Gabapentin in the management of dysautonomia following severe traumatic brain injury: a case series.

The pharmacological management of dysautonomia, otherwise known as autonomic storms, following acute neurological insults, is problematic and remains poorly researched. This paper presents six subjects with dysautonomia following extremely severe traumatic brain injury where gabapentin controlled paroxysmal autonomic changes and posturing in the early post-acute phase following limited success with conventional medication regimens. In two subjects, other medications were reduced or ceased without a recurrence of symptoms. It is proposed that medications that can block or minimise abnormal afferent stimuli may represent a better option for dysautonomia management than drugs which increase inhibition of efferent pathways. Potential mechanisms for these effects are discussed.

Elevated resting heart rate as a predictor of posttraumatic stress disorder after severe traumatic brain injury.

OBJECTIVE: This study indexed the relationship between resting heart rates (HRs) after injury and subsequent posttraumatic stress disorder (PTSD) in patients who sustained severe traumatic brain injury (TBI). METHODS: Patients who sustained a severe TBI (N = 68) had their resting HR assessed 1 week and 1 month after injury, and they were assessed for PTSD 6 months after injury with the PTSD Interview, a structured clinical interview based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised. RESULTS: PTSD was diagnosed in 23% of patients. PTSD participants had higher HRs at 1 week but not at 1 month after trauma than non-PTSD participants. This difference remained significant when the effect of posttraumatic amnesia was controlled, but it was not significant when the effect of Glasgow Coma Scale was controlled. CONCLUSION: These findings accord with the proposal that fear conditioning can occur outside the level of awareness and contribute to PTSD development.

Pharmacological management of Dysautonomia following traumatic brain injury.

PRIMARY OBJECTIVE: To document and critically evaluate the likely effectiveness of pharmacological treatments used in a sample of patients with Dysautonomia and to link these findings to previously published literature. RESEARCH DESIGN: Retrospective case control chart review. METHODS AND PROCEDURES: Data were collected on age, sex and GCS matched subjects with and without Dysautonomia (35 cases and 35 controls). Data included demographic and injury details, physiological parameters, medication usage, clinical progress and rehabilitation outcome. Descriptive analyses were undertaken to characterize the timing and frequency of CNS active medications. MAIN OUTCOMES AND RESULTS: Dysautonomic patients were significantly more likely to receive neurologically active medications. A wide variety of drugs were utilised with the most frequent being morphine/midazolam and chlorpromazine. Cessation of morphine/midazolam produced significant increases in heart rate and respiratory rate but not temperature. Chlorpromazine may have modified respiratory rate responses, but not temperature or heart rate. CONCLUSIONS: The features of Dysautonomia are similar to a number of conditions treated as medical emergencies. Despite this, no definitive treatment paradigm exists. The best available evidence is for morphine (especially intravenously), benzodiazepines, propanolol, bromocriptine and possibly intrathecal baclofen. Barriers to improving management include the lack of a standardized nomenclature, formal definition or accepted diagnostic test. Future research needs to be conducted to improve understanding of Dysautonomia with a view to minimizing disability.