Tuesday, September 1, 2015

Autonomic storms

Deepika A, Mathew MJ, Kumar SA, Devi BI, Shukla D. Paroxysmal sympathetic
hyperactivity in pediatric traumatic brain injury: A case series of four
patients. Auton Neurosci. 2015 Aug 6. [Epub ahead of print]

Paroxysmal sympathetic hyperactivity (PSH) is a condition in which there is extreme autonomic dysregulation leading to multiple episodes of sympathetic hyperactivity. Its occurrence after traumatic brain injury (TBI) in pediatric population is a neglected scenario. In our series, all pediatric patients with moderate and severe head injuries were studied and those patients who developed PSH were monitored for the PSH episodes. Four children out of 36 cases of pediatric severe traumatic brain injury developed features of PSH. Admission GCS of 3 children were 4/15 and 1 child was 6/15 and each of them had an ICU stay of more than 2weeks and a poor DRS score at discharge. The presence of PSH is known to produce poorer outcome in terms of overall mortality, time needed for recovery, chances of developing infections, etc. which was also seen in these cases presented here. Though some studies have provided guidelines for the management of PSH like symptomatic management and use of drugs like clonidine, bromocriptine, benzodiazepines, and gabapentin, strict management guidelines are not established and exact incidence in pediatric population is not determined.

In this study, two patients were treated with clonidine and two with morphine.

From the paper:
The authors (of a cited study) found that triad of hypertension, diaphoresis, and dystonia best predicted dysautonomia among clinical signs. The following drugs were used for treatment of dysautonomia: benzodiazepines, baclofen, clonidine, betablockers, and other antihypertensives. The children with dysautonomia experienced longer rehabilitation and worse functional outcome.

(In another study) The development of PSH was associated with a longer duration of coma and a higher incidence of death. The drugs that were found useful to suppress PSH episodes in these children were clonazepam, hydroxyzine, and delorazepam. The analgesic drugs showed little efficacy in suppressing PSH

Courtesy of:  http://www.mdlinx.com/neurology/medical-news-article/2015/08/28/paroxysmal-sympathetic-hyperactivity-autonomic-dysregulation-diffuse/6274734/?category=sub-specialty&page_id=1&subspec_id=317


  1. (of a cited study)Kirk KA, Shoykhet M, Jeong JH, Tyler-Kabara EC, Henderson MJ, Bell MJ, Fink EL. Dysautonomia after pediatric brain injury. Dev Med Child Neurol. 2012 Aug;54(8):759-64.



    Dysautonomia after brain injury is a diagnosis based on fever, tachypnea, hypertension, tachycardia, diaphoresis, and/or dystonia. It occurs in 8 to 33% of adults with brain injury and is associated with poor outcome. We hypothesized that children with brain injury with dysautonomia have worse outcomes and prolonged rehabilitation, and sought to determine the prevalence of dysautonomia in children and to characterize its clinical features.


    We developed a database of children (n = 249, 154 males, 95 females; mean [SD] age 11 years 10 months [5 y 7 mo]) with traumatic brain injury, cardiac arrest, stroke, infection of the central nervous system, or brain neoplasm admitted for rehabilitation to The Children's Institute of Pittsburgh between 2002 and 2009. Dysautonomia diagnosis, injury type, clinical signs, length of stay, and Functional Independence Measure for Children (WeeFIM) testing were extracted from medical records, and analysed for differences between groups with and without dysautonomia.


    Dysautonomia occurred in 13% of children with brain injury (95% confidence interval 9.3-18.0%), occurring in 10% after traumatic brain injury and 31% after cardiac arrest. The combination of hypertension, diaphoresis, and dystonia best predicted a diagnosis of dysautonomia (area under the curve = 0.92). Children with dysautonomia had longer stays, worse WeeFIM scores, and improved less on the score's motor component (all p ≤ 0.001).


    Dysautonomia is common in children with brain injury and is associated with prolonged rehabilitation. Prospective study and standardized diagnostic approaches are needed to maximize outcomes.

  2. (in another study)Pozzi M, Conti V, Locatelli F, Galbiati S, Radice S, Citerio G, Clementi E, Strazzer S. Paroxysmal Sympathetic Hyperactivity in Pediatric Rehabilitation: Clinical Factors and Acute Pharmacological Management. J Head Trauma Rehabil. 2014 Oct 13. [Epub ahead of print]



    Paroxysmal sympathetic hyperactivity (PSH) is widely described as occurring during intensive care, but in a number of patients it may last longer into the rehabilitation phase. Furthermore, drug therapy has been based on isolated observations. In this study, our aims are to describe a group of 26 pediatric rehabilitation patients with PSH and to quantify the effect of several drugs used to suppress PSH episodes.


    Neurorehabilitation unit of IRCCS Eugenio Medea, Bosisio Parini (LC), Italy.


    A total of 407 pediatric patients with postacute acquired brain injury, 26 of which had PSH.


    Retrospective cohort study.


    Descriptive demographic and clinical data. Odds ratios quantification of the efficacy of drug therapies administered acutely to suppress PSH episodes.


    PSH was associated with a longer duration of coma and a greater incidence of death. When administered acutely to suppress PSH episodes, the best drugs were clonazepam, hydroxyzine, and delorazepam, while analgesic drugs showed little efficacy.


    PSH, whether causative or not, is associated with a worse long-term course in rehabilitation. Clinical management of PSH may be helped by a number of acutely administered drug therapies.