Role of the triage nurse
Triage nurses play a vital role in ensuring steroid-dependent patients get the immediate treatment they need. Please give any steroid-dependent patient immediate attention. Unless they receive prompt treatment with high dose steroids, any serious injury or infection may trigger an adrenal crisis, because the patient is unable to mount a normal cortisol response to these physical stresses.
Vomiting in a steroid-dependent patient is a medical emergency. A decompensated patient may experience circulatory complications such as cardiac arrest or stroke, with comparatively little warning. The recommended treatment for prevention of adrenal crisis is explained in the ADSHG crisis guidelines.
Steroid-dependent patients will often carry some form of medical identification to verify their condition. The patient may be carrying the ADSHG emergency wallet card, an equivalent medical card from the Pituitary Foundation, or a blue steroid card issued by the Department of Health. They may also be wearing medical jewellery such as an engraved bracelet or necklace, or wearing a silicone ADSHG steroid alert wrist band. In some cases, the patient's family may have brought their emergency injection kit to the hospital.
In 2013, the ADSHG conducted a survey of steroid-dependent patients' emergency experiences. This survey generated over 1,000 responses from across the UK and Republic of Ireland. The findings were presented at the 2015 Society for Endocrinology annual conference. Below are some of the written comments about the positive aspects of their treatment.
In the 2013 emergency survey, around one quarter of steroid-dependent patients said they had experienced concerning delays before their condition was recognised by A & E staff and they were treated. Below are some quotes from the 2013 emergency survey to illustrate what can go wrong.
Role of the medical officer
Please give any steroid-dependent patient immediate attention. The recommended treatment for prevention of adrenal crisis is explained in the ADSHG crisis guidelines.
Please ensure the patient receives parenteral steroids immediately. It is inadvisable to delay by waiting until diagnostic results such as bloods, x-ray, ECG are available. The patient may deteriorate precipitously, even if they appear stable. Where the patient is dehydrated enough to need IV saline, this should again be commenced immediately, without waiting for a bed to become available.
The patient may have been given parenteral steroids before transportation to hospital; if so, establish how long ago. The half life of hydrocortisone is about 90 minutes and they may need a further dose.
Two-thirds of patients in our 2013 emergency survey (N=1042) were satisfied with the prompt treatment they received for their most recent adrenal crisis. Below are some of the comments they made about the positive aspects of their treatment:
In our 2013 emergency survey, around one quarter of steroid-dependent patients said they had experienced concerning delays before they were treated. This was a survey of over 1,000 patients from around the UK; the findings were presented at the 2015 Society for Endocrinology annual conference. Below are some quotes from the 2013 emergency survey to illustrate what can go wrong.
- Allolio 2015 Adrenal crisis, European Journal of Endocrinology 172 R115-R124
- Hahner et al. 2014 High incidence of adrenal crisis in educated patients with chronic adrenal insufficiency, Journal of Clinical Endocrinology & Metabolism 100 407-416
- Husebye et al. 2014 Consensus statement on the diagnosis, treatment and follow-up of patients with primary adrenal insufficiency, Journal of Internal Medicine 275 104-115
- Hahner et al. 2015 Timelines in the management of adrenal crisis - targets, limits and reality, Clinical Endocrinology 82 497-502
- White & Arlt 2010 Adrenal crisis in treated Addison's disease: a predictable but undermanned event, European Journal of Endocrinology 162 115-120