Addison's Disease Network

The Addison's Patient in Crisis.

Addisonian crisis is regarded as a potentially fatal acute medical emergency and should always be treated as such.

Symptoms may include nausea and/or vomiting, dizziness and confusion often accompanied by low blood pressure, drowsiness eventually progressing to coma, and severe headache akin to migraine. The patient may also complain of extreme weakness, bodily pain and/or tenderness, and of feeling feverish, & may be found to have tachycardia (fast heart rate), bradycardia (slow heart rate), or an irregular heart rate (palpitations).

In approximately 10-11% of patients, the blood bressure may rise instead of drop. It has been explained to me that this is due to patients in this group still being able to excrete large or excessive amounts of adrenaline. Adrenaline causes a rise, sometimes dramatic, in blood pressure.

Stress (however caused, be it shock from injury, illness, bereavement, even a long journey) and/or dehydration are the two factors most likely to start the cycle of a crisis in the Addison's patient. Both factors must be avoided as much as possible.

Many physicians advocate drinking at least three litres of water each day, even for the so-called normal patient. Excessive sweating is a common symptom of Addison's disease and therefore such patients may need to consume more than this recommendation. Sweating also results in loss of salt (sodium) which may dramatically increase the level of potassium in the blood. Replacing such lost sodium with one or two grams of common salt may be necessary and can sometimes prevent a crisis. However, a need for long term excessive salt intake should always be investigated.

Each Addison's disease patient should discuss with their GP (PCP) or endocrinologist what measures they should take if they find themselves in a situation, e.g. vomiting or diarrhœa, which could predispose them to a crisis. Many patients will have been prescribed injectible hydrocortisone (e.g. 100mg Solu Cortef) for emergency use and have received sufficient training for them to self administer, or their equally trained carer or partner to administer the injection for them.
However it is useful to have an 'aide memoire' for Addison's patients to refer to from time to time.

From comments & e-mails it has become obvious that a printer-friendly version of the following "Aide Memoire" for preparation & injection would be useful.

Please click the link to the printer-friendly version below and print it on both sides of a single 'A4' sheet. Keep it in the bag with your injection kit for easy access in emergency.
Keep one copy with each kit if you have more than one.

Please click here for the printer-friendly version.

Guide to preparing for use and self administering injectible Hydrocortisone

This guide is NOT intended to replace professional training.

For each prescribed vial of freeze dried injectible hydrocortisone the following are required, in addition to an accompanying vial of sterile injectible water as diluent for reconstitution.

  • One 2ml sterile syringe.
  • One 21gauge X 1½" sterile hypodermic needle.
  • One 23 gauge X 1" sterile hypodermic needle.
  • Two sterile 'Medi-swabs' or equivalent.

To aseptically prepare and administer the injection in case of Addison's crisis:-
  1. Remove the syringe from its packaging.
    It is easiest to 'burst' the plunger end first from the back of the packet. Do NOT put the syringe down or touch the needle mount.
  2. Remove the 21 gauge needle (usually colored green) in its plastic cover from its packaging. Depending on needle make this will necessitate either bursting it from the back of the packet as above, or 'flicking' the cap from the top of the integral plastic needle cover/package.
  3. Mount the syringe firmly on the needle. A slight twist may be needed to ensure they do not part company unexpectedly. The sheathed needle and syringe may now be laid down on a dry clean surface, in order to open the vials.
  4. The vials of sterile injectible water and freeze dried hydrocortisone will usually have one of three types of top......
    Either a plastic cap covering the pierceable bung; remove only the plastic cap, or an aluminium tear off tab, part of the cap assembly; remove the tear-off tab, or just a cap assembly holding the pierceable bung in place. Whichever you have, you should end up with the pierceable bungs exposed.
    (Please note:- in some parts of the world a combined double vial is used. With this version, follow the instructions to reconstitute the hydrocortisone ready for injection. Please mix thoroughly by repeated inversions of the vial(s). Do NOT shake vigorously to mix. You will get a lot of froth which will contain much of the HC which cannot be taken up into the syringe.)
  5. Wipe the surface of both bungs with an opened Medi-swab. Carefully remove the needle cover from the needle & syringe & pierce the bung of the water vial. Support the vial (upside down) and the syringe with one hand, and carefully withdraw all the liquid from the bottle by use of the plunger, with the other hand. Remove the needle & syringe.
  6. Carefully introduce the needle with syringe still attached into the vial of hydrocortisone. Vacuum will often draw the liquid down into the vial;
    DO NOT WITHDRAW THE NEEDLE & SYRINGE at this stage.
  7. Support the needle, syringe, and vial and gently swirl the contents until dissolved. This should only take 15-20 seconds or so, then carefully withdraw the amount of the contents instructed by your doctor or nurse, back into the syringe as above.
  8. Withdraw the needle from the vial, carefully remove it from the syringe and dispose of it safely, ideally in a correct 'Sharps Bin'. If there is none immediately available, it may be necessary in emergency to re-sheath the used needle as the least dangerous option but this must be done VERY carefully to avoid needle-stick injury. Replace the needle with a fresh 23 gauge needle (usually blue). The injection is now ready for use.
  9. Assuming you are self administering the injection, expose the skin on the upper thigh, on the same side as the hand you normally write with
  10. With your leg relaxed, select an area mid thigh, half way between the mid line and the outer side and clean the area with the second Medi-swab.
  11. Remove the needle cover from the needle and syringe assembly and grip the thigh with the opposite hand, with the thumb on the mid line and the fingers gripping the outer thigh to slightly raise and tension the skin.
  12. In one steady firm movement insert the needle into the area you have selected, swabbed, and are now gripping between your thumb and fingers, until only about half an inch (just over 1cm) remains above the surface.
  13. Gently and steadily depress the plunger until the syringe is empty.
  14. Withdraw the needle and exert pressure with the swab on the injection site.
  15. VERY carefully dispose of the syringe & needle etc. safely as above.
  16. NOW CALL FOR URGENT MEDICAL ASSISTANCE!

    Many physicians say that the injection may be repeated in 10-15 minutes if the patient deteriorates, or their condition does not improve.

    Addison's Crisis Letter.

    We have included a copy of an Addison's Disease Crisis Letter which it is recommended all Addison's patients carry with them at all times and which should be shown to any doctor or paramedic treating you, especially if you and/or your medical condition are not known to them.

    Please print the letter in colour. Close the 'Crisis Letter' window to return to here. It will be valid when completed, and signed by your doctor or endocrinologist. Please click the following link which will open the letter in a new window.

    Click here for the Addison's Crisis Letter.

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    Copyright © 2004-2010 Mike Welch