What are the next steps for a patient who received hydrocortisone 100 mg for acute trauma?

Post-Trauma Hydrocortisone Management

After administering hydrocortisone 100 mg for acute trauma, continue with hydrocortisone 200 mg per 24 hours as a continuous IV infusion (or 50 mg IV/IM every 6 hours) until the patient can tolerate oral intake, then transition to double their usual oral glucocorticoid dose for 24-48 hours before tapering back to baseline. 1

Immediate Next Steps

Continue Stress-Dose Steroid Coverage

• Initiate continuous IV infusion of hydrocortisone 200 mg over 24 hours immediately following the initial 100 mg bolus 1
• Alternative regimen if continuous infusion is impractical: hydrocortisone 50 mg IV or IM every 6 hours 1
• This dosing mimics the physiologic stress response, which increases cortisol production approximately 5-fold (to ~100 mg/day) following major trauma 1

Duration of Stress-Dose Coverage

• Continue the 200 mg/24h infusion while the patient remains NPO or has postoperative vomiting 1
• For uncomplicated recovery: maintain stress dosing for 24-48 hours, then transition to oral therapy 1
• For major trauma or complicated course: continue stress dosing for up to one week, using clinical judgment to guide duration 1

Transition to Oral Therapy

When Patient Can Tolerate Oral Intake

• Double the patient's usual oral glucocorticoid dose for 48 hours if recovery is uncomplicated 1
• For patients not previously on chronic steroids: initiate hydrocortisone 20-40 mg daily in divided doses, then taper over 24-48 hours 2
• Gradually taper back to baseline (or discontinue if not on chronic steroids) rather than stopping abruptly 2

Critical Monitoring Points

Watch for Adrenal Crisis

• If unexplained, fluid-unresponsive hypotension develops at any point, immediately administer hydrocortisone 100 mg IV push as this suggests adrenal insufficiency 1
• Adrenal crisis presents with hypotension, hyponatremia, hyperkalemia, and altered mental status 1
• Do not delay treatment for diagnostic testing—draw cortisol and ACTH levels but treat immediately if crisis is suspected 1

Assess for HPA Axis Suppression Risk

The initial 100 mg dose suggests concern for potential adrenal insufficiency. Consider if the patient has:

• Chronic steroid use (≥5 mg prednisone daily for ≥4 weeks, or equivalent) 1
• Any glucocorticoid exposure via oral, inhaled, topical, intranasal, or intra-articular routes 1
• Primary adrenal insufficiency (Addison's disease) or secondary adrenal insufficiency 1

Special Considerations for Trauma Patients

Evidence-Based Benefits in Trauma

• Stress-dose hydrocortisone (200 mg/day for 5-7 days) reduces hospital-acquired pneumonia risk in intubated trauma patients (35.6% vs 51.3% in placebo, HR 0.51) 3
• Increases ventilator-free days by 4-6 days compared to placebo 3
• Reduces hyponatremia incidence (0% vs 9.2% in placebo) 3
• May improve neurological outcomes in traumatic brain injury patients by reducing critical illness-related corticosteroid insufficiency 4

Mineralocorticoid Considerations

• Hydrocortisone provides both glucocorticoid and mineralocorticoid activity at stress doses (100 mg saturates HSD type 2 receptors) 1
• Do not substitute dexamethasone alone in patients with primary adrenal insufficiency, as it lacks mineralocorticoid activity 1, 5
• If patient has known primary adrenal insufficiency, resume fludrocortisone 0.05-0.2 mg daily once oral intake is established 1

Common Pitfalls to Avoid

Do Not Abruptly Discontinue

• Never stop stress-dose steroids abruptly—always taper gradually over 24-48 hours minimum 1, 2
• Abrupt cessation risks precipitating adrenal crisis, even in patients without baseline adrenal insufficiency 1

Monitor for Hyperglycemia

• Stress-dose steroids significantly increase blood glucose, particularly in diabetic patients 6
• Implement tight glucose monitoring and adjust insulin accordingly 6

Recognize Increased Surgical Complication Risk

• Patients on chronic steroids have higher rates of anastomotic leak (6.2% vs 3.3%), wound dehiscence, and infections 1
• Maintain heightened vigilance for surgical site infections and consider this in surgical planning 1

Ensure Adequate Fluid Resuscitation

• Hydrocortisone is not a substitute for adequate fluid resuscitation—always ensure volume status is optimized 1
• In adrenal crisis, rapidly administer 1L of 0.9% saline over one hour in addition to hydrocortisone 1