Treatment of Students with

Adrenal Crisis

This training was created for teachers and staff associated with students
diagnosed with adrenal insufficiency and suffering from an adrenal crisis.

EMS & Trauma Program

Created 3/2016
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 Credits

Thank you to the following people and organizations for

contributing to the creation of this training protocol:

•Oregon Department of Education School Nurse Advisory Group

•Adrenal Insufficiency United

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 Objectives

• Review changes to Oregon Revised Statute and Oregon Administrative Rule

• Identify training requirements
• Explain the requirements for a School Health Management Plan
• Provide general information about adrenal insufficiency and the dangers
associated with adrenal insufficiency.
• Be able to recognize the symptoms of a person who is experiencing adrenal
crisis and common factors that lead to adrenal crisis.
• Provide examples of the types of medications that are available for treating
adrenal crisis.
• Instruct on proper administration of several common medications that treats
adrenal crisis.
• Explain the importance of follow-up treatment.
 

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 State Law
• In 2015 the Oregon legislature amended ORS 433.800 –
433.830 (laws pertaining to the training of lifesaving treatments)
to authorize persons to be trained to administer medication to
students diagnosed with adrenal insufficiency who are suffering
from an adrenal crisis when a licensed health care provider is
not immediately available and whose parent or guardian has
provided the necessary medication and equipment for
administration.

• The Oregon Administrative Rules supporting this law (OAR 333-

055-0000 to 333-055-0035) were amended and adopted by the
Oregon Health Authority (OHA), Public Health Division in
February 2016 to support this training on the treatment of
students with adrenal insufficiency.

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Conducting Training

This training program must be conducted by one of the

following individuals:

•A physician licensed to practice in Oregon; or

•A nurse practitioner licensed to practice in Oregon; or
•A registered nurse licensed in Oregon.

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 Training Recipients
• The training should be provided on behalf of students with a known
diagnosis of adrenal insufficiency that places them at risk for adrenal
crisis.

• The person to be trained must be 18 years of age or older and must

have, or reasonably expect to have, responsibility for or contact with a
student diagnosed with adrenal insufficiency described above.
Individuals who are likely to fall under the definition of the law include
public or private school employees and school volunteers.

• The Oregon Administrative Rule states that school personnel must be

retrained every three years on adrenal crisis, but the OHA recommends
retraining every year to maintain competency.

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 School Health Management Plan

• For children in school, parents or guardians of children with adrenal

insufficiency must notify school personnel of their child’s medical
needs to initiate a health management plan (may be included in a
504 Plan or Individualized Education Plan (IEP)).

• This plan should document agreements among the parents or

guardian, school personnel, and the student's medical provider
about providing a safe and supportive learning environment for the
child with adrenal insufficiency.

• A school nurse, if available, is usually the lead staff for

implementation of a health management plan.

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School Health Management Plan
A School Health Management Plan must include:

•specific actions for school personnel to perform;

•a plan for communicating with parents and the child’s medical providers;
•school policies and procedures for administering medications, including
parental authorization;
•procedures for handling bodily fluids as encountered with vomiting,
injections; and
•an action plan for each child who has adrenal insufficiency, which includes
information about medications, dosage, method of administration and
frequency, procedures to follow during field trips or outings, and how to
handle emergency situations including specific signs and symptoms specific
to the student. The child’s medical provider writes and signs medical orders
to support the child’s health management plan at the school.

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 Adrenal Insufficiency

• Adrenal insufficiency is a chronic medical condition in

which the adrenal glands do not produce enough of the
necessary hormones (cortisol and aldosterone) to
respond to stressors such as illness and injury.

• These hormones help to maintain and regulate key

functions in the body such as blood pressure;
metabolism (how the body uses food for energy); the
immune system; and how the body responds to stress.

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 Adrenal Insufficiency
• Adrenal insufficiency is caused by congenital conditions,
cancers, tumors and many other conditions that affect the
pituitary gland, adrenal gland or other endocrine organs.

• Addison's disease, the common term for primary adrenal

insufficiency, occurs when the adrenal glands are
damaged and cannot produce enough cortisol.

• Much like a diabetic student who needs insulin, a student

with adrenal insufficiency is missing a hormone vital to life
and must take replacement medications on a daily basis.

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 Adrenal Glands

•The adrenal glands are

located on the top of the
kidneys

•The adrenal glands are made

up of two parts, the cortex and
the medulla

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 Daily Medications

There are many medications that a student can be prescribed to treat

adrenal insufficiency.

Solu-Cortef or Hydrocortisone are steroids that naturally occur in the

body and allow the body to metabolize glucose and control vascular
activity to maintain blood pressure. It also controls water and salt
balance within the body.

In order to keep their condition under control, a student is often

required to take a daily, oral dose of hydrocortisone, dexamethasone or
prednisone. The medication prescribed must be taken in the amount
and at the times identified in the student's health management plan.

