There is a normal bodily response to severe injury called the ‘sympathetic response’ that produces increased heart rate, increased respiratory rate, sweating, and elevated blood pressure. Up to one third of patients with severe traumatic brain injuries suffer from an exaggerated ‘sympathetic response’ some times referred to as ‘Sympathetic Storming’. Patients with sympathetic storming have episodes of increased heart rates over 150 beats per minute, systolic blood pressures over 170 mmHg, severe sweating, increased respiratory rates over thirty breaths per minutes, elevate temperature, diffuse tremors, and rigid posturing.
It is unknown what triggers sympathetic storming episodes but it is believed to be caused by noxious stimuli from muscle spasms and pain. External triggers are thought to contribute to sympathetic storming such as loud environmental noises, routine nursing care such as positional changes to prevent bedsores, and tracheal suctioning. Patients with sympathetic storming from traumatic brain injury or anoxic brain injury have a less favorable long-term neurological outcome than those without.
Untreated sympathetic storming produce excessive weight loss, immune suppression, and secondary brain damage from elevated temperatures, and potential for cardiac damage and arrhythmias. Half of all patients with sympathetic storming continue to be symptomatic and require active medical treatments after transfer to a rehabilitation facility.
Treatments include environmental measures to provide a cool and quiet environment of care to decrease external triggers. Medication management is required to treat the symptoms and signs of sympathetic storming and to prevent complications. Intensive Care Units manage sympathetic storming with intravenous morphine because it will suppress the overactive sympathetic nervous system and provides necessary pain relief if there are associated injuries that may potentially be the trigger source.
Elevated temperature is a consequence of sympathetic storming and potentially may cause secondary brain injury leading to adverse outcomes. Bromocriptine is used to decrease temperature. Elevated heart rates and blood pressures are controlled with the common blood pressure medications propranolol and clonidine. Baclofen has been proven to be effective in sympathetic storming and its mechanism may be related to decreasing painful muscle spasm that may be the trigger source. Some Level 1 Trauma Centers are using an implantable pump to deliver baclofen into the cerebral spinal fluid of the spine (intrathecal baclofen pump) to control difficult to manage sympathetic storming.
Early education of the family members is necessary so they understand that sympathetic storming is not an unexpected medical ‘set back’ but represents an anticipated consequence of a severe traumatic brain injury. With education, family members will be empowered to assist in the management of sympathetic storming by identifying environmental triggers, and by proactively providing a comfortable environment of care with music, massage, and quiet reading.
Nutrition management in patients with sympathetic storming is imperative since there is potentially a three-fold increase in caloric demands caused by the condition. Meeting the nutritional burden of the patient is complicated by the effect of sympathetic storming on the digestive system that decreases bowel activity. It is not uncommon that the nutritional demand cannot be met despite continuous feeding per gastric tube that it becomes medically necessary for supplemental nutrition by vein to meet the patient’s nutritional requirements. It is not uncommon for patients with sympathetic storming to be transferred to rehabilitation hospitals severely malnourished with profound weight loss.
Case managers must understand that the long-term outcomes associated with severe traumatic brain injured patients with sympathetic storming are generally poor. These patients must be transferred to a Traumatic Brain Injury Model System Hospital. At these specialized treatment facilities medications used for sympathetic storming should be weaned, nutrition must be optimized, and severe spasticity be treated.
Long-term proactive case management is necessary to execute the Academic Physician Life Care Plan. Complications are inevitably in this patient population and it is imperative that the case manager communicates with the patient’s medical providers in a timely fashion to prevent adverse outcomes.
