Riding Out the Storm: Sympathetic Storming after Traumatic Brain Injury

Denise M. Lemke

Disclosures

J Neurosci Nurs. 2004;36(1) 

In This Article

Clinical Presentation

Wilson's (1923) description of "fits" elicits a image of an uncontrolled response and others have continued to use this concept in defining the phenomenon with similar terms that describe the loss of control and the unpredictability of the episodes. Clinical presentation of storming includes alterations in level of consciousness, increased posturing, dystonia, hypertension, hyperthermia, tachycardia, tachypnea, diaphoresis, arrhythmias (atrial fibrillation, supraventricular tachycardia, bradycardia, atrioventricular dissociation, nodal rhythms, and preventricular/atrial beats), and agitation (Baguley et al., 1999; Boeve et al., 1998; Cartlidge & Shaw, 1981; Hackl et al., 1991; Horntagl et al., 1980; Klug et al., 1984; Neil-Dwyer, Cruickshank, & Doshi, 1990; Pranzatelli et al., 1991; Rosner et al., 1984; Rossitich & Bullard, 1988; Strum, 2002; Thorley, Wertsch, & Klingbeil, 2001). Symptoms, duration, and intensity vary from individual to individual and from episode to episode. These individuals generally are at a low level of neurological activity with minimal alertness, minimal awareness, and reflexive motor responses to stimulation and the storming can take a seemingly peaceful individual into a state of chaos.

The storming may occur as early as within the first 24 hours after injury, although frequently is delayed until the patient is transferred from the intensive care unit (ICU; Boeve et al., 1998; Cartlidge & Shaw, 1981; Hackl et al., 1991; Hortnag et al., 1980; Klug et al., 1984; Neil-Dwyer, Cruickshank, & Doshi, 1990; Pranzatelli et al., 1991; Rosner, et al., 1984; Rossitich & Bullard, 1988; Russo & O'Flaherty, 2000; Strum, 2002; Thorley, Wertsch, & Klingbeil, 2001). The delay in clinical presentation may be related to the use of paralytic agents, sedatives, and narcotics in the treatment of increased intracranial pressure (ICP) (Russo & O'Flaherty, 2000). These treatments effectively manage storming early in the injury and it is only when status stabilizes and medications are withdrawn that the clinical symptoms may appear.

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