Adrenal Insufficiency and Adrenal Crisis in the Dental Practice
Recognising the Patient Who Is Becoming Seriously Unwell
By Garry Perkins, former Paramedic and Founder of Sussex First Aid Courses Ltd
Medical emergencies in dental practice are thankfully uncommon, but when they happen they can be extremely challenging for the whole dental team.
Having taught medical emergency training to dental teams for many years, and having attended medical emergencies myself during my career as a paramedic, adrenal insufficiency is one of those conditions that I feel can easily be overlooked.
It may not immediately present as the textbook emergency we expect.
The patient may simply look unwell.
They may be weak, nauseated, dizzy, confused or hypotensive. They may vomit, complain of abdominal discomfort or appear to be deteriorating for reasons that are not immediately obvious.
Some of these features can mimic other medical emergencies.
That makes good assessment, careful history-taking and an open mind particularly important.
What is adrenal insufficiency?
The adrenal glands normally produce cortisol, a hormone that plays an essential role in helping the body respond to physical and emotional stress.
People with adrenal insufficiency cannot produce enough cortisol to meet the body's requirements.
There are different forms of adrenal insufficiency. Addison's disease is primary adrenal insufficiency, where the adrenal glands themselves are unable to produce sufficient hormones.
Secondary adrenal insufficiency can occur when there is inadequate stimulation of the adrenal glands from the pituitary gland, while tertiary adrenal insufficiency can occur following suppression of the body's normal cortisol system, including in some people who have been taking glucocorticoid steroid medication.
NICE recognises primary, secondary and tertiary adrenal insufficiency within its current guidance.
For dental teams, the exact endocrine diagnosis may be less important in the emergency than recognising:
This patient may be steroid-dependent and may be developing an adrenal crisis.
Why can dental treatment be relevant?
Stress increases the body's requirement for cortisol.
That stress may be physical, emotional or both.
For somebody with adrenal insufficiency, dental treatment, anxiety, pain, infection or an invasive procedure can potentially increase the demand placed on the body.
The Addison's Disease Self-Help Group specifically advises people with adrenal insufficiency to discuss steroid cover with their dental team before treatment and notes that some dental procedures may require additional glucocorticoid medication.
This does not mean that every patient with Addison's disease is going to experience an adrenal crisis in a dental chair.
It does mean that good preparation matters.
Medical history: history, history and more history
One of the most useful tools available to a dental team is often not a piece of emergency equipment.
It is the medical history.
Whenever possible, identify patients who:
Have Addison's disease
Have another diagnosed adrenal insufficiency
Take long-term steroid medication
Have recently reduced or stopped steroid medication
Carry an NHS Steroid Emergency Card
Carry emergency hydrocortisone
Have previously experienced an adrenal crisis
Have been given specific sick-day or procedure instructions by their specialist
NICE recommends that people with primary and secondary adrenal insufficiency are provided with emergency management kits and information about managing physiological stress and adrenal crisis.
For the dental practice, this highlights the importance of keeping the patient's medical history genuinely current rather than treating it simply as paperwork.
Ask about their emergency plan
Where a patient has known adrenal insufficiency, I would encourage the dental team to ask:
Do you have an adrenal insufficiency emergency plan?
Do you carry a Steroid Emergency Card?
Do you have emergency hydrocortisone with you?
Has your endocrinology or medical team given you instructions for dental procedures?
Have you ever experienced an adrenal crisis before?
What normally happens when you become unwell?
Where appropriate, record the patient's plan within their dental notes so that members of the team can find it quickly.
Patients with other significant conditions such as epilepsy, diabetes or severe allergy may also have individual emergency plans. The same principle applies:
knowing the plan before the emergency is far easier than trying to discover it during one.
Patients don't always declare everything
This is one of the realities of clinical practice.
Sometimes a significant medical condition is not disclosed.
Sometimes the patient does not realise that a medicine they take is important to their dental treatment.
Sometimes their medical history has changed since their previous appointment.
And occasionally a patient simply forgets.
That is why regular medical-history review matters.
For patients with complex medical needs, there is value in actively reviewing their medical history rather than asking only:
“Has anything changed?”
More focused questions may uncover important information.
What might an adrenal crisis look like?
An adrenal crisis is a medical emergency.
Possible features can include:
Profound weakness or fatigue
Dizziness
Hypotension
Collapse
Rapid pulse
Pallor
Cold or clammy skin
Nausea
Vomiting
Abdominal pain
Diarrhoea
Fever
Drowsiness
Confusion or altered mental state
Reduced consciousness
Dental emergency guidance describes features including collapse, pallor, cold and clammy skin, hypotension, dizziness, vomiting and diarrhoea.
