Pheochromocytoma Crisis — Management Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Acute crisis or elective?
   Catecholamine hypertensive crisis — acute or preoperative preparation? (A catecholamine-secreting tumor causing paroxysmal hypertensive crisis (triad of headache + sweating + palpitations + pallor), can be precipitated by palpation/anesthesia/an unopposed beta-blocker/certain drugs → hypertensive emergency/catecholamine cardiomyopathy/stroke/MI. Chronic vasoconstriction + contracted blood volume. Diagnosis: plasma/urine metanephrines → imaging to localize.)
   • Acute crisis (needs BP control) → Acute crisis → alpha-blockade first
   • Stable / elective preoperative preparation → Preoperative preparation
2. [End] Preoperative preparation
   Stable/preoperative: alpha-blockade first (phenoxybenzamine or selective alpha-1: doxazosin/prazosin) for 10–14 days + a high-sodium diet/volume expansion to correct the contracted volume; for tachycardia, add a beta-blocker only after adequate alpha-blockade; metyrosine may be added for malignant/unresectable disease. Elective surgical resection (usually laparoscopic).
3. [End] Acute crisis → alpha-blockade first
   Acute hypertensive crisis: alpha-blockade first — IV phentolamine (rapid-acting alpha antagonist) or nitroprusside/nicardipine to control BP + volume expansion; never use a beta-blocker before adequate alpha-blockade (unopposed alpha causes severe vasoconstriction/pulmonary edema/worse crisis), use a beta-blocker only after alpha-blockade for tachycardia/arrhythmia. ICU monitoring, manage cardiomyopathy/arrhythmia. Once stable, preoperative preparation + surgical resection (mnemonic: alpha before beta).

Source guidelines & references

• Pheochromocytoma crisis (AMBOSS; Endocrine Society guideline; Merck)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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