortisol deficiency leads to impaired vascular tone, reduced catecholamine sensitivity, and hypoglycaemia from failed gluconeogenesis. The reason hydrocortisone is prioritised is that it provides both glucocorticoid and mineralocorticoid activity at high doses, making fludrocortisone unnecessary acutely. NICE avoids rigid cortisol cut-offs because in critical illness, binding proteins fall and “normal” values may still be inadequate for physiological demand. The IM route is emphasised because vascular collapse often makes IV access difficult—this is a classic real-world pitfall. Finally, fluid resuscitation must be cautious and reassessed frequently, as children in adrenal crisis behave like mixed distributive and hypovolaemic shock, overlapping with sepsis physiology.

✅ Summary

Adrenocortical crisis in babies is a medical emergency. Key features: vomiting, lethargy, hypotension, hyponatremia, hyperkalemia, hypoglycemia. Immediate treatment with IV hydrocortisone, saline, and glucose is lifesaving. Prevention relies on early diagnosis of CAH and educating families on stress dosing of steroids.

The content on this website is provided for educational and informational purposes only to support exam preparation (e.g., MLA, MRCP, USMLE) and learning. This is NOT medical advice, diagnosis, treatment, or professional guidance. It does not replace consultation with a qualified healthcare professional, official guidelines (e.g., NICE, GMC, BNF), or supervised clinical practice. Always verify information with current, authoritative sources. Makindo and its contributors accept no liability for any reliance on this content, including errors, omissions, or any resulting harm, loss, or consequences. By using this site, you agree to these terms.

Adrenal crises (Paediatric) ✅