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Sivadasan A, Cortel-LeBlanc MA, Cortel-LeBlanc A, Katzberg H. Peripheral nervous system and neuromuscular disorders in the emergency department: A review. Acad Emerg Med 2024; 31:386-397. [PMID: 38419365 DOI: 10.1111/acem.14861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 11/30/2023] [Accepted: 12/21/2023] [Indexed: 03/02/2024]
Abstract
INTRODUCTION Acute presentations and emergencies in neuromuscular disorders (NMDs) often challenge clinical acumen. The objective of this review is to refine the reader's approach to history taking, clinical localization and early diagnosis, as well as emergency management of neuromuscular emergencies. METHODS An extensive literature search was performed to identify relevant studies. We prioritized meta-analysis, systematic reviews, and position statements where possible to inform any recommendations. SUMMARY The spectrum of clinical presentations and etiologies ranges from neurotoxic envenomation or infection to autoimmune disease such as Guillain-Barré Syndrome (GBS) and myasthenia gravis (MG). Delayed diagnosis is not uncommon when presentations occur "de novo," respiratory failure is dominant or isolated, or in the case of atypical scenarios such as GBS variants, severe autonomic dysfunction, or rhabdomyolysis. Diseases of the central nervous system, systemic and musculoskeletal disorders can mimic presentations in neuromuscular disorders. CONCLUSIONS Fortunately, early diagnosis and management can improve prognosis. This article provides a comprehensive review of acute presentations in neuromuscular disorders relevant for the emergency physician.
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Affiliation(s)
- Ajith Sivadasan
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Miguel A Cortel-LeBlanc
- Department of Emergency Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
- 360 Concussion Care, Ottawa, Ontario, Canada
| | - Achelle Cortel-LeBlanc
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
- 360 Concussion Care, Ottawa, Ontario, Canada
- Division of Neurology, Department of Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Hans Katzberg
- Ellen & Martin Prosserman Centre for Neuromuscular Diseases, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Abuzinadah AR, Almalki AK, Almuteeri RZ, Althalabi RH, Sahli HA, Hayash FA, Alrayiqi RH, Makkawi S, Maglan A, Alamoudi LO, Alamri NM, Alsaati MH, Alshareef AA, Aljereish SS, Bamaga AK, Alhejaili F, Abulaban AA, Alanazy MH. Utility of Initial Arterial Blood Gas in Neuromuscular versus Non-Neuromuscular Acute Respiratory Failure in Intensive Care Unit Patients. J Clin Med 2022; 11:jcm11164926. [PMID: 36013163 PMCID: PMC9410118 DOI: 10.3390/jcm11164926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/12/2022] [Accepted: 08/15/2022] [Indexed: 12/01/2022] Open
Abstract
Background: The arterial blood gas (ABG) parameters of patients admitted to intensive care units (ICUs) with acute neuromuscular respiratory failure (NMRF) and non-NMRF have not been defined or compared in the literature. Methods: We retrospectively collected the initial ABG parameters (pH, PaCO2, PaO2, and HCO3) of patients admitted to ICUs with acute respiratory failure. We compared ABG parameter ranges and the prevalence of abnormalities in NMRF versus non-NMRF and its categories, including primary pulmonary disease (PPD) (chronic obstructive pulmonary disease, asthma, and bronchiectasis), pneumonia, and pulmonary edema. Results: We included 287 patients (NMRF, n = 69; non-NMRF, n = 218). The difference between NMRF and non-NMRF included the median (interquartile range (IQR)) of pH (7.39 (7.32−7.43), 7.33 (7.22−7.39), p < 0.001), PaO2 (86.9 (71.4−123), 79.6 (64.6−99.1) mmHg, p = 0.02), and HCO3 (24.85 (22.9−27.8), 23.4 (19.4−26.8) mmol/L, p = 0.006). We found differences in the median of PaCO2 in NMRF (41.5 mmHg) versus PPD (63.3 mmHg), PaO2 in NMRF (86.9 mmHg) versus pneumonia (74.3 mmHg), and HCO3 in NMRF (24.8 mmol/L) versus pulmonary edema (20.9 mmol/L) (all p < 0.01). NMRF compared to non-NMRF patients had a lower frequency of hypercarbia (24.6% versus 39.9%) and hypoxia (33.8% versus 50.5%) (all p < 0.05). NMRF compared to PPD patients had lower frequency of combined hypoxia and hypercarbia (13.2% versus 37.8%) but more frequently isolated high bicarbonate (33.8% versus 8.9%) (all p < 0.001). Conclusions: The ranges of ABG changes in NMRF patients differed from those of non-NMRF patients, with a greater reduction in PaO2 in non-NMRF than in NMRF patients. Combined hypoxemia and hypercarbia were most frequent in PPD patients, whereas isolated high bicarbonate was most frequent in NMRF patients.
