Riding Out the Storm: Sympathetic Storming after Traumatic Brain Injury

Denise M. Lemke


J Neurosci Nurs. 2004;36(1) 

In This Article


The diagnosis actually becomes apparent within the clinical arena. Nursing clinical evaluation, most often over time, reveals the diagnosis. The nurse provides the most reliable data for diagnosis because the nurse monitors the individual over an extended period of time. Interpretation of this information leads to diagnosis and can provide clues into potential triggers of the episodes as well as effective treatment. Triggers are defined as anything that produces a storming episode, including simple nursing activities such as suctioning, turning, or bathing the individual. The ability to identify what triggers an episode can lead the nurse to pretreat the individual to abate or lessen the intensity of the storm.

Strum (2002) made the diagnosis on the presence of spontaneous episodic tachycardia, hyperthermia and HTN, whereas Baguley et al. (1999) thought that an individual needed to exhibit five of seven of the clinical features (tachycardia, tachypnea, hyperthermia, hypertension, dystonia, posturing, and diaphoresis) for the diagnosis. Horntagl et al. (1980) based the diagnosis of storming solely on the ability of intravenous (IV) morphine to abate the episode because morphine is a potent opiate and suppresses sympathetic activity.

Epinephrine, catecholamine, and thyroid studies can be performed to document the sympathetic surge, although they are costly and do not change treatment (Hackl et al., 1991; Hortnagl et al., 1980; Neil-Dwyer, Cruickshank, & Doshi, 1990; Rosner, Newsome, & Becker, 1984). Radiographics, such as CT or MRI of the brain, may rule out or define changes in injury but, as previously noted, do not make the diagnosis.

Acute hyperthermia in the individual with TBI requires a fever workup. Evaluation includes blood, urine, and sputum cultures; cultures of invasive lines (arterial, ventriculostomy, and venous); chest X ray; and, as clinically indicated, lower extremity Dopplers. A positive fever workup does not negate the possibility that the individual is storming and the fever may actually be a trigger.

Additional differential diagnoses that need to be considered beyond infection are seizures, new or expanding intracranial hemorrhage or edema, pulmonary emboli, hypoxia, thyroid storm, deep vein thrombosis, myocardial infarction (MI), alcohol or drug withdrawal, pain, or anxiety. Any of these above scenarios can have a similar clinical presentation, and careful assessment of the individual can assist in differentiating the diagnosis ( Table 1 ). Assessment of changes that need to be considered are quality and quantity of sputum, chest X ray, breath sounds, pain status, laboratory values (chemistry panel, thyroid panel, white blood cell count), 12-lead electrocardiogram (ECG), and cardiac enzymes to rule out MI, as well as history of alcohol or drug abuse to eliminate withdrawal as the etiology of the symptoms (Strum, 2002; Thorley, Wertsch, & Klingbeil, 2001). Workup should be directed at the specific suspected etiology.

Increases in ICP can be seen during the episode or an aftermath of the episode and need to be treated per ICU guidelines (Hackl et al., 1991; Hortnagl et al., 1980; Klug et al., 1984). There are differing opinions on whether elevation of ICP can be a trigger of the episodes or is just a consequence of the storm (Hackl et al.; Hortnag et al.; Klug et al.).


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