Weakness

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(Acute/Generalized)


TESTS

cbc

chem 10 (esp. K, Mg, Ca, Phos)

ecg

+/- CK (r/o myopathy)

+/- FVC (eval impending resp failure, i.e. Myasthenia)

+/- ABG/CT/LP/TSH/UA (rhabdo)


EXAMINATION


UPPER MOTOR NEURON

I. BRAIN

    Weakness - variable
    Bowel/Bladder -
    Reflexes - increased
    Sens - diminished
    Pain - no
    Asymmetric/unilateral

II. CORD

    Weakness - fixed level
    Bowel/Bladder - YES
    Reflexes - increased
    Sens - diminished
    Pain - +/-


LOWER MOTOR NEURON

III. NERVE

    Weakness - distal and ascends
    Bowel/Bladder - NO
    Reflexes - diminished
    Sens - nl/paresthesias
    Pain - no


END-PLATE/MUSCLE

IV. MOTOR END PLATE

    Weakness - head and descends
    Bowel/Bladder - NO
    Reflexes - nl/diminished
    Sens - nl
    Pain - no


V. MUSCLE

    Weakness - proximal
    Bowel/Bladder - NO
    Reflexes - nl/diminished
    Sens - nl
    Pain - +/-


DIFFERENTIAL DIAGNOSIS

I. UPPER

    A) Multiple sclerosis
    B) Poliomyelitis
    C) ALS (upper & lower motor)

II. CORD

    A) Painful
         i) Cord compression
    B) Painless
         i) Transverse myelitis
         ii) Spinal cord infarct
         iii) Intramedullary tumor

III. NERVE

    A) Guillian-Barre
    B) Toxic neuropthy (Ciguatera)
    C) Tick paralysis
    D) Diabetic neuropathy
    E) Porphyria

IV. MOTOR END PLATE

    A) Myasthenia gravis
    B) Botulism (descending)
    C) Organophosphate poisoning
    D) Lambert-Eaton

V. MUSCLE

    A) Painful
         i) Rhabdo
         ii) Alcoholic
         iii) Myopathy
         iv) Polymyositis
         v) Dermatomyositis
         vi) Toxins
         vii) Hypophos
         viii) Hypo-kalemia
         ix) Polymyalgia rheum
    B) Painless
         i) Familial periodic paralysis
         ii) Endocrine

VI. MIXED

    A) Upper & Lower Motor Neuron
         i) ALS
    B) Sensory & Motor
         i)

VII. NON-NEUROMUSCULAR

    A) MI
    B) Resp failure
    C) Sepsis
    D) Dehydration
    E) Anxiety
    F) Fibromyalgia/chronic fatigue
    G) Malignancy


EMERGENT THREAT/ED WORKUP

I. CORD

    - paralysis
    - MRI, neurologist

2. NERVE

    - resp failure
    - FEV1, airway mgt, ticks?, neurologist

3. MOTOR END PLATE

    - resp failure
    - FEV1, airway mgt, Tensilon Test?

4. MUSCLE

    - Rhabdo
    - urine myoglobin, serum CK, BUN/Cr
    serum K+


INTUBATION INDICATIONS

1) Severe fatigue

2) Inability protect airway

3) Rapidly increasing PaCO2

4) Hypoxemia despite O2

5) FVC <12 mL/kg

6) Neg Insp Force <20 cm H2O


2/26/06 DONALDSON (adapted from Rosen, Lampe, Birnbaumer)

adapted from Hockberger