{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,10]],"date-time":"2026-02-10T20:14:49Z","timestamp":1770754489901,"version":"3.50.0"},"reference-count":29,"publisher":"The Pediatric Pharmacy Association","issue":"4","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2015]]},"abstract":"<jats:p>Paroxysmal sympathetic hyperactivity (PSH) is a life-threatening condition characterized by hyperadrenergic activity and autonomic dysfunction. Also termed <jats:italic>autonomic storms<\/jats:italic>, PSH can occur after a variety of cerebral insults, most commonly traumatic brain injury. Limited pediatric literature is available, especially in patients with brain injury from hypoxia. No consensus exists for the terminology, diagnostic criteria, or treatment algorithm for PSH. Thus, the optimal management, including medication selection and dosing, remains unclear. We present the detailed treatment of a 9-year-old, African American male with hypoxic brain injury after pulseless arrest following status asthmaticus, who subsequently developed PSH. The patient began to experience episodes of tachycardia, hypertension, tachypnea, diaphoresis, rigidity, and dystonic posturing on hospital day 5. After ruling out other potential causes, a diagnosis of PSH was made. Episodes of PSH failed to respond to lorazepam or labetalol but were aborted successfully with morphine. Management of PSH after hypoxic brain injury required medications for acute treatment as well as for prevention of PSH. Morphine was found to be highly effective and safe for aborting the autonomic crises. Other agents more commonly described in the literature did not result in an adequate response and were associated with significant adverse effects. A combination of clonazepam, baclofen, and either propranolol or clonidine aided in reducing the frequency of episodes of PSH. We suggest using morphine for aborting severe episodes of PSH that do not respond to antihypertensive agents or benzodiazepines.<\/jats:p>","DOI":"10.5863\/1551-6776-20.4.335","type":"journal-article","created":{"date-parts":[[2020,10,27]],"date-time":"2020-10-27T19:45:46Z","timestamp":1603827946000},"page":"335-340","source":"Crossref","is-referenced-by-count":7,"title":["Morphine: An Effective Abortive Therapy for Pediatric Paroxysmal Sympathetic Hyperactivity After Hypoxic Brain Injury"],"prefix":"10.5863","volume":"20","author":[{"given":"Deborah S.","family":"Raithel","sequence":"first","affiliation":[{"name":"Pediatric Pharmacy Resident, Department of Pharmacy Practice, College of Pharmacy, University of Illinois, Chicago, currently at Comer Children's Hospital, The University of Chicago Medicine, Chicago"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kirsten H.","family":"Ohler","sequence":"additional","affiliation":[{"name":"Department of Pharmacy Practice, College of Pharmacy, University of Illinois, Chicago"},{"name":"Children's Hospital University of Illinois, University of Illinois Hospital & Health Sciences System, Chicago"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Isabel","family":"Porto","sequence":"additional","affiliation":[{"name":"Department of Pharmacy Practice, College of Pharmacy, University of Illinois, Chicago"},{"name":"Children's Hospital University of Illinois, University of Illinois Hospital & Health Sciences System, Chicago"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alma R.","family":"Bicknese","sequence":"additional","affiliation":[{"name":"Children's Hospital University of Illinois, University of Illinois Hospital & Health Sciences System, Chicago"},{"name":"Department of Pediatrics, College of Medicine, University of Illinois, Chicago"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Donna M.","family":"Kraus","sequence":"additional","affiliation":[{"name":"Department of Pharmacy Practice, College of Pharmacy, University of Illinois, Chicago"},{"name":"Department of Pediatrics, College of Medicine, University of Illinois, Chicago"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"3883","reference":[{"issue":"1","key":"i1551-6776-20-4-335-b1","series-title":"Neurorehabil Neural Repair","first-page":"41","article-title":"Central autonomic dysfunction following acquired brain injury in children","volume":"11","year":"1997","unstructured":"Krach\n              LE, \n            \n              Kriel\n              RL, \n            \n              Morris\n              WF, \n          \n          et al. Central autonomic dysfunction following acquired brain injury in children. Neurorehabil Neural Repair. 