The difficulty is that none of these symptoms belongs exclusively to adrenal crisis.
Hypoglycaemia, sepsis, syncope, cardiac problems and other serious illnesses may produce overlapping features.
This is why the dental team should avoid becoming fixated on making the perfect diagnosis.
Recognise the unwell patient first
One of the messages I continually reinforce during dental medical emergency training is:
You do not need to be an endocrinologist to recognise that your patient is seriously unwell.
Even an experienced clinician can find adrenal crisis difficult to identify.
If your patient is deteriorating, stop.
Call for help.
Work through a structured ABCDE assessment.
Current dental emergency guidance recommends the ABCDE approach when assessing and managing medical emergencies.
A – Airway
Is the airway open and clear?
B – Breathing
Assess respiratory rate, effort and oxygenation.
Monitor SpO₂ where appropriate.
C – Circulation
Check pulse, blood pressure, skin colour and perfusion.
Hypotension is an important warning sign.
D – Disability
Assess level of consciousness.
Consider blood glucose.
A low or abnormal glucose reading may alter your immediate management and can also help identify other causes of deterioration.
E – Exposure
Look for additional clues.
Is the patient febrile?
Are they vomiting?
Do they have a Steroid Emergency Card, MedicAlert information or emergency medication with them?
Stop dental treatment
If adrenal crisis is suspected, terminate dental treatment immediately.
The dental procedure is no longer the priority.
The patient is.
Call other members of the dental team and allocate roles.
One person can remain with the patient.
Another can bring the emergency equipment.
Another can call 999.
Someone should document observations, timings and treatment.
Good teamwork reduces cognitive overload and makes errors less likely.
Positioning
If the patient is hypotensive, dizzy or showing signs of circulatory collapse, lay them flat where clinically appropriate.
Continue monitoring their condition closely.
Be prepared for further deterioration.
Call 999
A suspected adrenal crisis needs urgent hospital treatment.
Call 999 and clearly explain that you have an unwell patient with suspected adrenal crisis or Addisonian crisis.
Give the ambulance service a concise clinical picture:
Known adrenal insufficiency or Addison's disease, if known
Current symptoms
Level of consciousness
Blood pressure and pulse if available
Oxygen saturation
Blood glucose
Treatment already provided
Any emergency hydrocortisone administered
NICE advises that someone experiencing an adrenal crisis should go to hospital immediately by ambulance.
Oxygen
Where clinically indicated, provide high-concentration oxygen using the practice's appropriate emergency oxygen equipment.
Dental emergency guidance describes oxygen at 15 litres per minute for adrenal crisis, and Resuscitation Council UK standards require dental practices to have equipment capable of providing high-concentration oxygen.
Continue to monitor the patient and follow current local and national guidance.
Emergency hydrocortisone
This is an important area for dental teams to understand.
Patients with known adrenal insufficiency may carry an emergency hydrocortisone injection kit.
NICE recommends emergency management kits for people with primary and secondary adrenal insufficiency, and states that intramuscular hydrocortisone can be given when adrenal crisis is suspected. For people aged 16 and over, the emergency dose is 100 mg hydrocortisone intramuscularly or intravenously.
Dental emergency guidance similarly refers to the patient's own emergency kit containing:
Hydrocortisone 100 mg IM
when managing suspected adrenal crisis.
There is an important human-factors consideration here.
Different hydrocortisone products may require different preparation, and some emergency kits may require a powdered drug to be mixed before injection.
Dental professionals should therefore familiarise themselves with the relevant guidance, their scope of practice and the patient's emergency plan before an emergency occurs, rather than trying to learn an unfamiliar preparation while a patient is deteriorating.
Where the patient is conscious and able to manage their own prescribed medication, support them in following their established emergency plan.
If in doubt, call 999 and seek immediate clinical advice.
The dose is 100 mg — not 100 g
This deserves emphasis because medication errors can occur easily when people are under pressure.
For an adult suspected adrenal crisis, current NICE guidance refers to:
100 mg hydrocortisone
not 100 grams.
Medication preparation, dose checking and clear communication between team members are important parts of safe emergency management.
Does the dental practice need to stock hydrocortisone?
Dental teams should distinguish between the standard practice emergency-drug kit and a patient's individual emergency medication.
Current UK dental guidance includes adrenal insufficiency among medical emergencies that teams need to recognise and manage, but practices should follow the current national guidance applicable to their setting regarding which emergency drugs must routinely be stocked.
A patient with known adrenal insufficiency may bring their own prescribed emergency hydrocortisone kit.
This is another reason to identify the risk before treatment begins.
Preparation reduces human-factor errors
Medical emergencies place people under stress.
