What is the prognosis of sympathetic storming in pediatric patients with Traumatic Brain Injury (TBI) in the Intensive Care Unit (ICU)?

From the Guidelines

Sympathetic storms in pediatric TBI ICU patients generally indicate a poor prognosis, as they reflect severe brain injury with autonomic dysregulation. These paroxysmal episodes of hypertension, tachycardia, hyperthermia, tachypnea, posturing, and diaphoresis typically occur within the first week after injury and correlate with worse outcomes, including higher mortality and increased risk of long-term neurological deficits. Management should focus on a multimodal approach using beta-blockers (propranolol 0.5-1 mg/kg/day divided q6h), alpha-2 agonists (clonidine 0.1-0.3 mg/dose q6h), and GABA-ergic agents (baclofen 5-10 mg q8h) as supported by the most recent evidence 1. Opioids like morphine (0.05-0.1 mg/kg/dose q2-4h) may help control symptoms, while maintaining neuroprotective measures including ICP monitoring, temperature control, and seizure prophylaxis. Early recognition and aggressive treatment of sympathetic storms are crucial, as uncontrolled episodes can exacerbate secondary brain injury through increased metabolic demands and cerebral blood flow. Regular neurological assessments and EEG monitoring should continue throughout treatment to distinguish storms from seizures or other complications. While some children may recover with appropriate management, the presence of sympathetic storms often signals diffuse axonal injury and brainstem involvement, which are associated with prolonged recovery and rehabilitation needs.

Key considerations in the management of sympathetic storms in pediatric TBI patients include:

• Early recognition and aggressive treatment to prevent exacerbation of secondary brain injury
• Multimodal approach to management, including beta-blockers, alpha-2 agonists, and GABA-ergic agents
• Maintenance of neuroprotective measures, including ICP monitoring, temperature control, and seizure prophylaxis
• Regular neurological assessments and EEG monitoring to distinguish storms from seizures or other complications
• Consideration of the potential for prolonged recovery and rehabilitation needs in patients with sympathetic storms.

The use of beta-blockers, such as propranolol, has been supported by recent evidence 1 as a potential therapeutic option for reducing mortality after TBI, although the quality of evidence is very low and the recommendation is conditional. The most recent and highest quality study on this topic is from 2024 1, which provides guidance on the management of pediatric mild traumatic brain injury.

In terms of prognosis, the presence of sympathetic storms in pediatric TBI patients is associated with a poor outcome, including higher mortality and increased risk of long-term neurological deficits. However, with appropriate management, some children may recover and have a better prognosis. The prognosis is influenced by various factors, including the severity of the injury, the presence of diffuse axonal injury and brainstem involvement, and the effectiveness of treatment.

Overall, the management of sympathetic storms in pediatric TBI patients requires a comprehensive and multimodal approach, with a focus on early recognition, aggressive treatment, and maintenance of neuroprotective measures.

From the Research

Prognosis of Sympathetic Storming in Pediatric Patients with TBI

• The prognosis of sympathetic storming, also known as Paroxysmal Sympathetic Hyperactivity (PSH), in pediatric patients with Traumatic Brain Injury (TBI) is generally poor 2, 3.
• PSH is characterized by recurrent episodes of sympathetic hyperactivity, including tachycardia, systolic hypertension, hyperthermia, tachypnea, and diaphoresis 2.
• The presence of PSH in pediatric TBI patients is associated with increased mortality, longer recovery times, and a higher risk of developing infections 3.
• Studies have shown that the use of certain medications, such as propranolol, may help reduce the severity of PSH and improve outcomes in TBI patients 4.
• However, the exact incidence of PSH in pediatric TBI patients is not well established, and strict management guidelines have not been developed 3.

Clinical Manifestations and Management

• The clinical manifestations of PSH in pediatric TBI patients include tachycardia, hypertension, tachypnea, and hyperthermia 2, 3.
• Management of PSH in pediatric TBI patients typically involves symptomatic treatment and the use of medications such as clonidine, bromocriptine, benzodiazepines, and gabapentin 3.
• Early recognition and treatment of PSH are critical to improving outcomes in pediatric TBI patients 4.

Outcome and Recovery

• The outcome and recovery of pediatric TBI patients with PSH are generally poor, with a high risk of long-term disability and mortality 5, 3.
• Studies have shown that the use of propranolol in the early stages of TBI may improve outcomes and reduce the severity of PSH 4.
• However, further research is needed to fully understand the prognosis and management of PSH in pediatric TBI patients 2, 3.