Autonomic Storming

Side view MRIAutonomic Dysfunction: “Storming back from brain injury”

Michael Sefton, Ph.D.

WESTBOROUGH, MA Whittier Rehabilitation Hospital in Westborough, MA maintains a medical unit designed to help patients recover from their traumatic brain injuries.  Traumatic brain injuries  or TBI can occur at any time while working, playing, driving, or riding a bike!  TBI is described as a public health problem that results from a sudden force being applied to the head and brain that results from high-speed acceleration-deceleration force coupled with secondary injuries from axonal shearing, cerebral edema, hypoxia, bleeding within the cranium, and autonomic dysfunction.  In prior published work I have cited the impact of concussion on the brain and it is now well-known that repeated concussions can lead to a significant long-term decline in memory, mood, and behavior (Sefton, 2014).

Patients recovering from TBI often pass through stages as they regain their sense of well-being.  These stages are often depend upon the extent and breadth of symptoms due to traumatic injury and the unique recovery each patient undertakes.  In this report I’d like to describe autonomic storming and its role in the recovery from brain injury.

Autonomic regulation is the role of the brain stem that maintains the diurnal pattern of arousal for wakeful activity and sleep hygiene.  The brain stem regulates heart rate and respiratory drive as well.  These functions are vital to survival and comprise the autonomic nervous system.  The ANS functions as the brain and body’s alarm system signaling the need for fight-flight activation.  When this system is damaged due to traumatic brain injury the recovering subject can have wild swings of autonomic arousal such as elevated heart rate – patients sometimes chug along at 140-160 while autonomic storming.   Paroxysmal changes in blood pressure may pose significant risk, respiratory rate may become tachypnic, patients frequent are febrile and may become excessively sweaty  as a consequence of autonomic dysfunction.  Autonomic dysfunction must be carefully managed in patients recovering from TBI.  Some patient’s are managed using a class of cardioactive medication known as beta blockers to gradually reduce the impact of autonomic storming.

Case review 22-year-old male – He became extremely agitated during a visit with his family.  He had been doing very well in his recovery and exhibited few if any signs of AD.  The entire family had been visiting and throwing an squishy ball into a door mounted basketball hoop.  The noise slowly became too much for the boy and his body was flooded with adrenaline – the fight-flight mechanism was off and running.  He was overwhelmed and become motor restless, agitated, and physically threatening.  He was unsafe by removing a hard cervical collar he was prescribed.  He could not maintain the nonweight bearing status to his left leg. He was angry and profane.

As the signs of this escalate it becomes the responsibility of everyone interacting with the patient to gradually reduce the degree of noise and stimulation within the environment.  It is important to limit the environmental noise and allow for frequent rest breaks during the rehabilitation process.  Consider using PRN medications such as extra beta blockers to gradually lessen the adrenergic load on the patient.  In this case, the patient was transfered to the trauma center to rule out intracranial bleeding, post traumatic seizure, or other metabolic dysfunction causing his agitated behavior.

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