Post Head Injury Autonomic Complications Medication
- Author: Stephen Kishner, MD, MHA; Chief Editor: Consuelo T Lorenzo, MD more...
Medication Summary
Because a wide array of neurotransmitters are involved in the pathways of autonomic control, a wide array of medications exert an influence on this system.[3, 8, 9, 10]
The effectiveness of chlorpromazine and bromocriptine (a dopamine antagonist and a dopamine agonist, respectively) in the treatment of ADS illustrates the complexity of the neurotransmitter regulation pathways and the variability of the lesions that can cause the syndrome.
Propranolol, a lipophilic beta blocker, has successfully been used to control ADS.[11] Beta blockade has been shown to decrease hypertension and hemodynamic abnormalities. Beta blockade does not alter diaphoresis, which is mediated via sympathetic cholinergic neurons. As with all beta blockers, use caution when using in patients with diabetes and asthma.
Clonidine has been effective in normalizing plasma epinephrine and in reducing plasma norepinephrine levels, effectively decreasing blood pressure. Alpha-adrenergic and beta-adrenergic blockers prevent electrocardiographic changes and cardiac arrhythmias associated with TBI. However, clonidine is known to cause sedation.
Bromocriptine has been used to help combat the hyperthermia and diaphoresis that occur with ADS.[12, 13]
Dantrolene has been a useful treatment for extensor posturing but has shown minimal effect against other components of ADS.[12]
Morphine has been effective in abolishing ADS, as has naltrexone. Gabapentin has been found to be effective in controlling the autonomic symptoms and the dystonic posturing of ADS.[10]
Beta blockers
Class Summary
May block effect of vasodilators, decreasing platelet adhesiveness and aggregation, stabilizing the membrane, and increasing the release of oxygen to tissues.
Propranolol (Inderal)
Beta blockers oppose the multisystemic effects of excessive adrenergic tone.
Dopamine agonists
Class Summary
Inhibit noxious input to spinal cord.
Bromocriptine (Parlodel)
Central dopamine excess and central dopamine insufficiency are viewed as contributing to dysregulation of autonomic pathways. Agonists or antagonists may be helpful in treating ADS.
Chlorpromazine (Thorazine)
Mechanisms include blocking postsynaptic mesolimbic dopamine receptors, anticholinergic effects, and depression of RAS. Blocks alpha-adrenergic receptors and depresses release of hypophyseal and hypothalamic hormones. As a rule, however, dopamine antagonists are avoided in patients with TBI
Muscle relaxants
Class Summary
Modulate muscle contractions.
Dantrolene (Dantrium)
Stimulates muscle relaxation by modulating skeletal muscle contractions at a site beyond the myoneural junction and by acting directly on muscle itself. Most patients respond to 400 mg/d or less.
Opioids
Class Summary
Pain control is essential to quality patient care. Analgesics such as opioids ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or injuries.
Morphine (Duramorph, Astramorph, MS Contin, MSIR, Oramorph)
Opioid receptor system is involved in the regulation of central autonomic pathways. ADS has been found to be responsive to narcotics. As a rule, however, narcotics and other sedating medications are avoided in patients with TBI.
Naltrexone (ReVia)
Cyclopropyl derivative of oxymorphone that acts as a competitive antagonist at opioid receptors. ADS has been found to be responsive to naltrexone.
Anticonvulsants
Class Summary
These agents terminate clinical and electrical seizure activity of the brain.
Gabapentin (Neurontin)
Membrane stabilizer, a structural analogue of inhibitory neurotransmitter gamma-amino butyric acid (GABA), which paradoxically is thought not to exert effect on GABA receptors. Appears to exert action via the alpha(2)delta1 and alpha(2)delta2 auxiliary subunits of voltage-gaited calcium channels.
Baguley IJ, Heriseanu RE, Cameron ID, et al. A critical review of the pathophysiology of dysautonomia following traumatic brain injury. Neurocrit Care. 2008;8(2):293-300. [Medline].
Baguley IJ. The excitatory:inhibitory ratio model (EIR model): An integrative explanation of acute autonomic overactivity syndromes. Med Hypotheses. 2008;70(1):26-35. [Medline].
Srinivasan S, Lim CC, Thirugnanam U. Paroxysmal autonomic instability with dystonia. Clin Auton Res. Dec 2007;17(6):378-81. [Medline].
Blackman JA, Patrick PD, Buck ML, et al. Paroxysmal autonomic instability with dystonia after brain injury. Arch Neurol. Mar 2004;61(3):321-8. [Medline]. [Full Text].
Rabinstein AA. Paroxysmal sympathetic hyperactivity in the neurological intensive care unit. Neurol Res. Oct 2007;29(7):680-2. [Medline].
Baguley IJ, Nicholls JL, Felmingham KL. Dysautonomia after traumatic brain injury: a forgotten syndrome?. J Neurol Neurosurg Psychiatry. Jul 1999;67(1):39-43. [Medline]. [Full Text].
