What are the symptoms and management of a catecholamine surge?

Symptoms of Catecholamine Surge

A catecholamine surge presents with the classic triad of severe headache, palpitations, and profuse sweating, accompanied by marked hypertension (often >180/120 mmHg), tachycardia, pallor, and piloerection ("cold sweat"). 1, 2

Cardinal Clinical Features

Classic Triad (90% Specificity When Episodic)

• Severe headache - often described as pounding or throbbing 1, 2
• Palpitations - with sinus tachycardia being the most common rhythm abnormality 3
• Profuse sweating (diaphoresis) - characteristically described as "cold sweat" with pallor and piloerection 1, 2

Cardiovascular Manifestations

• Severe hypertension - systolic blood pressure often exceeding 220 mmHg, with approximately 95% of patients presenting with elevated blood pressure 1, 2
• Paroxysmal hypertension - occurs in 50% of cases, while the other 50% have sustained hypertension 2
• Extreme blood pressure variability - in severe cases (pheochromocytoma crisis), systolic BP can oscillate between 30-300 mmHg at 20-30 minute intervals 4
• Tachycardia and cardiac arrhythmias - ranging from sinus tachycardia to life-threatening ventricular arrhythmias 3
• Chest pain - may mimic acute coronary syndrome with ST segment changes and elevated troponin 4

Autonomic and Neurological Symptoms

• Tremor and anxiety - due to excessive adrenergic stimulation 5
• Pallor - from peripheral vasoconstriction 1
• Mydriasis (pupillary dilation) - from sympathetic activation 1
• Altered mental status - in severe cases, can progress to decreased consciousness and encephalopathy 4

Metabolic Manifestations

• Hyperglycemia - from catecholamine-induced insulin resistance and increased gluconeogenesis 6
• Hyperthermia - particularly in pheochromocytoma multisystem crisis 4

Severe Presentations: Catecholamine Crisis

Life-Threatening Features

• Hypertensive emergency - blood pressure ≥180/120 mmHg with target organ damage 7
• Cardiogenic shock - paradoxically, some patients present with hypotension or shock rather than hypertension 1, 3
• Takotsubo (stress-induced) cardiomyopathy - acute transient left ventricular dysfunction with apical ballooning, particularly in postmenopausal women 1
• Acute pulmonary edema - from acute left ventricular failure 1
• Multiple organ dysfunction - in pheochromocytoma multisystem crisis, characterized by high fever, severe BP variability, and encephalopathy 4

Cardiac Complications

• Acute myocardial infarction - from catecholamine-induced coronary vasospasm or direct myocardial injury 1
• Ventricular arrhythmias - including ventricular tachycardia and fibrillation 3
• Cardiomyopathy - both dilated and hypertrophic forms can occur 3
• Sudden cardiac death - though relatively uncommon, can occur from severe arrhythmias 1

Important Clinical Pitfalls

Diagnostic Challenges

• Mimics acute coronary syndrome - chest pain with ECG changes (ST depression, QT prolongation, T wave inversion) and elevated cardiac biomarkers may occur without actual coronary occlusion 1, 4
• Orthostatic hypotension - can occur paradoxically in epinephrine-predominant tumors despite overall catecholamine excess 1
• Absence of all classic symptoms - not all patients present with the complete triad; some may have only hypertension and tachycardia 1

Context-Specific Presentations

• Perioperative crises - can be triggered by anesthetic induction (fentanyl, propofol, rocuronium) even before surgical manipulation 8
• Drug-induced exacerbation - beta-blocker monotherapy can precipitate unopposed alpha-stimulation causing paradoxical severe hypertension 1, 5
• Tumor manipulation - abdominal palpation or procedures can trigger massive catecholamine release 9

Management Priorities

Immediate Treatment of Catecholamine Crisis

• Alpha-adrenergic blockade is mandatory - phentolamine 5-15 mg IV bolus for acute hypertensive crisis, with onset in 1-2 minutes 1
• Never use beta-blockers first - this is the most critical error that can precipitate hypertensive crisis from unopposed alpha-stimulation 5
• Short-acting agents for BP control - use direct-acting sympathomimetics (phenylephrine, norepinephrine) or short-acting drugs (esmolol, nitroprusside) for fluctuating blood pressure 1
• Avoid indirect agents - dopamine may overshoot desired effect due to metabolism to epinephrine and norepinephrine 1
• Aggressive fluid resuscitation - high-dose IV fluids (1-2 liters) are essential as patients are typically volume depleted 5, 4

Supportive Measures

• Benzodiazepines for agitation - help control sympathetic hyperactivity and reduce catecholamine release 1
• Cooling measures for hyperthermia - antipyretics are typically ineffective as fever results from muscle hyperactivity, not hypothalamic dysregulation 1
• Avoid epinephrine - can cause paradoxical reduction in blood pressure in catecholamine excess states 10