PEM Pearls: Hydrocortisone stress-dosing in adrenal insufficiency for children

During your shifts in the pediatric ED, you may encounter a few patients with adrenal insufficiency or adrenal crisis. Some of the most common causes include those patients with Addison disease, pituitary hypothalamic pathology, and those patients on chronic steroids. When these patients get sick or sustain trauma, it is important to consider giving them a stress dose of hydrocortisone. Patients in adrenal insufficiency or crisis can present with dehydration, weakness, nausea, vomiting, confusion, lethargy, and severe hypotension refractory to vasopressors. ^1–3

Commonly, the recommended dose of hydrocortisone is 50 mg/m2. Measuring the m2 is a reflection of the Body Surface Area (BSA), which in the acute setting, such as the emergency department, it can be difficult to calculate.

Dr. Sonny Tat (UCSF Assistant Professor of EM and Pediatrics) remembers it by thinking about the loose change in his pocket. The Coin Mnemonic which allows you to quickly estimate the initial stress dose of hydrocortisone. Check out the 2-minute Trick of the Trade video, if you are a visual learner.

Animated Video on Hydrocortisone Stress-Dosing (Trick of the Trade)

For small-sized kids (neonates to 3 years old), give 25 mg IV/IM (or think of a quarter)
For medium-sized kids (3-12 years old), give 50 mg IV/IM (or think of a half-dollar)
For large-sized kids (12+ years old), give 100 mg IV/IM (or think of a dollar coin).

For further detail, you can also check out CHOP’s algorithm for treating pediatric patients in adrenal crisis.

Kefer MP. Adrenal Insufficiency and Adrenal Crisis. In: Tintinalli’s Emergency Medicine Manual. 7th ed. McGraw Hill Professional; 2012:641-644.

Clinical Practice Guidelines : Adrenal crisis and acute adrenal insufficiency. The Royal Children’s Hospital Melbourne. http://www.rch.org.au/clinicalguide/guideline_index/Adrenal_crisis_and_Acute_adrenal_insufficiency/. Published March 2016.

Steroid Stress Dosing and Weaning – Clinical Pathway: Emergency, ICU, Inpatient and Outpatient Specialty Care. Children’s Hospital of Philidelphia. http://www.chop.edu/clinical-pathway/steroid-stress-dosing-and-weaning-clinical-pathway. Published September 2014.