Riding Out the Storm: Sympathetic Storming after Traumatic Brain Injury

Denise M. Lemke

Disclosures

J Neurosci Nurs. 2004;36(1) 

In This Article

Treatment

Treatment of storming is aimed at abating the symptoms and limiting the stress response. The overall goal of medication is to dampen the sympathetic outflow or act as the parasympathetic system. Thus, sedatives, opiate receptor agonists, beta-blockers, and CNS depressants have been used. Unfortunately, these medications can dampen the level of responsiveness in an already minimally responsive individual, making assessment of neurological changes difficult.

Multiple drugs including morphine sulfate, oxycodone, midazolam (Versed), propranolol (Inderal), clonidine (Catapres), chlorpromazine, bromocriptine, dantrolene (Dantrium), atenolol, and labetalol (Normadyne) have shown effectiveness in treating storming (Baguley et al., 1999; Boeve et al., 1998; Bullard, 1987; Cartlidge & Shaw, 1981; Do, Sheen, & Brumfield, 2000; Hackl et al., 1991; Horntagl et al., 1980; Klug et al., 1984; Neil-Dwyer, Cruickshank, & Doshi, 1990; Pranzatelli et al., 1991; Rosner, Newsome & Becker, 1984; Rossitich & Bullard, 1988; Russo & O'Flaherty, 2000; Strum, 2002; Thorley, Wertsch, & Klingbeil, 2001); see Table 2 . Diazepam (Valium), pentobarbital, betamethasone, mannitol, lorazepam (Ativan), baclofen (Lioresal), phenytoin (Dilantin), and droperidol (Inapsine) are additional drugs identified within the literature with varied success (Baguley et al.; Boeve et al.; Horntagl et al.; Pranzatelli et al.; Rossitich & Bullard; Strum; Thorley, Wertsch, & Klingbeil).

A common starting point of treatment, advocated by Horntagl et al. (1980) is a 10-mg dose of IV morphine sulfate in ventilated individuals with an as-needed scheduling or continuous IV drip. While the patient is in the ICU, IV medication may be preferred for quick control of the storming early in the injury. Once the patient's status stabilizes, the enteric route is preferred because it decreases frequency of the medication, reduces cost, and allows for eventual transfer to an acute care ward or long-term-care facility. Therefore, enteric routes should be utilized when possible.

In individuals whose symptoms are difficult to control, a starting point can be a combination of morphine or oxycodone with bromocriptine (Boeve et al., 1998). Morphine and oxycodone are both opiate receptor agonists that suppress sympathetic outflow (Boeve et al.; Strum, 2002). A continuous IV morphine drip or scheduled oxycodone may be indicated if the storming episodes are difficult to regulate. Oxycodone is used over combination medications with acetaminophen to avoid acetaminophen overdose and provide a medication that can be used for breakthrough fever.

Bromocriptine, a dopamine receptor agonist, has been effective in reducing hyperthermia and diaphoresis in individuals during storming (Bullard, 1987; Russo & O'Flaherty, 2000; Thorley, Wertsch, & Klingbeil, 2001; Strum, 2002). There may also be a mild hypotensive effect with the bromocriptine (Russo & O'Flaherty). Russo & O'Flaherty (2000) recommend starting at 0.025 mg/kg twice a day and increasing to 0.05 mg/kg three times a day as needed to control the symptoms.

Propranolol, a beta-blocker, can be added if necessary and is particularly helpful if tachycardia and HTN dominate the episodes. Propranolol suppresses sympathetic outflow, slowing neuronal activity (Bullard, 1987; Strum, 2002). Bradycardia is a common side effect of propranolol, although it generally does not pose a problem with the young TBI population. In the symptomatic individual with severe hypotension or hypotension with syncope, the use of propranolol may need to be reassessed. This may be extremely difficult to assess in the minimally responsive individual, and practitioners may prefer to define a lower blood pressure limit based on their professional comfort level or switch to an alternative agent. Propranolol is also titrated up as status indicates. Clonidine and labetalol are alternatives to propanolol. Clonidine lowers circulating plasma levels of epinephrine and norepinephrine (Boeve et al., 1999; Strum), and labetalol provides alpha 1 and both beta 1 and beta 2 adrenergic receptor blockage (Do, Sheen, & Brumfield, 2000).

Again as previously noted, IM, IV, or oral chlorpromazine can be helpful with severe hyperthermia by rapidly reducing the core temperature (Strum, 2002). The ability to maintain body temperature within a normal range can lessen the severity of the storming or abate the storm. Whenever there is a temperature spike, the individual should be evaluated for potential infection and care needs to be taken that use of acetaminophen and hypothermia blankets to treat the fever do not mask an infection.

If persistent dystonia or posturing is noted, dantrolene can be added. Dantrolene decreases the release of calcium, which interferes with skeletal muscle contraction causing relaxation. There is not a clear CNS response, though drowsiness is a major side effect (Baguley et al., 1999; Strum, 2002).

The individual ends up defining the appropriate drug regime. Frequently it is trial and error before the appropriate medication or combination of medications proves effective. Inability to control the storming episodes can delay transfer to a subacute facility, because many facilities are reluctant to take an individual who requires such a high level of care.

As the storming episodes stabilize, trial withdrawal of medications is recommended, withdrawing one medication at a time by slowly decreasing the dosage of each medication (Boeve et al., 1999; Russo & O'Flaherty, 2000). The stability of the individual may signify return of regulatory control, and medications used to slow neuronal output now can dampen the functional capacity of the individual. As in adding medications, the withdrawal of medications can be challenging.

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