A 34-year-old woman presents to the emergency department with blood pressure 240/140 mmHg, pounding headache, palpitations, and profuse sweating. Plasma free metanephrines are markedly elevated and CT shows a 4 cm left adrenal mass. Which drug is the most appropriate initial agent for acute BP control?
- A Propranolol
- B Phentolamine ✓
- C Hydrochlorothiazide
- D Enalaprilat
Correct answer: B. Phentolamine
Explanation
Pheochromocytoma crisis is treated with an alpha adrenergic blocker such as phentolamine, which directly antagonizes catecholamine mediated vasoconstriction. Beta blockade must never be given first because unopposed alpha stimulation can worsen hypertension and precipitate coronary spasm; beta blockers are added only after alpha blockade is established. Diuretics and ACE inhibitors do not address the catecholamine driven vasoconstriction and have no role in this emergency.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.