In a patient with pheochromocytoma experiencing an immediate hypertensive crisis, what is the first priority treatment?

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In a pheochromocytoma crisis, the immediate problem is excessive alpha-adrenergic vascular tone from catecholamines, which drives dangerous hypertension. The first priority is rapid alpha-adrenergic blockade to quickly reverse vasoconstriction and lower blood pressure. IV phentolamine is a fast-acting, nonselective alpha blocker that provides immediate relief of crisis-level hypertension and symptoms. After stabilization, you transition to a longer-acting alpha blocker such as phenoxybenzamine to maintain blockade in the perioperative period.

Starting a beta-blocker right away is avoided because blocking beta receptors before alpha blockade can leave unopposed alpha-mediated vasoconstriction, potentially worsening the hypertension. ACE inhibitors don’t provide the rapid, alpha-directed control needed in an acute crisis and aren’t first-line in this scenario.