Critical Care Medicine-Endocrine Disorders>>>>>Management During Critical Illness
Question 1#

A 48-year-old woman presents with severe headache. She has a history of refractory hypertension, intermittent headaches, and palpitations. Her vital signs are notable for blood pressure of 242/100 mm Hg and oxygen saturation of 85% on room air. Chest Xray shows diffuse pulmonary edema, and oxygenation improves with high flow nasal cannula. She is admitted to the ICU for blood pressure management and respiratory support. Collection of 24- hour urinary vanillylmandelic acid and metanephrines are started.

Until these results return, which of the following medications would be most appropriate to start to manage her hypertension?

A. Labetalol
B. Esmolol
C. Phentolamine
D. Phenoxybenzamine

Correct Answer is C


Correct Answer: C

This patient presents in hypertensive emergency secondary to pheochromocytoma. The triad of refractory hypertension, headaches, and palpitations is classic for pheochromocytoma. The diagnosis is confirmed with elevated urinary VMA and metanephrine levels. The essential tenet of pheochromocytoma management is alpha-adrenergic blockade and correction of intravascular volume depletion. The typical agents for alpha blockade are phentolamine and phenoxybenzamine. Phentolamine is available as an intravenous agent and has an onset of action of 1 to 2 minutes, lasting 3 to 10 minutes. Phenoxybenzamine is only available orally and would be inappropriate for immediate blood pressure lowering in this symptomatic patient. Beta-blockade should not be administered initially as the impairment of beta-mediated vasodilation can result in unopposed alpha-mediated vasoconstriction and may lead to circulatory collapse. Thus, labetalol and esmolol are not appropriate first line agents.


  1. Vincent JL, Abraham E, Moore FA, et al, eds. Textbook of Critical Care. 7th ed. Philadelphia, PA: Elsevier; 2017.