Weakness: Difference between revisions
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==Background==
== Background ==
Acute/Generalized


==Workup==
Acute/Generalized
#cbc
 
#chem 10 (esp. K, Mg, Ca, Phos)
== Workup ==
#ecg
 
#+/- CK (r/o myopathy)
#cbc  
#+/- FVC (eval impending resp failure, i.e. Myasthenia)
#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)
#+/- ABG/CT/LP/TSH/UA (rhabdo)


==Diagnosis==
== Diagnosis ==
===Upper Motor Neuron===
 
* BRAIN
=== Upper Motor Neuron ===
**Weakness - variable
 
**Bowel/Bladder -
*BRAIN  
**Reflexes - increased
**Weakness - variable  
**Sens - diminished
**Bowel/Bladder - 
**Pain - no
**Reflexes - increased  
**Asymmetric/unilateral
**Sens - diminished  
* CORD
**Pain - no  
**Weakness - fixed level
**Asymmetric/unilateral<br>
**Bowel/Bladder - YES
*BRAINSTEM<br>
**Reflexes - increased
**&nbsp;"crossed" findings - ipsilateral cranial nerve weakness and contralateral hemiparesis&nbsp;
**Sens - diminished
*CORD  
**Weakness - fixed level  
**Bowel/Bladder - YES  
**Reflexes - increased  
**Sens - diminished  
**Pain - +/-
**Pain - +/-


===Lower Motor Neuron===
=== Lower Motor Neuron ===
* NERVE
 
**Weakness - distal and ascends
*NERVE  
**Bowel/Bladder - NO
**Weakness - distal &gt; proximal and ascends  
**Reflexes - diminished
**Bowel/Bladder - NO  
**Sens - nl/paresthesias
**Reflexes - diminished  
**Sens - nl/paresthesias  
**Pain - no
**Pain - no


===End-Plate/Muscle===
=== End-Plate/Muscle ===
* MOTOR END PLATE
 
**Weakness - head and descends
*MOTOR END PLATE  
**Bowel/Bladder - NO
**Weakness - occular,bulbar and descends, fatigable
**Reflexes - nl/diminished
**Bowel/Bladder - NO  
**Sens - nl
**Reflexes - nl/diminished  
**Pain - no
**Sens - nl  
*MUSCLE
**Pain - no  
**Weakness - proximal
*MUSCLE  
**Bowel/Bladder - NO
**Weakness - proximal &gt; distal
**Reflexes - nl/diminished
**Bowel/Bladder - NO  
**Sens - nl
**Reflexes - nl/diminished  
**Sens - nl  
**Pain - +/-
**Pain - +/-


==DDX==
== DDX ==
# UPPER
 
## [[Multiple Sclerosis]]
#UPPER  
## Poliomyelitis
##[[Multiple Sclerosis]]  
## [[ALS]] (upper & lower motor)
##Poliomyelitis  
# CORD
##[[ALS]] (upper &amp; lower motor)  
## Painful
#CORD  
### Cord compression
##Painful  
## Painless
###Cord compression  
### Transverse Myelitis
##Painless  
### Spinal cord infarct
###Transverse Myelitis  
### Intramedullary tumor
###Spinal cord infarct  
# NERVE
###Intramedullary tumor  
## Guillian-Barre
#NERVE  
## Toxic neuropthy ([[Ciguatera]])
##Guillian-Barre  
## Tick paralysis
##Toxic neuropthy ([[Ciguatera]])  
## Diabetic neuropathy
##Tick paralysis  
## Porphyria
##Diabetic neuropathy  
# MOTOR END PLATE
##Porphyria  
## [[Myasthenia Gravis]]
#MOTOR END PLATE  
## [[Botulism]] (descending)
##[[Myasthenia Gravis]]  
## Organophosphate Poisoning
##[[Botulism]] (descending)  
## [[Lambert-Eaton]]
##Organophosphate Poisoning  
# MUSCLE
##[[Lambert-Eaton]]  
## Painful
#MUSCLE  
### [[Rhabdo]]
##Painful  
### Alcoholic
###[[Rhabdo]]  
### Myopathy
###Alcoholic  
### Polymyositis
###Myopathy  
### Dermatomyositis
###Polymyositis  
### Toxins
###Dermatomyositis  
### Hypophos
###Toxins  
### [[Hypokalemia]]
###Hypophos  
### Polymyalgia rheum
###[[Hypokalemia]]&nbsp;- post prandial/ family hx/ thyroid
## Painless
###Polymyalgia rheum  
### Familial periodic paralysis
##Painless  
### Endocrine
###Familial periodic paralysis  
# MIXED
###Endocrine  
## Upper & Lower Motor Neuron
#MIXED  
### [[ALS]]
##Upper &amp; Lower Motor Neuron  
## Sensory & Motor
###[[ALS]]  
###
##Sensory &amp; Motor  
# NON-NEUROMUSCULAR
###Peripheral neuropathy
## [[MI]]
#NON-NEUROMUSCULAR  
## Resp failure
##[[MI]]  
## [[Sepsis]]
##Resp failure  
## Dehydration
##[[Sepsis]]  
## Anxiety
##Dehydration  
## Fibromyalgia/chronic fatigue
##Anxiety  
## Malignancy
##Fibromyalgia/chronic fatigue  
##Malignancy
 
