Pheochromocytoma Hypertensive Crisis Management

Algorithm Steps

1. ▶

   Start

   Pheochromocytoma Crisis

   Severe hypertension from catecholamine excess

   1. ●

      Action

      Recognize Clinical Features

      Classic paroxysmal presentation

      • Severe hypertension (often >200/120 mmHg)
      • Palpitations, tachycardia (or reflex bradycardia)
      • Headache (severe, pounding)
      • Diaphoresis (profuse sweating)
      • Pallor (from vasoconstriction)
      • Anxiety, panic, sense of doom
      • Tremor, weakness
      1. ●

         Action

         Common Triggers

         Events that precipitate crisis

         • Tumor manipulation (surgery, biopsy)
         • Anesthesia induction
         • Certain medications (metoclopramide, glucagon, TCAs, MAOIs)
         • Physical exertion, straining
         • Bladder distension (bladder paraganglioma)
         • Tyramine-rich foods
         • Contrast media
         1. ●

            Action

            1. Immediate Stabilization

            ICU admission, monitoring

            • ICU admission mandatory
            • Arterial line for continuous BP monitoring
            • Central line for vasoactive medications
            • Cardiac monitoring (arrhythmia risk)
            • Large-bore IV access
            1. ●

               Action

               2. Alpha-Blockade FIRST

               CRITICAL: Always before beta-blockade

               • Phentolamine 2-5 mg IV bolus, repeat q5 min prn
               • Target SBP <140 mmHg (or <120 if aortic dissection)
               • OR Nicardipine 5-15 mg/hr IV infusion
               • OR Nitroprusside 0.25-10 mcg/kg/min (if phentolamine unavailable)
               • May need continuous phentolamine infusion
               1. ⚠

                  Warning

                  ⚠️ NEVER Beta-Blocker First!

                  Unopposed alpha-stimulation risk

                  • Beta-blockade without alpha causes:
                  • - Unopposed alpha-vasoconstriction
                  • - Paradoxical hypertension
                  • - Potential cardiovascular collapse
                  • ALWAYS establish alpha-blockade first!
               2. ●

                  Action

                  3. Beta-Blockade (AFTER Alpha)

                  Only after adequate alpha-blockade

                  • Esmolol preferred (short-acting): 500 mcg/kg bolus, then 50-200 mcg/kg/min
                  • OR Labetalol 20 mg IV q10min (has both alpha and beta activity)
                  • Target HR <100 bpm
                  • Treats reflex tachycardia from alpha-blockade
                  • Only initiate when BP controlled with alpha-blocker
                  1. ●

                     Action

                     4. Volume Expansion

                     Address chronic volume contraction

                     • Chronic catecholamine excess causes volume contraction
                     • Once alpha-blocked: Give IV fluids
                     • 0.9% NS or LR 1-2 L
                     • Prevents hypotension when tumor removed
                     • Continue high-sodium diet preoperatively
                     1. ●

                        Action

                        6. Monitoring

                        Close ICU monitoring

                        • Continuous arterial BP
                        • Cardiac telemetry
                        • Glucose (hyperglycemia common)
                        • Urine output
                        • Watch for cardiomyopathy (Takotsubo-like)
                        1. ●

                           Action

                           7. Definitive Treatment

                           Surgical resection is cure

                           • Preoperative alpha-blockade for 10-14 days
                           • Phenoxybenzamine 10 mg BID, titrate to orthostatic symptoms
                           • OR Doxazosin/Prazosin (shorter acting)
                           • Add beta-blocker after several days of alpha
                           • Metyrosine if uncontrolled (inhibits catecholamine synthesis)
                           • Laparoscopic adrenalectomy when stable
                           1. ✓

                              Outcome

                              Crisis Controlled

                              Proceed to preoperative preparation

                           2. ⚠

                              Warning

                              Emergency Surgery

                              If tumor rupture or refractory crisis

                              • Emergent surgery rarely needed
                              • Continue IV alpha-blockade intraoperatively
                              • Expect BP lability during tumor manipulation
                              • Hypotension after tumor removal (treat with fluids/pressors)
                  2. ●

                     Action

                     5. Arrhythmia Management

                     Catecholamine-induced arrhythmias

                     • Esmolol for SVT/AFib (after alpha-blockade)
                     • Lidocaine for ventricular arrhythmias
                     • Amiodarone if refractory
                     • Correct electrolyte abnormalities
                     • Avoid digoxin (arrhythmogenic with catecholamines)