A 38-year-old woman presents to the emergency department with severe headache, profuse sweating, and palpitations lasting 2 hours. Blood pressure is 185/110 mmHg, heart rate 112/min, and she appears anxious. She reports episodic symptoms over the past 6 months with sudden onset of chest tightness and tremor. Serum glucose is 180 mg/dL despite no prior diabetes. 24-hour urine metanephrines are markedly elevated at 1200 µg (normal <400). CT abdomen shows a 3.5 cm left adrenal mass. Which is the most appropriate next step in management?

Explanation

## Pheochromocytoma Crisis Management **Key Point:** Pheochromocytoma requires sequential pharmacological preparation BEFORE surgery to prevent intraoperative hypertensive crisis and arrhythmias. ### Preoperative Preparation Protocol The standard approach is: 1. **Alpha-blockade first** — phenoxybenzamine (non-selective, irreversible) 10 mg daily, titrated up to 40–80 mg/day over 7–10 days 2. **Beta-blockade second** — only AFTER adequate alpha-blockade to prevent unopposed alpha-mediated vasoconstriction 3. **Surgical resection** — performed once blood pressure is controlled and intravascular volume is expanded **High-Yield:** The cardinal rule is **ALPHA BEFORE BETA**. Beta-blockade alone causes paradoxical hypertension and coronary vasospasm due to unopposed alpha-adrenergic effects. ### Why This Patient Needs Preoperative Preparation | Finding | Significance | |---------|-------------| | BP 185/110, HR 112, profuse sweating | Catecholamine excess — risk of intraoperative storm | | Elevated 24-hr urine metanephrines | Confirms diagnosis; quantifies catecholamine burden | | 3.5 cm adrenal mass on CT | Localizes tumor; surgical candidate | | Episodic symptoms over 6 months | Indicates paroxysmal release; uncontrolled preoperatively is dangerous | **Clinical Pearl:** Failure to alpha-block preoperatively increases risk of: - Intraoperative hypertensive crisis (>250 mmHg) - Myocardial infarction - Stroke - Arrhythmias (including VF) - Mortality rate rises from <1% to ~5% ### Timeline for This Patient ```mermaid flowchart TD A[Confirmed pheochromocytoma<br/>BP 185/110, HR 112]:::outcome A --> B[Start phenoxybenzamine<br/>10 mg daily, titrate to 40-80 mg/day]:::action B --> C[After 7-10 days of alpha-blockade<br/>Add beta-blocker propranolol]:::action C --> D{BP controlled?<br/>HR 60-80?}:::decision D -->|Yes| E[Proceed to adrenalectomy]:::action D -->|No| F[Increase alpha/beta doses]:::action F --> D E --> G[Intraoperative monitoring<br/>Phentolamine/esmolol ready]:::action G --> H[Successful tumor removal]:::outcome ``` **Mnemonic:** **ALPHA-BETA RULE** — Always Alpha before Beta in pheochromocytoma. [cite:Harrison 21e Ch 405]