From the Research
Treatment of paroxysmal sympathetic hyperactivity (PSH) in the setting of a brain bleed requires a multimodal approach targeting both symptoms and underlying mechanisms, with first-line treatment typically including beta-blockers such as propranolol (20-60 mg every 6 hours) or labetalol (100-300 mg every 6-8 hours) to control tachycardia and hypertension, as supported by the most recent study 1.
Key Considerations
- The goal of treatment is to prevent secondary brain injury from sympathetic storms, which can worsen outcomes through increased intracranial pressure and metabolic demands.
- A combination of medications from different classes seems to be the most effective approach in managing PSH symptoms, as noted in 2 and 3.
- Gabapentin (300-400 mg three times daily) or pregabalin (75-150 mg twice daily) are effective for managing the sympathetic surge, and opioids like morphine (2-4 mg IV every 4 hours as needed) or fentanyl can help reduce sympathetic outflow in severe cases.
- Benzodiazepines such as diazepam (5-10 mg every 6-8 hours) or midazolam may be added for additional symptom control, and dexmedetomidine (0.2-0.7 mcg/kg/hr) is useful in ICU settings for its sympatholytic effects.
Treatment Approach
- Treatment should be initiated promptly and titrated based on symptom control, with careful monitoring of vital signs and neurological status.
- Environmental modifications like minimizing stimulation and maintaining a quiet setting are important adjuncts to pharmacological management.
- The use of rectal propranolol, as described in 4, may be considered as an alternative route of administration when oral intake is contraindicated.
Important Medications
- Propranolol: 20-60 mg every 6 hours
- Labetalol: 100-300 mg every 6-8 hours
- Gabapentin: 300-400 mg three times daily
- Pregabalin: 75-150 mg twice daily
- Morphine: 2-4 mg IV every 4 hours as needed
- Fentanyl: as needed for severe cases
- Diazepam: 5-10 mg every 6-8 hours
- Midazolam: as needed for additional symptom control
- Dexmedetomidine: 0.2-0.7 mcg/kg/hr in ICU settings