Sympathetic storming 

Epidemiology 
- Typically occurs in young patients with significant/diffuse brain injury - TBI/DAI, SAH, big IPH, etc.
- Archetypally a young male with bad DAI -- likely no true gender predilection but rather trauma tends to affect male > female. And perhaps age predilection because young people have a more robust sympathetic response, or maybe because the degree of neurological injury that is typically associated tends to be mortal in older adults, or maybe because high grade SAH or IPH or diffuse injury occurs more in middle age than late age

Pathophys
- Poorly understood
- Originally believed to be exclusively a function of deep white matter injury; however its also seen in bilateral/diffuse cortical injury
- Perhaps decrease in the dampening signals? exaggerated sympathetic response to all stim, instead of only to severe/noxious stim.

Clinical Presentation 
- Paroxysmal bouts of tachycardia, hypertension, diaphoresis, fever, mydriasis
- Characteristically waxing/waning, rather than constant (i.e. alcohol withdrawal)
- Typically occurs 3-5 days after the initial injury, and resolves on the scale of days to weeks but can start as early as immediately after the injury and last for years

Treatment 
- Very severe (i.e. uncontrollable blood pressures leading to problematic sequelae) - precedex gtt and/or esmolol gtt
- Less severe/transitioning off gtts/on the floor - clonidine, propanolol, gabapentin (especially useful for controlling storming that directly follows stim - like turning/bathing/etc)
- Some people believe that opiates like morphine are an integral part of treating storming, some people don't.
- You can always snow people into the ground with propofol or drips of benzos or narcotics, but it's an inelegant solution and some people believe that they are suboptimal ways of treating storming.