1997;11(1):41\u201345."},{"issue":"2","key":"i1551-6776-20-4-335-b2","series-title":"Ann Neurol","first-page":"126","article-title":"A review of paroxysmal sympathetic hyperactivity after acquired brain injury","volume":"68","year":"2010","unstructured":"Perkes\n              I, \n            \n              Baguley\n              IJ, \n            \n              Nott\n              MT, \n            \n              Menon\n              DK.\n            \n          \n          A review of paroxysmal sympathetic hyperactivity after acquired brain injury. Ann Neurol. 2010;68(2):126\u2013135."},{"issue":"10","key":"i1551-6776-20-4-335-b3","series-title":"Brain Injury","first-page":"925","article-title":"Paroxysmal sympathetic hyperactivity after acquired brain injury: a review of diagnostic criteria","volume":"25","year":"2011","unstructured":"Perkes\n              IE, \n            \n              Menon\n              DK, \n            \n              Nott\n              MT, \n            \n              Baguley\n              IJ.\n            \n          \n          Paroxysmal sympathetic hyperactivity after acquired brain injury: a review of diagnostic criteria. Brain Injury. 2011;25(10):925\u2013932."},{"issue":"2","key":"i1551-6776-20-4-335-b4","series-title":"Mayo Clin Proc","first-page":"148","article-title":"Paroxysmal sympathetic storms (\u201cdiencephalic seizures\u201d) after severe diffuse axonal head injury","volume":"73","year":"1998","unstructured":"Boeve\n              BF, \n            \n              Wijdicks\n              EFM, \n            \n              Benarroch\n              EE, \n            \n              Schmidt\n              KD.\n            \n          \n          Paroxysmal sympathetic storms (\u201cdiencephalic seizures\u201d) after severe diffuse axonal head injury. Mayo Clin Proc. 1998;73(2):148\u2013152."},{"issue":"4","key":"i1551-6776-20-4-335-b5","series-title":"Pediatr Neurol","first-page":"724","article-title":"Sympathetic storms in a child with a midbrain glioma: a variant of diencephalic seizures","volume":"21","year":"1999","unstructured":"Goh\n              KYC, \n            \n              Conway\n              EJ, \n            \n              DaRosso\n              RC, \n          \n          et al. Sympathetic storms in a child with a midbrain glioma: a variant of diencephalic seizures. Pediatr Neurol. 1999;21(4):724\u2013744."},{"issue":"3","key":"i1551-6776-20-4-335-b6","series-title":"J Paediatr Child Health","first-page":"283","article-title":"Bromocriptine for the management of autonomic dysfunction after severe traumatic brain injury","volume":"36","year":"2000","unstructured":"Russo\n              RN, \n            \n              O'Flaherty\n              S.\n            \n          \n          Bromocriptine for the management of autonomic dysfunction after severe traumatic brain injury. J Paediatr Child Health. 2000;36(3):283\u2013285."},{"issue":"10","key":"i1551-6776-20-4-335-b7","series-title":"Brain Injury","first-page":"917","article-title":"Dysautonomia syndrome in the acute recovery phase after traumatic brain injury: relief with intrathecal baclofen therapy","volume":"15","year":"2001","unstructured":"Cuny\n              E, \n            \n              Richer\n              E, \n            \n              Castel\n              JP.\n            \n          \n          Dysautonomia syndrome in the acute recovery phase after traumatic brain injury: relief with intrathecal baclofen therapy. Brain Injury. 2001;15(10):917\u2013925."},{"issue":"3","key":"i1551-6776-20-4-335-b8","series-title":"Rev Neurol","first-page":"143","article-title":"Autonomic dysfunction in children with traumatic brain injury [in Spanish]","volume":"43","year":"2006","unstructured":"Rodr\u00edguez\n              N, \n            \n              Febrer\n              A, \n            \n              Mel\u00e9ndez\n              M.