The storm — paroxysmal sympathetic hyperactivity
| Patient | 31M, acute phase |
|---|---|
| Injurydiffuse axonal injury with brainstem involvement | |
| Severity | Worst GCS 5 |
| Days since injury | 5 |
| Before the injuryIndependent. Carpenter, no prior illness. | |
| PrecautionsPSH — vitals monitored through every session; triggers documented; Recent extubation — airway status watched during positioning; Severe injury — all handling graded and brief | |
Test yourself
Mid-storm, what does the therapist do?
The teaching
Paroxysmal sympathetic hyperactivity is the severe-TBI complication that masquerades as everything else — sepsis, pain, seizures, agitation — and the consensus name is what turns six mysteries into one management plan. The therapist’s jobs are three: stop and protect mid-storm, document the trigger, and restart in monitored sips once the team has control. What you do with it: treat the episode as a stop sign, keep the trigger log like it matters — because it does — and never mistake a settled morning for a resolved mechanism.
- Episodes increasing in frequency or duration despite trigger control — escalate the same day
- Any episode with airway compromise or sustained posturing — this is a medical emergency, not a therapy note
Read next
The full sequence
This page carries the case’s first decision. The full sequence — every decision, the examination by domain, and the debrief that grades you — is in the drill, and the library is included with membership.
Sources on this page: Meyfroidt G, Baguley IJ, Menon DK. Paroxysmal sympathetic hyperactivity: the storm after acute brain injury. Lancet Neurol. 2017. Baguley IJ et al. Paroxysmal sympathetic hyperactivity after acquired brain injury: consensus on conceptual definition, nomenclature, and diagnostic criteria. J Neurotrauma. 2014 · Baguley IJ et al. Paroxysmal sympathetic hyperactivity after acquired brain injury: consensus on conceptual definition, nomenclature, and diagnostic criteria. J Neurotrauma. 2014. Meyfroidt G, Baguley IJ, Menon DK. Paroxysmal sympathetic hyperactivity: the storm after acute brain injury. Lancet Neurol. 2017 · Meyfroidt G, Baguley IJ, Menon DK. Paroxysmal sympathetic hyperactivity: the storm after acute brain injury. Lancet Neurol. 2017. Carney N et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery. 2017