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Accident & Emergency staff


ADSHG

  • Each year, around one in ten steroid-dependent patients will experience symptoms approaching adrenal crisis, and one in twelve will present to Accident & Emergency for medical treatment. Vomiting is the single biggest factor contributing to adrenal crisis, present in around 80% of cases. Vomiting in a steroid-dependent patient should always be regarded as a medical emergency. This article outlines the core responsibilities of A & E personnel in recognising and responding to adrenal emergencies.

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.

 

"My husband showed the ADSHG adrenal crisis letter to the receptionist and within 5 minutes the triage nurse took me through to a bed, put me straight on to fluids and I was given hydrocortisone via drip."

 

"As soon as I was seen by triage I was immediately taken to resuscitation, treated urgently and listened to. The doctor immediately agreed to give me hydrocortisone by IV along with IV fluids and IV antibiotics and anti-sickness injections."

 

"Brought straight in and quickly given IV fluids. Steroid emergency card was very helpful for ambulance staff and hospital A&E staff – the red ADSHG card."

 

"Going through triage in A and E in 4 minutes flat as I had a letter from my GP already stating I was a text book case of untreated Addison's."

 

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.

 

"My son had to beg the reception staff to take my ADSHG emergency card through to the emergency team to make them give me some attention."

 

"Upon triage, even though I stated Addison's disease, I was triaged as vomiting so therefore was put as a low priority. It was about three hours before I received injected steroids even though I asked repeatedly. By the time I got it I was in a very bad state."

 

"The triage nurse had no idea about adrenal insufficiency and what the condition means - he said that I was not having an allergic reaction so therefore I did not need an injection!"

 

"I was lying on a trolley and the nurse took my BP and announced that I wasn't having a crisis because my BP was okay! Luckily the doctor listened and went along with me. I was very ill and in hospital for 6 days."

 

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:

 

"Doctor knew exactly what was required and was quick to administer hydrocortisone IV and fluids. A keen eye was kept on my blood pressure and soaring temperature; this continued when I was put on a ward. Once stabilised, I was checked for other problems."

 

"Admission to a Respiratory Unit, all the staff seemed to know exactly what they were doing. The doctors gave me the necessary injections for the adrenal crisis and also started immediate treatment for the pneumonia/severe sepsis."

 

"I was given IV steroids and IV fluids within 5 minutes of being taken into A & E."

 

"Within 10 minutes of arriving at the hospital, an endocrinologist on their weekend shift attended."

 

"I was promptly given intravenous steroids and IV fluids and admitted for further tests. Potassium also low - given via a drip. In hospital for five days."

 

"It was approximately midnight when I went to A&E with vomiting, (which turned out to be norovirus) and one of the two doctors on duty had trained with an endocrinologist. They knew just what to do - how lucky was I? This was then followed up satisfactorily on the ward for a two day stay."

 

"No hesitation in A&E to inject me or take extra precautions with checks due to adverse effects that had brought on a hemiplegic migraine episode that affected my whole left side."


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.

 

"A & E staff spent ages going through my medical history and trying to find out about Addison's before they would administer this life-saving drug. They did not seem to know how critical it was for me to have the hydrocortisone injection immediately."

 

"Staff in A & E were reluctant to treat me with IV hydrocortisone and instead gave me 2 anti-sickness injections which failed to work. When I was sick again, treatment with hydrocortisone and IV fluids was finally started."

 

"Only the endocrinologist knew how to deal with it. None of the other doctors were any use. One even suggested 'Did I not think it could be migraine?'"
 
"Staff could have been quicker at receiving me, rather than me having to sit in corridor waiting for bed to be made up – which resulted in me collapsing out of the chair onto the floor in rapid deterioration."

 

"After being seen by a consultant who agreed I needed hydrocortisone and saline drips I was still waiting 45 minutes later to receive anything, whilst my condition continued to deteriorate. Only after my husband went to see what the delay was, did I get my treatment."

 

"I needed IV fluids immediately. it was obvious I was dehydrated. There was delay of four hours whilst repetitive questions were asked about medical history, ECG, tracings were taken etc, before I was connected to the drip."

 

"It was a clean efficient hospital and I felt looked after rather than ignored. Although it took a long time to get me on a drip it was because they were not convinced it was a crisis and were waiting for test results."

 

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The Addison’s Disease Self-Help Group is the support group for people with Addison’s disease or adrenal insufficiency and their families in the UK and Ireland.The group was formed in 1984 and is a UK registered charity no. 1179825.

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