Red flags
- Shock refractory to fluids + norad
- Hypoglycaemia
- Hyponatraemia + hyperkalaemia
First steps
- ABCDE + IV access
- Hydrocortisone 100 mg IV bolus then 200 mg/24 h infusion or q6h
- IV saline 1 L over 1 h then titrated
- Correct hypoglycaemia (50 mL 50% dextrose)
Key investigations
- Random cortisol + ACTH before steroids (if possible)
- U&E, glucose, TFT, calcium
- Short synacthen test after stabilisation
Differentials
- Sepsis, cardiogenic shock, other endocrine (hypothyroid myxoedema)
Initial management
- Treat cause: infection, medication non-compliance, surgery
- Fludrocortisone 0.1 mg OD when on <50 mg hydrocortisone/day
- Sick day rules education
Referral
- Endocrinology
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