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Adrenal Insufficiency vs. Adrenal Crisis
Adrenal Insufficiency: Adrenal Crisis:
– Chronic condition – Acute
– Adrenal glands fail – This is an exacerbation of a
to produce specific students adrenal
stress hormones insufficiency which can be
– The student will caused by:
• Illness
take daily
• Injury
medications
• Stress
• Missing daily medications

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 Adrenal Crisis Triggers

• Illnesses such as a cold or the flu

• An injury, such as a twisted ankle or a broken bone

• Exposure to stressful situations; i.e. a fire-drill

• Missing or stopping daily steroid medications

Staff should refer to the School Health Management

Plan for each student that suffers from adrenal
insufficiency and become familiar with what triggers
their adrenal crisis and how it presents.
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Adrenal Crisis
Adrenal crisis is a sudden, severe worsening of
symptoms which may include:
• Severe pain in the lower back, • Red cheeks (not attributed with
abdomen or legs recess or PE class)
• Muscle weakness or cramping • Dizziness
• Trouble focusing • Loss of appetite
• Lethargy • Dark rings under the eyes
• Stomach ache • Changes in emotional
• Nausea and/or vomiting behaviors- student may seem
• Diarrhea upset, angry or more tearful
than normal
• Dehydration
• Fainting or passing out
• Low blood pressure
• Fever (over 100°F)
• Headache

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 Stress Dose
• When a person who does NOT suffer from adrenal
insufficiency suffers significant physical or emotional stress,
they produce up to 10X the normal amount of hormones
needed in response to the event.

• Patients with Adrenal Insufficiency cannot produce these

hormones and must be given an extra dose of medication (on
top of their daily prescribed dose) when their body experiences
physical or emotional stress.

• This is called a “STRESS DOSE.” Depending on the severity

of the event, a stress dose may be given orally or via injection.

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 Stress Dose

• Your student’s School Health Management

Plan will have:
– instructions for oral stress dosing for minor illness or
injury

– instructions for emergency injection for serious illness

or injury.

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 Adrenal Crisis

• Each student is different and will deteriorate differently.

This is related to their age, physical condition and the
specific stress event.

• One third of adrenal crises occur outside of the home.

• Vomiting and diarrhea account for most adrenal crisis

events because it interferes with the absorption of their
daily, prescribed medication.

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Adrenal Crisis

• If your student is unconscious, very lethargic or hard to

keep awake, he/she is at risk of adrenal crisis.

• If your student has suffered a traumatic injury such as

a broken bone, he/she is at risk for adrenal crisis.

• Be sure you have reviewed your student’s School

Health Management Plan for the instructions on when
to give the student an injection.

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 Crisis Medications

When there is suspected adrenal crisis, additional doses of oral

medication may be necessary, or an injectable medication, such
as Solu-Cortef or Solu-Medrol may be required.

Injectable medications are given intra-muscularly, which means

that it is injected into a large muscle, such as the thigh or
buttock.

Remember to consult the student’s School Health Management

Plan for the appropriate medication and administration.

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 Treatment

• WHEN IN DOUBT, INJECT!

– The lack of Cortisol (stress hormone) during adrenal crisis
puts your student at risk of disability and death.

– Even if the student is not in crisis, administering the

medication will not have any adverse effects.

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 Medication Access and Storage

Plans should be in place to assure that medication is readily available

and in close proximity of the student.

Consideration of transportation activities such as field trips or other off

facility functions must be taken into account when planning emergency
measures for possible treatment of adrenal crisis.

Depending on the age of the child and school policies, it may be

advisable for students to carry their own medication during these
special activities and trained personnel must accompany the child.

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 Medication Access and Storage

Oral medication – hydrocortisone tablets should be

stored at room temperature (68°-77°F), fludrocortisone
acetate (Florinef) should be stored at room temperature
(between 59 and 86 degrees) and away from excess heat
and moisture.
 
Injectable medications – Act-o-Vials of Solu-Cortef or
Solu-Medrol should be stored at room temperature (68°-
77°F), in a dry place protected from light. The solution
should only be used if it is clear.

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 Treatment
If you determine that your student is suffering from an
adrenal crisis:
– Instruct someone to call 911 and the student’s parents.
– If the student is still conscious, keep talking to them and
reassure them that you are there to help. Keep them calm.
– Get the injection ready
– Administer the injection and wait with the student until help
arrives.
– The injection will start to take effect in 15 minutes.
– Give the empty vial to the Emergency Medical Responders
when they arrive.

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 Equipment Needed

• Non-sterile gloves
• Medication
• Syringe and injection
needle
• Alcohol swab
• Cotton ball or tissue
• Sharps container

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 Preparing for Administration

1. Assemble medication and check the expiration date.

2. Consider location where medication is to be injected. If the

injection needs to be in the buttock or upper thigh, it will be
necessary for the student to pull down pants or raise a skirt. This
should occur in a private location and steps should be taken to make
the student as comfortable as possible. Consider having a blanket or
curtain. It is recommended that two personnel be present if possible.