\n            \n          \n          Autonomic dysfunction in children with traumatic brain injury [in Spanish]. Rev Neurol. 2006;43(3):143\u2013146."},{"issue":"3","key":"i1551-6776-20-4-335-b9","series-title":"J Parenter Enteral Nutr","first-page":"281","article-title":"Severe weight loss and hypermetabolic paroxysmal dysautonomia following hypoxic ischemic brain injury: the role of indirect calorimetry in the intensive care unit","volume":"32","year":"2008","unstructured":"Mehta\n              NM, \n            \n              Bechard\n              LJ, \n            \n              Leavitt\n              K, \n            \n              Duggan\n              C.\n            \n          \n          Severe weight loss and hypermetabolic paroxysmal dysautonomia following hypoxic ischemic brain injury: the role of indirect calorimetry in the intensive care unit. J Parenter Enteral Nutr. 2008;32(3):281\u2013284."},{"issue":"4","key":"i1551-6776-20-4-335-b10","series-title":"Pediatric Neurosurg","first-page":"299","article-title":"A unique pattern of intracranial pressure in a patient with traumatic paroxysmal sympathetic storm","volume":"46","year":"2010","unstructured":"Woo\n              HJ, \n            \n              Park\n              SH, \n            \n              Hwang\n              SK.\n            \n          \n          A unique pattern of intracranial pressure in a patient with traumatic paroxysmal sympathetic storm. Pediatric Neurosurg. 2010;46(4):299\u2013302."},{"issue":"4","key":"i1551-6776-20-4-335-b11","series-title":"Pediatr Neurosurg","first-page":"275","article-title":"Paroxysmal autonomic instability with dystonia in a child: rare manifestation of an interpenduncular tuberculoma","volume":"47","year":"2011","unstructured":"Singh\n              DK, \n            \n              Singh\n              N.\n            \n          \n          Paroxysmal autonomic instability with dystonia in a child: rare manifestation of an interpenduncular tuberculoma. Pediatr Neurosurg. 2011;47(4):275\u2013278."},{"issue":"9","key":"i1551-6776-20-4-335-b12","series-title":"Arch Phys Med Rehabil","first-page":"1515","article-title":"Hyperbaric oxygen therapy in the management of paroxysmal sympathetic hyperactivity after severe traumatic brain injury: a report of 6 cases","volume":"92","year":"2011","unstructured":"Lv\n              LQ, \n            \n              Hou\n              LJ, \n            \n              Yu\n              MK, \n          \n          et al. Hyperbaric oxygen therapy in the management of paroxysmal sympathetic hyperactivity after severe traumatic brain injury: a report of 6 cases. Arch Phys Med Rehabil. 2011;92(9):1515\u20131518."},{"issue":"1","key":"i1551-6776-20-4-335-b13","series-title":"J Neurosurg Anesthesiol","first-page":"87","article-title":"Paroxysmal sympathetic hyperactivity in a child with Moyamoya disease","volume":"26","year":"2014","unstructured":"Deepika\n              A, \n            \n              Reddy\n              M, \n            \n              Shukla\n              D.\n            \n          \n          Paroxysmal sympathetic hyperactivity in a child with Moyamoya disease. J Neurosurg Anesthesiol. 2014;26(1):87\u201388."},{"issue":"7","key":"i1551-6776-20-4-335-b14","series-title":"Neurol Research","first-page":"680","article-title":"Paroxysmal sympathetic hyperactivity in the neurological intensive care unit","volume":"29","year":"2007","unstructured":"Rabinstein\n              AA.\n            \n          \n          Paroxysmal sympathetic hyperactivity in the neurological intensive care unit. Neurol Research. 2007;29(7):680\u2013682."},{"issue":"6","key":"i1551-6776-20-4-335-b15","series-title":"J Rehabil Med","first-page":"502","article-title":"Decreasing incidence of paroxysmal sympathetic hyperactivity syndrome in the vegetative state","volume":"44","year":"2012","unstructured":"Pignolo\n              L, \n            \n              Rogano\n              S, \n            \n              Quintieri\n              M, \n          \n          et al. Decreasing incidence of paroxysmal sympathetic hyperactivity syndrome in the vegetative state. J Rehabil Med. 2012;44(6):502\u2013504."