Rectal propranolol controls paroxysmal sympathetic hyperactivity: a case report.

Area of Science:

• Neurology
• Critical Care Medicine
• Pharmacology

Background:

• Paroxysmal sympathetic hyperactivity (PSH) impacts 10% of acquired brain injury survivors, causing significant morbidity.
• Standard PSH treatments include oral beta-blockers and alpha-2 antagonists.
• Altered gastrointestinal tracts in critically ill patients can preclude oral medication administration.

Observation:

• A 15-year-old male with severe intra-abdominal injuries developed PSH after cardiac arrest and anoxic brain injury.
• Due to contraindications for oral intake, PSH symptoms were managed with rectal propranolol suppositories.
• Additional treatments included intravenous morphine, dexmedetomidine, and a transdermal clonidine patch.

Findings:

• Rectal administration of propranolol (40 mg every 6 hours) provided symptomatic control of PSH.
• The patient demonstrated clinical improvement and was transferred to a rehabilitation facility.
• This case report is the first to document successful use of propranolol suppositories in a clinical setting.

Implications:

• Rectal propranolol suppositories represent a viable alternative route for PSH management when oral administration is not possible.
• This approach may improve outcomes for critically ill patients with brain injuries and gastrointestinal dysfunction.
• Further research into rectal formulations for PSH treatment is warranted.