Thread by @sigman_md

1/ 🧵Ready to play a game #EmoryNCCTweetorials #Neurotwitter #FOAMncc ?

Review these images carefully. Poll in next tweet.

2/ What do all of these diverse #braininjury cases have in common?

3/ All of these patients developed paroxysmal sympathetic hyperactivity (PSH) or #neurostorming

Here you will find PSH resources to

✅Understand the pathophys of #PSH
✅Rule out mimics
✅Diagnose PSH
✅Treat PSH

4/ One accepted theory regarding the pathophysiologic basis of PSH is the "excitatory:inhibitory ratio model"

➡️pubmed.ncbi.nlm.nih.gov/28816118/

5/ Normally:
🧠multiple circuits (both cortical and subcortical) regulate activity in brainstem nuclei
🧠these circuits provide inhibition to spinal-reflex arcs that provide balance of interneuons of motor and sympathetic efferent pathways

6/ Injury and disconnection of these inhibitory pathways lead to⬆️motor and sympathetic activity to typically non-noxious stimuli

7/ A common misconception: PSH occurs only in TBI patients

💡majority of all patients with PSH have underlying TBI
💡other brain injuries like hypoxic ischemic injury, ischemic and hemorrhagic stroke, hydrocephalus and demyelinating disease are associated with PSH

8/ We know via neuro-imaging studies that the following lesion locations are assoc. w/ PSH

🧠Diffuse axonal injury
🧠Periventricular white matter
🧠Corpus callosum
🧠Diencephalon
🧠Midbrain
🧠Pons

9/ 🚨PSH is a problem

↑ICU LOS
↑Hosp LOS
↑Time on ventilator

Associated with worse outcomes in some studies

10/ So, how do you know if your patient has PSH?

1⃣They have associated brain injury (TBI, anoxic, stroke, etc.)
2⃣Use this table to help you

11/ PSH is a diagnosis of exclusion. 🛑Before you diagnose PSH, look for mimics 🕵️‍♀️

12/ There’s a great PSH Assessment tool which can be used to aid your diagnosis

pubmed.ncbi.nlm.nih.gov/24731076/

Let’s break it down.

13/ First, add up all the points using the "clinical features scale"

14/ Then, add up all the points for the diagnostic likelihood tool

15/ add the 2 tools together to assess the likelihood of your diagnosis

16/ Now, it’s time to treat PSH. Make sure you have options to

🚨Abort acute episodes
🚨Start maintenance treatment if you’ve had >4 episodes or these are lasting more than 48 hours or so

17/ Don’t forget to treat/assess for urinary retention, constipation and other causes of discomfort (pain, new infections) as these can trigger PSH!

18/ What have we learned re PSH?

✅Caused by injury to inhib sympathetic and motor pathways
✅Can present ~24 hrs-weeks out from injury
✅Diagnosis of excl
✅Use scoring tool to help diagnosis
✅There are many tx options

19/ Enjoy (or don't) this quick reference PSH sheet

20/ Other PSH pearls🦪 to share?

@caseyalbin @Capt_Ammonia @Tracey1milligan
@JimSiegler @AaronLBerkowitz
@drdangayach @pouyeah
@subinmatthews @JimmySuhMD @emcrit
@LDCritCare @Emcrit @EricLawson90
@neuro_intensive @caseyhall @CajalButterfly