},{"issue":"2","key":"i1551-6776-20-4-335-b16","series-title":"Neurocrit Care","first-page":"293","article-title":"A critical review of the pathophysiology of dysautonomia following traumatic brain injury","volume":"8","year":"2008","unstructured":"Baguley\n              IJ, \n            \n              Heriseanu\n              RE, \n            \n              Cameron\n              ID, \n          \n          et al. A critical review of the pathophysiology of dysautonomia following traumatic brain injury. Neurocrit Care. 2008;8(2):293\u2013300."},{"issue":"2","key":"i1551-6776-20-4-335-b17","series-title":"Curr Treatment Options in Neurol","first-page":"151","article-title":"Treatment of paroxysmal sympathetic hyperactivity","volume":"10","year":"2008","unstructured":"Rabinstein\n              AA, \n            \n              Benarroch\n              EE.\n            \n          \n          Treatment of paroxysmal sympathetic hyperactivity. Curr Treatment Options in Neurol. 2008;10(2):151\u2013157."},{"issue":"5","key":"i1551-6776-20-4-335-b18","series-title":"Brain Injury","first-page":"409","article-title":"Pharmacological management of dysautonomia following traumatic brain injury","volume":"18","year":"2004","unstructured":"Baguley\n              IJ, \n            \n              Cameron\n              ID, \n            \n              Green\n              AM, \n          \n          et al. Pharmacological management of dysautonomia following traumatic brain injury. Brain Injury. 2004;18(5):409\u2013417."},{"issue":"2","key":"i1551-6776-20-4-335-b19","series-title":"Curr Opin Crit Care","first-page":"139","article-title":"Manifestations of the hyperadrenergic state after acute brain injury","volume":"18","year":"2012","unstructured":"Hinson\n              HE, \n            \n              Sheth\n              KN.\n            \n          \n          Manifestations of the hyperadrenergic state after acute brain injury. Curr Opin Crit Care. 2012;18(2):139\u2013145."},{"issue":"5","key":"i1551-6776-20-4-335-b20","series-title":"J Neurol Neurosurg Psychiatry","first-page":"539","article-title":"Gabapentin in the management of dysautonomia following severe traumatic brain injury: a case series","volume":"78","year":"2007","unstructured":"Baguley\n              IJ, \n            \n              Heriseanu\n              RE, \n            \n              Gurka\n              JA, \n          \n          et al. Gabapentin in the management of dysautonomia following severe traumatic brain injury: a case series. J Neurol Neurosurg Psychiatry. 2007;78(5):539\u2013541."},{"issue":"2","key":"i1551-6776-20-4-335-b21","series-title":"Neurocrit Care","first-page":"233","article-title":"Paroxysmal sympathetic hyperactivity after traumatic brain injury","volume":"13","year":"2010","unstructured":"Bower\n              RS, \n            \n              Sunnarborg\n              R, \n            \n              Rabinstein\n              AA, \n            \n              Wijdicks\n              EF.\n            \n          \n          Paroxysmal sympathetic hyperactivity after traumatic brain injury. Neurocrit Care. 2010;13(2):233\u2013234."},{"issue":"6","key":"i1551-6776-20-4-335-b22","series-title":"Ann Neurol","first-page":"609","article-title":"Diencephalic seizures: responsiveness to bromocriptine and morphine","volume":"21","year":"1987","unstructured":"Bullard\n              DE.\n            \n          \n          Diencephalic seizures: responsiveness to bromocriptine and morphine. Ann Neurol. 1987;21(6):609\u2013611."},{"issue":"3","key":"i1551-6776-20-4-335-b23","series-title":"Neurocrit Care","first-page":"288","article-title":"Paroxysmal sympathetic storm","volume":"2","year":"2005","unstructured":"Diamond\n              AL, \n            \n              Callison\n              RC, \n            \n              Shokri\n              J, \n          \n          et al. Paroxysmal sympathetic storm. Neurocrit Care. 2005;2(3):288\u2013291."