Rectal Propranolol Controls Paroxysmal Sympathetic Hyperactivity: A Case Report

Paroxysmal sympathetic hyperactivity (PSH) affects approximately 10% of survivors of acquired brain injury and is associated with substantial morbidity. The most effective maintenance therapies include oral β‐blockers and α‐2 antagonists. We report the use of rectal propranolol for symptomatic control of PSH in a critically ill patient with an altered gastrointestinal tract for whom oral intake was contraindicated. A 15‐year‐old Caucasian male with no past medical history was admitted status post all‐terrain vehicle rollover with multiple intra‐abdominal injuries. On hospital day 40, the patient experienced cardiac arrest with a subsequent anoxic brain injury, which was complicated by the development of PSH on post‐arrest day 1. Because of his altered gastrointestinal tract, he was symptomatically managed with propranolol 40 mg per rectum every 6 hours in the form of specially prepared suppositories, intravenously infused morphine and dexmedetomidine, and a transdermal clonidine patch. The patient improved clinically during this treatment and was transferred to a rehabilitation facility. This is the first case report to describe successful use of propranolol suppositories in a clinical environment. This case supports the use of propranolol suppositories as a potential alternative route when oral administration is not possible.