De Tanti A, Gasperini G, Rossini M. Paroxysmal episodic hypothalamic instability with hypothermia after traumatic brain injury. Brain Inj. Dec 20 2005;19(14):1277-83. [Medline].
Baguley IJ, Cameron ID, Green AM, et al. Pharmacological management of dysautonomia following traumatic brain injury. Brain Inj. May 2004;18(5):409-17. [Medline].
Becker R, Benes L, Sure U, et al. Intrathecal baclofen alleviates autonomic dysfunction in severe brain injury. J Clin Neurosci. Jul 2000;7(4):316-9. [Medline].
Baguley IJ, Heriseanu RE, Gurka JA, et al. Gabapentin in the management of dysautonomia following severe traumatic brain injury: a case series. J Neurol Neurosurg Psychiatry. May 2007;78(5):539-41. [Medline].
Chiolero RL, Breitenstein E, Thorin D. Effects of propranolol on resting metabolic rate after severe head injury. Crit Care Med. Apr 1989;17(4):328-34. [Medline].
Rossitch E, Bullard DE. The autonomic dysfunction syndrome: aetiology and treatment. Br J Neurosurg. 1988;2(4):471-8. [Medline].
Russo RN, O'Flaherty S. Bromocriptine for the management of autonomic dysfunction after severe traumatic brain injury. J Paediatr Child Health. Jun 2000;36(3):283-5. [Medline].
Baguley IJ, Slewa-Younan S, Heriseanu RE, et al. The incidence of dysautonomia and its relationship with autonomic arousal following traumatic brain injury. Brain Inj. Oct 2007;21(11):1175-81. [Medline].
Baguley IJ. Nomenclature of "paroxysmal sympathetic storms". Mayo Clin Proc. Jan 1999;74(1):105. [Medline].
Boeve BF, Wijdicks EF, Benarroch EE. Paroxysmal sympathetic storms ("diencephalic seizures") after severe diffuse axonal head injury. Mayo Clin Proc. Feb 1998;73(2):148-52. [Medline].
Cheshire WP, Freeman R. Disorders of sweating. Semin Neurol. Dec 2003;23(4):399-406. [Medline].
Clifton GL, Robertson CS, Kyper K. Cardiovascular response to severe head injury. J Neurosurg. Sep 1983;59(3):447-54. [Medline].
Clifton GL, Ziegler MG, Grossman RG. Circulating catecholamines and sympathetic activity after head injury. Neurosurgery. Jan 1981;8(1):10-4. [Medline].
Fernández-Ortega JF, Prieto-Palomino MA, Muñoz-López A, et al. [Dysautonomic seizures in patients admitted to an intensive care unit following severe traumatic brain injury]. Rev Neurol. Oct 16-31 2004;39(8):715-8. [Medline].
Hamill RW, Woolf PD, McDonald JV. Catecholamines predict outcome in traumatic brain injury. Ann Neurol. May 1987;21(5):438-43. [Medline].
Horn LJ, Sherer M. Rehabilitation of traumatic brain injury. In: Grabois M, Garrison SJ, Hart KA, et al, eds. Physical Medicine and Rehabilitation: The Complete Approach. Malden, Mass: Blackwell Science; 2000:1290-1.
Meythaler JM, Stinson AM. Fever of central origin in traumatic brain injury controlled with propranolol. Arch Phys Med Rehabil. Jul 1994;75(7):816-8. [Medline].
Ropper AH. Acute autonomic emergencies and autonomic storm. In: Low PA, ed. Clinical Autonomic Disorders. Boston, Mass: Little, Brown; 1993:747-56.
Sandel ME, Abrams PL, Horn LJ. Hypertension after brain injury: case report. Arch Phys Med Rehabil. Jul 1986;67(7):469-72. [Medline].
Scott JS, Ockey RR, Holmes GE. Autonomic dysfunction associated with locked-in syndrome in a child. Am J Phys Med Rehabil. May-Jun 1997;76(3):200-3. [Medline].
Sherman MA, Shutov AA. [Clinical course of autonomic nervous system disorders in veterans with consequences of combat mild brain injury]. Zh Nevrol Psikhiatr Im S S Korsakova. 2003;103(1):17-20. [Medline].
Shiozaki T, Taneda M, Kishikawa M, et al. Transient and repetitive rises in blood pressure synchronized with plasma catecholamine increases after head injury. Report of two cases. J Neurosurg. Mar 1993;78(3):501-4. [Medline].
Thorley RR, Wertsch JJ, Klingbeil GE. Acute hypothalamic instability in traumatic brain injury: a case report. Arch Phys Med Rehabil. Feb 2001;82(2):246-9. [Medline].
Whyte J, Filion DT, Rose TR. Defective thermoregulation after traumatic brain injury. A single subject evaluation. Am J Phys Med Rehabil. Oct 1993;72(5):281-5. [Medline].
Print
