Adrenal insufficiency

Any person, 4 weeks to 15 years, presenting with a previous diagnosis of adrenal insufficiency who presents as unwell. This excludes a newly diagnosed patient in the ED. To be used in conjunction with primary presenting protocol.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
General appearance/first impressions	Position of comfort

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning

Breathing

Assessment	Intervention
Respiratory rate and work of breathing Consider auscultation of chest (breath sounds) Oxygen saturation (SpO2)	Assist ventilation as clinically indicated Apply oxygen to maintain SpO2 over 93%

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Heart rate Blood pressure	Assess circulation Attach cardiac monitor if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern Consider 12 lead ECG Ensure a full set of observations has been documented before giving hydrocortisone
Unstable or unwell Hypotension Tachycardia Vomiting Diarrhoea Drowsy	Insert IV cannula, if trained Give hydrocortisone as per patient's management plan If the plan is unavailable, give hydrocortisone IV/IM, once only: Less than 8 kg: 25 mg 8–12 kg: 50 mg 12–30 kg: 75 mg Over 30 kg: 100 mg Do not delay hydrocortisone. Use the IM route if IV access is unavailable. Consider sepsis in the unstable or unwell child
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension	If signs of shock present or moderate to severe dehydration, give sodium chloride 0.9% at 20 mL/kg IV/intraosseous bolus once only, maximum dose 1000 mL
Moderately unwell Fever 38°C and over Moderate illness or injury Mild vomiting and/or diarrhoea	Give hydrocortisone as per patient's management plan, if available If vomiting persists, consider imminent adrenal crisis and treat as unstable or unwell
Mildly unwell Fever less than 38°C Tolerating oral intake Appears well	Continue A to G assessment

Disability

Assessment	Intervention
AVPU	If AVPU shows reduced level of consciousness, continue to assess GCS, pupillary response and limb strength
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment as clinically indicated
Pain	Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment

Exposure

Assessment	Intervention
Temperature	Measure temperature
Head-to-toe assessment, including posterior surfaces	Check and document any abnormalities

Fluids

Assessment	Intervention
Hydration status	Assess fluids, in and out. Document on fluid balance chart. Include gastrointestinal losses
Nausea and/or vomiting	If present, see nausea and/or vomiting section

Glucose

Assessment

Intervention

BGL

Measure BGL. See medication table for 40% glucose gel dosing If BGL between 2 mmol/L and 3 mmol/L and NOT symptomatic (Yellow Zone criteria): give quick-acting carbohydrate: Up to 12 months: milk feed and/or 40% glucose gel buccal 12 months and over: sugary soft drink or fruit juice or 40% glucose gel buccal reassess BGL in 15–30 minutes and repeat treatment until BGL over 3 mmol/L If BGL less than 2 mmol/L OR symptomatic (Red Zone criteria) OR unable to tolerate oral glucose: give 40% glucose gel buccally in incremental doses, as tolerated, while establishing IV access give 10% glucose, 2 mL/kg by slow IV injection once only if IV access delayed, give: Up to 25 kg: glucagon 0.5 mg IM, once only 25 kg and over: glucagon 1 mg IM, once only reassess BGL in 15 minutes Once stabilised, give patient long-acting carbohydrate and continue to check BGL hourly, or as clinically indicated

Focused assessment

Complete a dehydration focused assessment.

Complete the focused assessment in conjunction with the primary presenting problem.

Precautions and notes

• Adrenal crisis most commonly occurs in the context of an intercurrent injury or illness.
• Manage the cause of the adrenal crisis concurrently.
• Steroid and fluid replacement, plus close monitoring and management of glucose and potassium levels, are a priority.
• The adrenal crisis triad involves low serum sodium, high serum potassium and low serum glucose.
• Some patients may arrive with individual hydrocortisone for injection vials. These are safe to use.

Interventions and diagnostics

Specific treatment

Manage adrenal insufficiency as priority, and consider second ECAT protocol for primary presenting problem.

---

Analgesia

If pain score 1–6 (mild–moderate): give paracetamol 15 mg/kg orally once only, maximum dose 1000 mg

If severe pain present, give analgesia and escalate as per local CERS protocol.

Consider non-pharmacological pain relief (appendix).

---

Nausea and/or vomiting

If nausea and/or vomiting is present and over 6 months give:

---

Procedural analgesia

For pain relief required during procedures only, not used to replace appropriate analgesia.

Sucrose 24%

• 1–18 months: give 1–2 mL orally per procedure
• Maximum dose:
  • 1–3 months: up to 5 mL in 24 hours
  • 3–18 months: up to 10 mL in 24 hours.

Repeat as needed up to the maximum dose.

---

Radiology

Radiology will depend on the working diagnosis. It needs to be requested by a medical or nurse practitioner. If there is concern for urgent radiology, escalate as per local CERS protocol.

---

Pathology

• FBC, UEC, VBG, glucose

Medications

The patient’s weight is mandatory for calculating fluid and medication doses.

The Broselow Tape or APLS weight table (appendix) can be used only in circumstances where the patient cannot be weighed.

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Medications with contraindications or requiring dose adjustment are marked:

• ^H for patients with known hepatic impairment
• ^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au