Weakness: Difference between revisions
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== Workup == | == Workup == | ||
On all pts: | '''On all pts:''' | ||
#CBC (anemia) | #CBC (anemia) | ||
#Chem 10 (electrolyte disturbance,hypoglycemia, uremia) | #Chem 10 (electrolyte disturbance,hypoglycemia, uremia) | ||
#ECG (Ischemia,hypo/hyperkalemia) | #ECG (Ischemia,hypo/hyperkalemia) | ||
Consider: | '''Consider:''' | ||
#CK (mypoathies) | #CK (mypoathies) | ||
#ESR | #ESR |
Revision as of 05:04, 16 August 2013
Approach
Determine if pt has actual neuromuscular weakness (suggesting CNS dysfuction) or non-neuromuscular weakness.
DDX
- Neuromuscular weakness involves derangement of CNS (UMN), PNS (LMN), the motor endplate, or the muscle:
- Can't miss dx:
- UMN: CVA, Intracerebral Hemorrhage (ICH), Multiple Sclerosis, ALS (UMN & LMN).
- Spinal cord disease: Infection (Epidural Abscess (Spinal)), infarction/ischemia, trauma (Spinal Cord Syndromes), inflammation (Transverse Myelitis), tumor.
- Peripheral nerve disease: Guillain-Barre Syndrome, toxins (Ciguatera), Tick Paralysis, DM neuropathy (non-emergent).
- NMJ disease: Myasthenia Gravis crisis, Botulism, Organophosphate Toxicity, Lambert-Eaton Myasthenic Syndrome.
- Muscle disease: dermatomyositis, polymyositis, alcoholic myopathy, Rhabdomyolysis.
- Can't miss dx:
- Non-neuromuscular weakness can be infectious, cardiovascular, metabolic, toxicologic:
- Can't miss dx:
- ACS/MI
- Arrhythmia/Syncope
- severe infection/Sepsis
- Hypoglycemia
- Periodic paralysis (electrolyte disturbance, K, Mg, Ca)
- Respiratory failure
- Emergent Dx:
- Symptomatic Anemia
- Severe dehydration
- Hypothyroidism
- Polypharmacy
- Malignancy
- Can't miss dx:
Workup
On all pts:
- CBC (anemia)
- Chem 10 (electrolyte disturbance,hypoglycemia, uremia)
- ECG (Ischemia,hypo/hyperkalemia)
Consider:
- CK (mypoathies)
- ESR
- CXR and UA (pt w/infectious sx and elderly)
- FVC (if e/o resp compromise, i.e. Myasthenia, GBS)
- CT head (if focal findings, AMS, h/o cancer, h/o any trauma in pt on anticoagulation)
- LP (CNS infection, GBS)
HPI
Physical Exam
Focus on clarifying if pt has true loss of strength and determining distribution of deficits. Check for trauma, carotid bruits, thyroid enlargement, irregular rhythm, unequal pulses, rashes or ticks.
Neuro Exam Findings
Upper Motor Neuron
- BRAIN
- Weakness - variable
- Bowel/Bladder -
- Reflexes - increased
- Sens - diminished
- Pain - no
- Asymmetric/unilateral
- BRAINSTEM
- "crossed" findings - ipsilateral cranial nerve weakness and contralateral hemiparesis
- CORD
- Weakness - fixed level
- Bowel/Bladder - YES
- Reflexes - increased
- Sens - diminished
- Pain - +/-
Lower Motor Neuron
- NERVE
- Weakness - distal > proximal and ascends
- Bowel/Bladder - NO
- Reflexes - diminished
- Sens - nl/paresthesias
- Pain - no
End-Plate/Muscle
- MOTOR END PLATE
- Weakness - occular,bulbar and descends, fatigable
- Bowel/Bladder - NO
- Reflexes - nl/diminished
- Sens - nl
- Pain - no
- MUSCLE
- Weakness - proximal > distal
- Bowel/Bladder - NO
- Reflexes - nl/diminished
- Sens - nl
- Pain - +/-
Intubation Indications
- Severe fatigue
- Inability protect airway
- Rapidly increasing PaCO2
- Hypoxemia despite O2
- FVC <12 mL/kg
- Neg Insp Force <20 cm H2O
Source
8/15/13 CELEDON (adapted from Rosen, Tintinalli, Intro to Clincal EM, Lampe, Birnbaumer, Donaldson)