What are the indications for hydrocortisone (corticosteroid) in the emergency department?

Indications for Hydrocortisone in the Emergency Department

The primary indications for hydrocortisone in the emergency department are adrenal crisis, septic shock unresponsive to fluids and vasopressors, and perioperative stress coverage for patients with adrenal insufficiency.

Adrenal Crisis

• Adrenal crisis is a life-threatening emergency requiring immediate hydrocortisone administration without waiting for diagnostic confirmation 1

• Clinical presentation includes:

  • Hypotension unresponsive to fluids 1
  • Nausea, vomiting, abdominal pain (sometimes with peritoneal irritation) 1
  • Fatigue, malaise, muscle pain or cramps 1
  • Dehydration leading to hypotension and shock 1
  • Impaired cognitive function, confusion, loss of consciousness 1
  • Laboratory findings: hyponatremia, hyperkalemia, increased creatinine, hypoglycemia (in children) 1

• Treatment protocol:

  • Immediate IV administration of hydrocortisone 100 mg bolus 1, 2
  • Followed by 100-300 mg/day as continuous infusion or divided doses every 6 hours 1, 2
  • Rapid administration of 0.9% saline (1L over an hour) 1
  • Treatment of precipitating conditions 1

Septic Shock

• Hydrocortisone is indicated in septic shock when adequate fluid resuscitation and vasopressor therapy fail to restore hemodynamic stability 1
• Recommended dosage: 200 mg/day as continuous infusion or in divided doses 1
• Continuous infusion is preferred over bolus administration to avoid glucose fluctuations 3
• Taper hydrocortisone when vasopressors are no longer required 1

Perioperative Stress Coverage

• Patients with known or suspected adrenal insufficiency require hydrocortisone supplementation during surgery based on the degree of surgical stress 1
• Dosing recommendations by procedure type:
  • Major surgery with long recovery: 100 mg hydrocortisone IM just before anesthesia, then 100 mg IM every 6 hours until able to eat and drink, followed by double oral dose for 48+ hours 1
  • Major surgery with rapid recovery: 100 mg hydrocortisone IM before anesthesia, then 100 mg IM every 6 hours for 24-48 hours, followed by double oral dose for 24-48 hours 1
  • Minor surgery: 100 mg hydrocortisone IM before anesthesia, then double oral dose for 24 hours 1
  • Dental procedures: Extra morning dose 1 hour prior to surgery, then double oral dose for 24 hours 1

Immune-Related Adverse Events

• Hydrocortisone is indicated for management of immune checkpoint inhibitor-related adrenal insufficiency 1
• Dosing based on severity:
  • Grade 2 (moderate symptoms): Outpatient corticosteroid treatment at 2-3 times maintenance dose (hydrocortisone 30-50 mg total daily dose) 1
  • Grade 3-4 (severe symptoms): IV stress dose steroids: Hydrocortisone 50-100 mg every 6-8 hours initially 1

Critical Illness-Related Corticosteroid Insufficiency (CIRCI)

• Consider hydrocortisone in critically ill patients with vasopressor-dependent shock who respond poorly to fluids and vasopressors 1, 4
• Diagnosis suggested by random total cortisol <10 μg/dL or delta cortisol <9 μg/dL after ACTH stimulation 4
• Recommended dose: 200-300 mg/day in divided doses or as continuous infusion for ≥7 days 4

Administration Considerations

• Route options: IV, IM, or continuous infusion 2
  • IV administration results in immediate bioavailability with peak levels at 10-20 minutes 3
  • IM administration is rapidly absorbed with therapeutic levels reached within 11±5 minutes 3
• For emergency use, IV is the preferred initial route 2
• Administration technique:
  • IV push: Administer over 30 seconds (100 mg) to 10 minutes (500 mg or more) 2
  • For IV infusion: First prepare solution by adding not more than 2 mL of Bacteriostatic Water for Injection, then add to 100-1000 mL of appropriate IV fluid 2

Important Caveats and Pitfalls

• Do not delay hydrocortisone administration in suspected adrenal crisis while waiting for diagnostic confirmation 1, 5
• Infections are major precipitating causes of adrenal crisis; maintain high index of suspicion in patients with known adrenal insufficiency who present with infection 5
• Patients with adrenal insufficiency should carry an emergency card and emergency kit for parenteral hydrocortisone self-administration 5
• Corticosteroids should not be administered for sepsis in the absence of shock 1
• When using etomidate for rapid sequence intubation, consider hydrocortisone administration due to potential adrenal suppression, particularly in patients with cirrhosis and septic shock 1

By promptly recognizing the indications for hydrocortisone in the emergency department and administering appropriate doses, clinicians can significantly reduce morbidity and mortality in these critical conditions.