Adrenergic storm
A life-threatening surge of adrenaline and noradrenaline.
An adrenergic storm happens when the body suddenly releases massive amounts of adrenaline and noradrenaline into the bloodstream, with a smaller rise in dopamine. This surge can be fatal due to dangerously fast heart rate and extremely high blood pressure, and the risk is much greater for anyone with existing heart conditions. With quick treatment, the outlook is generally positive; doctors usually give high doses of diazepam or other benzodiazepines along with beta blockers.
Behavioral symptoms resemble an overdose of amphetamines, cocaine, or caffeine. The central nervous system becomes overstimulated, leading to constant movement, unpredictable mental states such as mania, rage, or suicidal thoughts, and a high body temperature. Delirium can occur but is uncommon. Physical symptoms are more severe and include heart arrhythmias, heart attack, or stroke in people prone to coronary disease. Breathing becomes fast and shallow, while pulse and blood pressure climb to dangerous levels. Other complications include rhabdomyolysis, where excessive physical activity breaks down voluntary muscles, releasing myoglobin into the blood and potentially clogging the kidneys, causing renal failure. This muscle breakdown is especially common in storms triggered by stimulant drugs like phenethylamines, including cathinones or amphetamines.
Several things can cause an adrenergic storm. In the United States, cocaine overdose is the most common trigger. Any stimulant drug can cause it if taken in high enough doses, though even non-psychotropic drugs rarely provoke a reaction. Monoamine oxidase inhibitors (MAOIs) are a class of drugs that block the enzyme monoamine oxidase, which normally breaks down compounds with a primary amine group, such as tyramine. MAOIs can be reversible—working only until the drug leaves the body—or irreversible, where the drug permanently binds to and destroys the enzyme. Irreversible MAOIs are more dangerous because it takes about two weeks for the body to regenerate functional MAO enzymes. There are two subtypes: MAO-A and MAO-B. Both break down tyramine, but only MAO-A is found in the gastrointestinal tract and handles most of the tyramine we consume. The small amount that enters the bloodstream is mostly broken down in the liver, where both types act.
A subarachnoid hemorrhage, a severe condition where a neural membrane tears and the brain is co
- field
- Medical emergency / Toxicology
- known_for
- Life-threatening catecholamine surge causing tachycardia, hypertension, and psychiatric symptoms
- common_causes
- Stimulant overdose (especially cocaine or methamphetamine), MAOI-tyramine interaction, subarachnoid hemorrhage
- first-line_treatment
- Diazepam and non-selective beta blockers; antipsychotics for severe psychiatric reactions
Lore & Background
Adrenergic storms are usually caused by overdoses of stimulants, especially cocaine or methamphetamine, or eating foods high in tyramine while taking monoamine oxidase inhibitors. A subarachnoid hemorrhage can also cause an adrenergic storm. A catecholamine storm is part of the normal course of rabies infection, and is responsible for the severe feelings of agitation, terror, and dysautonomia present in the pre-coma stage of the disease. In the United States, cocaine overdose is the leading cause. Any stimulant drug has the capacity to cause this syndrome if taken in sufficient doses, but even non-psychotropic drugs can very rarely provoke a reaction.
Reader's Guide
The adrenergic storm is a critical medical event requiring prompt intervention. Behavioral symptoms include hyperkinetic movement, mania, rage, suicidal behavior, and hyperthermia; delirium can also be present but rarely. Physical symptoms include heart arrhythmias, heart attack or stroke in at-risk individuals, rapid shallow breathing, and dangerously elevated pulse and blood pressure. Complications such as rhabdomyolysis, especially from stimulant drugs like phenethylamines, can lead to renal failure. Treatment involves gastric lavage or activated charcoal if overdose is suspected, followed by first-line agents diazepam and a non-selective beta blocker; other antihypertensives like clonidine may be used if beta blockers are contraindicated. Antipsychotics, once discouraged due to QT prolongation concerns, are now encouraged for severe psychiatric symptoms based on research since 2019 showing rare side effects. Underlying conditions such as pheochromocytoma must be addressed after stabilizing the patient. The condition overlaps with serotonin syndrome, but abnormal echocardiograms or chest pain point to adrenergic storm, while uncontrollable movements, high fever, eye rolling, and bruxism suggest serotonin syndrome.
Did You Know?
- Adrenergic storms are usually caused by overdoses of stimulants, especially cocaine or methamphetamine, or eating foods high in tyramine while taking monoamine oxidase inhibitors.
- A subarachnoid hemorrhage can cause an adrenergic storm through increased intracranial pressure forcing catecholamines out of vesicles.
- Rhabdomyolysis is especially common in adrenergic storms caused by phenethylamines such as cathinones or amphetamines.
- Antipsychotics were formerly discouraged for treatment because of potential QT interval prolongation, but research since 2019 shows severe side effects are rare.
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