3. Wash hands

4. Put on gloves

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 Preparing Medication “Act-o-Vial”
1. Make sure that the medication is clear and not
expired.
2. Press down on the plastic activator (cap) and force
the diluent (liquid) into the lower chamber of
powdered medication. The rubber stopper
separating the two will fall into the lower chamber.
3. Gently mix the solution by turning the vial upside
down several times. DO NOT SHAKE. *The
solution will initially appear cloudy, then clear. If
the solution does not clear, do not administer the
medication to the student and wait for rescue
personnel to arrive.
4. Remove the plastic tab covering the center of the
stopper (small circular disc on the plastic cap).

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 Preparing Medication – Reconstitution
1. Use a 4x4 gauze to snap off the top of the
glass ampule.
2. Use a filter needle to draw up all of the fluid
from the glass ampule.
3. Remove the filter needle from the syringe and
replace it with a regular straight needle.
4. Remove the cap from the vial of powder
medication.
5. Insert the syringe and inject the fluid.
6. Gently mix the solution by turning the vial
upside down several times. DO NOT SHAKE.
*The solution will initially appear cloudy, then
clear. If the solution does not clear, do not
administer the medication to the student and
wait for rescue personnel to arrive.

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 Drawing Up the Medication

1. Wipe the top of the Act-o-Vial or Reconstitution Vial with an alcohol

swab.
2. Take the cap off of the syringe and insert the needle squarely
through the center of the top rubber stopper, just until the tip of the
needle is visible in the vial.
3. Invert the vial and withdraw the required dose.
4. Always be cautious when handling needles.

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 Administering Medications
5. Uncover the area to be injected (upper thigh or buttock).
6. Use an alcohol swab to cleanse the injection site on the skin.
7. Hold the syringe like a dart.

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 Administering Medications

8. Using the thumb and first two fingers, spread the skin while
pushing down lightly.

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 Administering Medications

9. Dart the needle into the injection site, going straight into the tissue
at a 90-degree angle.
10. Depress the syringe plunger, administering the drug into the
student.

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 Administering Medications

11. With draw the syringe quickly and discard into a sharps container.
12. Use a cotton ball or tissue and massage the injection site gently.
13. Clean up and dispose of waste safely.
14. Remove gloves.

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 After Administration of an Injection

• Do not leave the child unattended.

• Advise the 911 dispatcher of the type of medication given.

• Turn the student on his or her side and monitor their

breathing.

• If the student’s condition worsens, advise the 911

dispatchers of the change in status.

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 Scenario #1

• A student with diagnosed adrenal insufficiency suffers a broken

wrist after falling from a jungle gym on a sunny day. She is crying in
pain and states her stomach hurts.

• What would you do?

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 Scenario #1 Answer

• Call 911 and call the student’s parents.

• Reassure the student that you are there to help and keep them calm.

• Retrieve the student’s stress dose of medication and administer the

injection.
• Stay with the student and place them on their side while waiting for
EMS to arrive.
• Monitor the student’s breathing and level of consciousness.

• If the student’s condition changes, alert 911 dispatchers.

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 Scenario #2

• A student with know adrenal insufficiency suffers a skinned knee

while running from a bee. The child complains of pain to the knee,
but is happy that the bee “went away.” The child is alert and has no
other complaints.

• What would you do?

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 Scenario #2 Answer

• The child is not suffering from an adrenal crisis at this time.

• Treat the student for their skinned knee and monitor them.
• If no other symptoms arise, the student is not at risk for adrenal
crisis.

• Notify the student’s parents of what happened so that they can

continue to monitor their child later.

• Attempt to keep the child relaxed throughout the rest of the day, by
not adding any additional stress and by avoiding emotional triggers.

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 Summary
• Students who are diagnosed with adrenal insufficiency
are unable to produce the hormones needed when
responding to specific emotional or physical stressors
such as:
– A broken limb
– A fire drill
– The flu

• Students will need a “STRESS DOSE” of medication

when they are suffering from an adrenal crisis.

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Summary
Adrenal crisis is a sudden, severe worsening of
symptoms which may include:
• Severe pain in the lower back, • Red cheeks (not attributed with
abdomen or legs recess or PE class)
• Muscle weakness or cramping • Loss of appetite
• Trouble focusing • Dark rings under the eyes
• Lethargy • Changes in emotional
• Stomach ache behaviors- student may seem
• Nausea and/or vomiting upset, angry or more tearful
than normal
• Diarrhea
• Fainting or passing out
• Dehydration
• Fever (over 100°F)
• Low blood pressure
• Dizziness
• Headache
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 Summary

Review and be familiar with your student’s School

Health Management Plan for:
– the student’s baseline activity level, attitude and behavior.
– the specific emotional or physical stressors that might
trigger an adrenal crisis.
– the student’s past history with adrenal crisis.
– the medication and administration route that is prescribed
to the student from their physician to use during an
adrenal crisis.

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 Summary

When in doubt,
INJECT the student with their STRESS DOSE!

– The lack of Cortisol (stress hormone) during adrenal crisis

puts your student at risk of disability and death.

– Even if the student is not in crisis, administering the

medication will not have any adverse effects.

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