Even experienced clinicians can experience:
Tunnel vision
Loss of situational awareness
Difficulty recalling doses
Communication problems
Duplication of tasks
Failure to complete basic observations
Fixation on an incorrect diagnosis
I have seen this throughout my career.
There is no shame in saying:
“I need help.”
In fact, recognising your own limitations early is good clinical practice.
Call other team members.
Allocate tasks.
Speak out loud.
Share what you are thinking.
If somebody notices something different, listen to them.
The dental nurse, receptionist or another clinician may have noticed something that changes the picture.
Keep an open mind
A patient with adrenal insufficiency can still have:
Hypoglycaemia
A cardiac emergency
Anaphylaxis
Sepsis
A stroke
Syncope
Another unrelated medical emergency
Do not allow the fact that they have Addison's disease to stop you considering other causes.
Equally, do not dismiss a deteriorating steroid-dependent patient simply because their presentation does not look exactly like the textbook description of adrenal crisis.
Treat what you find.
Use ABCDE.
Monitor.
Reassess.
Call for expert help.
History may be your best friend
When the patient is able to communicate, keep asking useful questions.
What happened before they arrived?
Have they been unwell?
Have they vomited?
Have they taken their normal steroid medication?
Have they recently reduced their steroid dose?
Have they experienced this feeling before?
Do they have a care plan?
Where is their emergency medication?
Have they taken an additional steroid dose today?
Is there another medical condition that could explain what is happening?
Good history-taking can rapidly change the direction of your management.
For me, this remains one of the most useful principles in emergency care:
History, history and more history.
Annual medical-emergency training should include the less obvious emergencies
Anaphylaxis, cardiac arrest, choking, asthma and hypoglycaemia rightly receive considerable attention during dental medical-emergency training.
But teams should also discuss the medical emergencies that may be less familiar.
Adrenal insufficiency is now specifically recognised within current dental emergency guidance.
Training should give teams an opportunity to practise:
Recognising deterioration
ABCDE assessment
Taking a focused medical history
Retrieving emergency equipment
Oxygen administration
Monitoring observations
Checking blood glucose
Calling 999 using a structured handover
Finding and following an individual patient's emergency plan
Locating a patient's emergency hydrocortisone kit
Working effectively as a team
Managing human factors under pressure
The purpose is not to turn every dental professional into an expert in adrenal medicine.
It is to make the team safe, organised and effective until specialist help arrives.
Preparation before treatment
For a known steroid-dependent patient, preparation may include:
Review the medical history.
Ask about their emergency plan.
Check whether they carry a Steroid Emergency Card.
Clarify any instructions from their medical or endocrine team.
Know where their emergency hydrocortisone is kept.
Make sure the dental team knows where the practice emergency equipment is.
Make sure oxygen is available and ready for use.
Consider whether the proposed dental procedure or the patient's current health requires further medical advice before treatment.
For significant or invasive dental procedures, patients with adrenal insufficiency may need specific steroid-cover advice from their medical team.
The most important skill may simply be recognising that something isn't right
Adrenal crisis can be confusing.
It can challenge experienced healthcare professionals.
The dental team should not become paralysed because they cannot put an exact diagnostic label on the patient.
If the patient is becoming seriously unwell:
Stop treatment.
Call for help.
Use ABCDE.
Lie them flat if hypotensive where appropriate.
Give oxygen where clinically indicated.
Check observations and blood glucose.
Find their emergency plan and medication if available.
Call 999 for suspected adrenal crisis.
Continue to monitor and reassess until help arrives.
And above all:
Recognise the sick patient in front of you.
Safe, effective and workable first aid delivered by a calm and organised dental team can make an enormous difference while waiting for the emergency services.
Medical Emergencies CPD for Dental Teams
At Sussex First Aid Courses, our dental medical-emergency training is designed around the situations teams may actually face in practice.
We place a strong emphasis on practical scenarios, ABCDE assessment, emergency drugs and equipment, effective team communication and the human factors that influence decision-making when something unexpected happens.
Adrenal insufficiency is a good example of why medical-emergency training needs to go beyond simply practising CPR once a year.
Teams need the confidence to recognise the deteriorating patient, call for appropriate help and provide safe emergency care until the ambulance service arrives.
About the author
Garry Perkins is a former paramedic with more than 35 years' experience in emergency care and the Director and Founder of Sussex First Aid Courses Ltd. He has extensive experience delivering medical-emergency CPD training to dental teams.
Sussex First Aid Courses Ltd 0800 069 9931 info@sussexfirstaidcourses.co.uk. www.sussexfirstaidcourses.co.uk
This article is intended for general professional education and does not replace current BNF, NICE, Resuscitation Council UK or relevant dental clinical guidance, local policies, an individual patient's emergency plan or appropriate practical training.
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