},{"issue":"3","key":"i1551-6776-20-4-335-b24","series-title":"Neurocrit Care","first-page":"217","article-title":"Dexmedetomidine for the treatment of paroxysmal autonomic instability with dystonia","volume":"7","year":"2007","unstructured":"Goddeau\n              RP,  Jr\n            \n              Silverman\n              SB, \n            \n              Sims\n              JR.\n            \n          \n          Dexmedetomidine for the treatment of paroxysmal autonomic instability with dystonia. Neurocrit Care. 2007;7(3):217\u2013220."},{"issue":"2","key":"i1551-6776-20-4-335-b25","series-title":"J Neurol","first-page":"276","article-title":"Susceptibility weighted imaging in a patient with paroxysmal sympathetic storms","volume":"256","year":"2009","unstructured":"Huang\n              P, \n            \n              Lin\n              W, \n            \n              Huang\n              P, \n            \n              Khor\n              GT.\n            \n          \n          Susceptibility weighted imaging in a patient with paroxysmal sympathetic storms. J Neurol. 2009;256(2):276\u2013278."},{"issue":"6","key":"i1551-6776-20-4-335-b26","series-title":"Neurologist","first-page":"384","article-title":"Morphinesensitive paroxysmal sympathetic storm in pontine intracerebral hemorrhage","volume":"16","year":"2010","unstructured":"Ko\n              S, \n            \n              Kim\n              CK, \n            \n              Lee\n              S, \n          \n          et al. Morphinesensitive paroxysmal sympathetic storm in pontine intracerebral hemorrhage. Neurologist. 2010;16(6):384\u2013385."},{"issue":"12","key":"i1551-6776-20-4-335-b27","series-title":"J Palliat Med","first-page":"1355","article-title":"Paroxysmal sympathetic hyperactivity (sympathetic storm) in a patient with permanent vegetative state","volume":"14","year":"2011","unstructured":"Levy\n              ER, \n            \n              McVeigh\n              U, \n            \n              Ramsay\n              AM.\n            \n          \n          Paroxysmal sympathetic hyperactivity (sympathetic storm) in a patient with permanent vegetative state. J Palliat Med. 2011;14(12):1355\u20131357."},{"issue":"1","key":"i1551-6776-20-4-335-b28","series-title":"Korean J Internal Med","first-page":"51","article-title":"Paroxysmal autonomic dysregulation with fever that was controlled by propranolol in a brain neoplasm patient","volume":"22","year":"2007","unstructured":"Oh\n              SJ, \n            \n              Hong\n              YK, \n            \n              Song\n              E.\n            \n          \n          Paroxysmal autonomic dysregulation with fever that was controlled by propranolol in a brain neoplasm patient. Korean J Internal Med. 2007;22(1):51\u201354."},{"issue":"6","key":"i1551-6776-20-4-335-b29","series-title":"Clin Auton Res","first-page":"378","article-title":"Paroxysmal autonomic instability with dystonia","volume":"17","year":"2007","unstructured":"Srinivasan\n              S, \n            \n              Lim\n              CCT, \n            \n              Thirugnanam\n              U.\n            \n          \n          Paroxysmal autonomic instability with dystonia. Clin Auton Res. 2007;17(6):378\u2013381."}],"container-title":["The Journal of Pediatric Pharmacology and Therapeutics"],"original-title":[],"link":[{"URL":"https:\/\/jppt.kglmeridian.com\/view\/journals\/jppt\/20\/4\/article-p335.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"http:\/\/meridian.allenpress.com\/jppt\/article-pdf\/20\/4\/335\/1785983\/1551-6776-20_4_335.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/jppt.kglmeridian.com\/downloadpdf\/journals\/jppt\/20\/4\/article-p335.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/jppt.kglmeridian.com\/downloadpdf\/journals\/jppt\/20\/4\/article-p335.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,5,16]],"date-time":"2025-05-16T00:38:44Z","timestamp":1747355924000},"score":1,"resource":{"primary":{"URL":"https:\/\/jppt.kglmeridian.com\/view\/journals\/jppt\/20\/4\/article-p335.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2015]]},"references-count":29,"journal-issue":{"issue":"4"},"URL":"https:\/\/doi.org\/10.5863\/1551-6776-20.4.335","relation":{},"ISSN":["1551-6776"],"issn-type":[{"value":"1551-6776","type":"print"}],"subject":[],"published":{"date-parts":[[2015]]}}}