Adrenal Insufficiency Emergency Plan (Stress-Dosing Letter)

Document Title: Adrenal Insufficiency Emergency Plan (Stress-Dosing Letter)

Patient Name: [patient full name]

Date of Birth: [date of birth]

Primary Diagnosis: [primary adrenal insufficiency / congenital adrenal hyperplasia (CAH) / secondary adrenal insufficiency / glucocorticoid-induced adrenal suppression]

⚠️ STEROID-DEPENDENT – RISK OF ADRENAL CRISIS ⚠️

Prepared by: [clinician name, credentials, clinic/hospital]

Date Issued: [date issued]   Valid Until: [expiration date or "Review annually and with any dose/weight change"]

Emergency Contacts:

• Clinic (daytime): [phone number]
• After-hours/On-call: [phone number]

(Format all medication doses with leading zeros and no trailing zeros; write out "by mouth," "intramuscular," and "emergency room" in lay sections; abbreviations acceptable in ED/EMS section.)

---

Emergency Actions

Danger Signs (Inject intramuscular hydrocortisone immediately, then call 911):

• Repeated vomiting or cannot keep oral medications down
• Severe lethargy, confusion, fainting, or not waking normally
• Seizure
• Signs of shock (very weak, clammy, dizzy, minimal urine output)
• Serious injury or major trauma
• Any situation that feels like an emergency

If danger signs present: Give emergency injection → Call 911 → Go to the emergency room by ambulance

If no danger signs but significant illness: Start oral stress dosing (see below) and monitor closely. If worsening or unable to take oral medication, treat as emergency.

When in doubt, give the injection and call 911. There is no overdose risk in an emergency.

Baseline Regimen & Stress Dosing

Baseline Daily Medications:

• Glucocorticoid: [medication name], [dose in mg], by mouth [schedule with times], [formulation]
• Mineralocorticoid (if applicable): fludrocortisone, [dose in mg], by mouth [timing]

Current Weight: [weight in kg] as of [date obtained]

(For pediatric patients, weight is required. If unavailable, include: "Use age-based dosing and verify with endocrinology as soon as possible.")

Situation	Oral Dose	Frequency	Duration	Escalate If
Mild cold, normal energy	No change	—	—	Fever develops or worsens
Fever, significant fatigue, infection, minor injury	[stress dose in mg] by mouth	Every [6 / 8] hours	Until 24 hours after fever resolves	Vomiting, unable to take oral, not improving
Severe illness, major trauma, perioperative	Seek emergency care; give intramuscular hydrocortisone injection if not in a medical setting

Emergency Injection Instructions

When oral medication cannot be taken or kept down:

1. If vomiting occurs within 30 minutes of an oral dose, give one repeat dose.
2. If vomiting recurs or the patient cannot take oral medication, give an intramuscular injection immediately.
3. If altered mental status or unconscious, inject immediately and call 911.

Emergency Injection Order:

• Medication: Hydrocortisone for injection
• Dose: [patient-specific dose in mg]
• Volume: [volume in mL after reconstitution]
• Route: Intramuscular, mid-outer thigh

(If emergency injection dose is not specified, display in bold: "Emergency injection dose not specified—contact endocrinology immediately.")

Preparation: [Act-O-Vial / powder with diluent / premixed syringe] — [brief preparation steps appropriate to selected product]. Check expiration date; use only if solution is clear.

Injection Steps: Clean site with alcohol wipe → Insert needle at 90 degrees into mid-outer thigh → Inject medication → Dispose of needle safely → Note time given: ______

After injection: Call 911 immediately. Bring this plan and all steroid medications. Tell responders: "This patient has adrenal insufficiency and is steroid-dependent."

Instructions for ED/EMS Clinicians

Diagnosis: [diagnosis] — Steroid-dependent, at risk for adrenal crisis.

Do not delay treatment to obtain diagnostic studies.

• Hydrocortisone: [weight-appropriate dose] IV/IM immediately, then [continued dosing schedule]
• IV normal saline bolus for hypotension/dehydration
• Monitor glucose (treat hypoglycemia if present), electrolytes, blood pressure, heart rate

Contact endocrinology urgently. Admit or observe until stable and tolerating oral intake.

School/Childcare Addendum

(Include this section only if applicable. If a separate school authorization form exists, replace with: "For medication administration authorization, see [form name], kept [location].")

• Kit Location: [where emergency kit is stored]
• Authorized Staff: [school nurse and/or trained designees]
• Field Trips: Kit and plan must accompany student; trained adult must be present
• After Emergency Action: Call 911 first, then notify parent/guardian
• Documentation: Record time of symptoms, oral dose given, injection given, EMS called, parents notified

---

Scope: This plan is for patient, family, caregivers, school staff, and emergency clinicians. It does not replace emergency medical care.

Training Acknowledgment:

• [ ] Caregiver trained on stress dosing (date: ______)
• [ ] Caregiver trained on intramuscular injection (date: ______)
• [ ] School staff trained (date: ______)

Clinician Signature: ______________________   Date/Time: ______