Adrenal hemorrhage, found in about 1% of autopsies, is not rare but is commonly overlooked and often fatal. Severe stress (perhaps mediated by ACTH action), physical trauma, and/or anticoagulant therapy are usually responsible. Abdominal pain from adrenal capsular distension and fever are present, followed by weakness, fatigue, hypotension, and other features of rapidly advancing adrenal insufficiency. In severely traumatized patients, the possibly adrenal origin of these relatively nonspecific manifestations is frequently overlooked antemortem. If adrenal hemorrhage is considered, it is easily diagnosed by ultrasound, CT, or MR imaging and confirmed by fine-needle aspiration, which may even confer therapeutic benefit by reducing intra-adrenal pressure. Low serum Cortisol measurements and subnormal responses to IV cosyntropin (ACTH), preceded by dexamethasone administration to avoid continuing clinical deterioration, indicate adrenal insufficiency. Therapy includes continuous IV hydrocortisone infusion at about 300 mg/day in normal saline, with oral fludrocortisone when vomiting stops and tapering of dosage to maintenance levels as improvement occurs. Because adrenal necrosis is often incomplete at autopsy, adrenocortical regeneration can occur, followed by complete recovery provided that rapid diagnosis and vigorous therapy have been instituted without delay. The importance of considering the possible presence of adrenal hemorrhage in severely stressed, traumatized, and/or anticoagulated patients is obvious.