== Emergent Threat/ED Workup  ==
 
#CORD
##paralysis
##MRI, neurologist
##consdier steroids in high suspicion
#NERVE
##resp failure
##FEV1, airway mgt, ticks?, neurologist
#MOTOR END PLATE
##resp failure
##FEV1, airway mgt, Tensilon Test?
#MUSCLE
##Rhabdo
##urine myoglobin, serum CK, BUN/Cr
##serum K+
 
=== Intubation Indications  ===


==Emergent Threat/ED Workup==
#Severe fatigue
# CORD
#Inability protect airway  
## paralysis
#Rapidly increasing PaCO2
## MRI, neurologist
#Hypoxemia despite O2
# NERVE
#FVC &lt;12 mL/kg
## resp failure
#Neg Insp Force &lt;20 cm H2O
## FEV1, airway mgt, ticks?, neurologist
# MOTOR END PLATE
## resp failure
## FEV1, airway mgt, Tensilon Test?
# MUSCLE
## Rhabdo
## urine myoglobin, serum CK, BUN/Cr
## serum K+


===Intubation Indications===
== Source  ==
# Severe fatigue
# Inability protect airway
# Rapidly increasing PaCO2
# Hypoxemia despite O2
# FVC <12 mL/kg
# Neg Insp Force <20 cm H2O


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


adapted from Hockberger
adapted from Hockberger  


[[Category:Neuro]]
[[Category:Neuro]]

Revision as of 16:57, 22 January 2013

Background

Acute/Generalized

Workup

  1. cbc
  2. chem 10 (esp. K, Mg, Ca, Phos)
  3. ecg
  4. +/- CK (r/o myopathy)
  5. +/- FVC (eval impending resp failure, i.e. Myasthenia)
  6. +/- ABG/CT/LP/TSH/UA (rhabdo)

Diagnosis

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 - +/-

DDX

  1. UPPER
    1. Multiple Sclerosis
    2. Poliomyelitis
    3. ALS (upper & lower motor)
  2. CORD
    1. Painful
      1. Cord compression
    2. Painless
      1. Transverse Myelitis
      2. Spinal cord infarct
      3. Intramedullary tumor
  3. NERVE
    1. Guillian-Barre
    2. Toxic neuropthy (Ciguatera)
    3. Tick paralysis
    4. Diabetic neuropathy
    5. Porphyria
  4. MOTOR END PLATE
    1. Myasthenia Gravis
    2. Botulism (descending)
    3. Organophosphate Poisoning
    4. Lambert-Eaton
  5. MUSCLE
    1. Painful
      1. Rhabdo
      2. Alcoholic
      3. Myopathy
      4. Polymyositis
      5. Dermatomyositis
      6. Toxins
      7. Hypophos
      8. Hypokalemia - post prandial/ family hx/ thyroid
      9. Polymyalgia rheum
    2. Painless
      1. Familial periodic paralysis
      2. Endocrine
  6. MIXED
    1. Upper & Lower Motor Neuron
      1. ALS
    2. Sensory & Motor
      1. Peripheral neuropathy
  7. NON-NEUROMUSCULAR
    1. MI
    2. Resp failure
    3. Sepsis
    4. Dehydration
    5. Anxiety
    6. Fibromyalgia/chronic fatigue
    7. Malignancy

Emergent Threat/ED Workup

  1. CORD
    1. paralysis
    2. MRI, neurologist
    3. consdier steroids in high suspicion
  2. NERVE
    1. resp failure
    2. FEV1, airway mgt, ticks?, neurologist
  3. MOTOR END PLATE
    1. resp failure
    2. FEV1, airway mgt, Tensilon Test?
  4. MUSCLE
    1. Rhabdo
    2. urine myoglobin, serum CK, BUN/Cr
    3. 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

Source

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

adapted from Hockberger

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