Weathering the Storms
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The paroxysms have stopped, but the patient likely has residual dystonia and spasticity, with amounts varying from patient to patient. There is little known about what causes the sympathetic system to become hyperactive, but a number of theories have been proposed.
Perkes, Baguley, Nott, and Menon noted three in particular. The first related to assumptions that the brainstem excitatory centers no longer have cortical control over them, resulting in a hypersympathetic state. The third theory relates to an association between afferent stimuli information from the body to the brain and the sympathetic hyperactivity. Some evidence, has shown that the afferent stimuli theory has the most traction. Regardless of whether the mechanisms are known or unknown today, there is ample reason to focus on treatment of PSH.
The main reason is that without treatment, there is potential for increased morbidity as a result of PSH. Hyperthermia that could result in secondary brain injury is one such concern. Another concern is decerebrate or decorticate posturing.
Weathering the Storms
Lemke noted a variety of secondary concerns that can lead to increased morbidity. There can be increased secondary brain injury due to decreases in cerebral tissue oxygenation. Hypertension can also impact secondary injury due to risk of bleeds as well as cardiac arrhythmias resulting from storming that can lead to long-term cardiac dysfunction. Increased metabolic activity can lead to increased blood sugar levels and core temperatures, potentially resulting in muscle waste and weight loss, and kidney dysfunction among others. The treatment and management of PSH to date has been pharmacologically based, with the most common drugs being those that depress the central nervous system, and therefore suppress the sympathetic nervous system Lemke, Common medications include morphine, fentanyl, and midazolam.
Intrathecal Baclofen has been successful while limiting the sedating effects of some other medications reported in Lemke, In addition, other medications are used to target specific symptoms, and Lemke has an excellent overview of medication use and their actions to treat PSH. Treatment and a better understanding of the pathophysiology are two areas that are in need of further research.
Better understanding of the mechanisms of PSH will help to guide better treatment, if not prevention. More precise treatment protocols will also assist with ensuring that long term comorbidities are prevented. As the adage goes, a brain injury often happens to the whole family, and not just the individual with the injury, because of the often enduring and lifelong changes that occur to both the individual and their family and social network.
Weathering the Storm: Hurricanes and Birth Outcomes
To that end, education of the family regarding PSH is extremely important. As Lemke notes, it can also be beneficial to the family, in that active involvement can reduce feelings of helplessness in dealing with their loved ones injury. Baguley, IJ. Mayo Clinic Proceedings; Gabapentin in the management of dysautonomia following severe traumatic brain injury: a case series. Journal of Neurology Neurosurgery and Psychiatry; 78; Dysautonomia after brain injury: a forgotten syndrome?
Journal of Neurology Neurosurgery and Psychiatry; 67; Journal of Neurology Neurosurgery and Psychiatry; 69; Kishner, S and Lorenzo, CT. Post head injury autonomic complications. Lemke Riding out the storm: sympathetic storming after traumatic brain injury. Journal of Neuroscience Nursing; 36 1. Sympathetic storming after severe traumatic brain injury. Critical Care Nurse; 27; Prolonged paroxysmal sympathetic storming associated with spontaneous subarachnoid hemorrhage. Case Reports in Medicine; article ID McCorry, LK Physiology of the autonomic nervous system.
American Journal of Pharmaceutical Education ; 71; A review of paroxysmal sympathetic hyperactivity after acquired brain injury. Annals of Neurology; 68; Rabinstein, AA Paroxysmal sympathetic hyperactivity in the neurological intensive care unit. Neurological Research; 29; At Rainbow Rehabilitation Centers, Inc. When you become an employee at Rainbow or one of its affiliates, you can take advantage of a variety of great benefits for you and your family if eligible, including:.
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Weathering Storms - WHYY
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Storming, What’s in a name?
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