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Affiliation(s)
- Ahmad R. Abuzinadah
- Neurology Division, Internal Medicine Department, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- Neuromuscular Medicine Unit, King Abdulaziz University Hospital, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- Correspondence: ; Tel.: +966-555987830; Fax: +966-126400855
| | | | | | | | | | | | | | - Seraj Makkawi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah 22384, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah 22384, Saudi Arabia
- Department of Medicine, Ministry of the National Guard-Health Affairs, Jeddah 22384, Saudi Arabia
| | - Alaa Maglan
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah 22384, Saudi Arabia
| | - Loujen O. Alamoudi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah 22384, Saudi Arabia
| | - Noof M. Alamri
- Neurology Division, Department of Medicine, Ministry of the National Guard-Health Affairs, Riyadh 11426, Saudi Arabia
| | - Maha H. Alsaati
- Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Aysha A. Alshareef
- Neurology Division, Internal Medicine Department, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- Neuromuscular Medicine Unit, King Abdulaziz University Hospital, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Sultan Saeed Aljereish
- Department of Internal Medicine, King Saud University Medical City, College of Medicine, King Saud University, Riyadh 11472, Saudi Arabia
| | - Ahmed K. Bamaga
- Neurology Division, Pediatric Department, King Abdulaziz University Hospital, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Faris Alhejaili
- Pulmonology Division, Internal Medicine Department, King Abdulaziz University Hospital, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Ahmad Abdulaziz Abulaban
- Neurology Division, Department of Medicine, Ministry of the National Guard-Health Affairs, Riyadh 11426, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh 11426, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh 11426, Saudi Arabia
| | - Mohammed H. Alanazy
- Department of Internal Medicine, King Saud University Medical City, College of Medicine, King Saud University, Riyadh 11472, Saudi Arabia
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Rao AK, Sobel J, Chatham-Stephens K, Luquez C. Clinical Guidelines for Diagnosis and Treatment of Botulism, 2021. MMWR Recomm Rep 2021; 70:1-30. [PMID: 33956777 PMCID: PMC8112830 DOI: 10.15585/mmwr.rr7002a1] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Botulism is a rare, neurotoxin-mediated, life-threatening disease characterized by flaccid descending paralysis that begins with cranial nerve palsies and might progress to extremity weakness and respiratory failure. Botulinum neurotoxin, which inhibits acetylcholine release at the neuromuscular junction, is produced by the anaerobic, gram-positive bacterium Clostridium botulinum and, rarely, by related species (C. baratii and C. butyricum). Exposure to the neurotoxin occurs through ingestion of toxin (foodborne botulism), bacterial colonization of a wound (wound botulism) or the intestines (infant botulism and adult intestinal colonization botulism), and high-concentration cosmetic or therapeutic injections of toxin (iatrogenic botulism). In addition, concerns have been raised about the possibility of a bioterrorism event involving toxin exposure through intentional contamination of food or drink or through aerosolization. Neurologic symptoms are similar regardless of exposure route. Treatment involves supportive care, intubation and mechanical ventilation when necessary, and administration of botulinum antitoxin. Certain neurological diseases (e.g., myasthenia gravis and Guillain-Barré syndrome) have signs and symptoms that overlap with botulism. Before the publication of these guidelines, no comprehensive clinical care guidelines existed for treating botulism. These evidence-based guidelines provide health care providers with recommended best practices for diagnosing, monitoring, and treating single cases or outbreaks of foodborne, wound, and inhalational botulism and were developed after a multiyear process involving several systematic reviews and expert input.
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Affiliation(s)
- Agam K Rao
- Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC
| | - Jeremy Sobel
- Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC
| | - Kevin Chatham-Stephens
- Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC
| | - Carolina Luquez
- Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, CDC
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Melone MA, Heming N, Meng P, Mompoint D, Aboab J, Clair B, Salomon J, Sharshar T, Orlikowski D, Chevret S, Annane D. Early mechanical ventilation in patients with Guillain-Barré syndrome at high risk of respiratory failure: a randomized trial. Ann Intensive Care 2020; 10:128. [PMID: 32997260 PMCID: PMC7525233 DOI: 10.1186/s13613-020-00742-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 09/18/2020] [Indexed: 02/06/2023] Open
Abstract
Introduction About 30% of patients with Guillain-Barré syndrome become ventilator dependent, of whom roughly 75% develop pneumonia. This trial aimed at assessing the impact of early mechanical ventilation (EMV) on pneumonia occurrence in GBS patients. We hypothesize that EMV will reduce the incidence of pneumonia. Methods This was a single centre, open-label, randomized controlled trial performed on two parallel groups. 50 intensive care unit adults admitted for Guillain-Barré syndrome and at risk for acute respiratory failure. Patients were randomized to early mechanical ventilation via face-mask or endotracheal intubation owing to the presence or absence of impaired swallowing (experimental arm), or to conventional care (control arm). The primary outcome was the incidence of pneumonia up to intensive care unit discharge (or 90 days, pending of which occurred first). Findings Twenty-five patients were randomized in each group. There was no significant difference between groups for the incidence of pneumonia (10/25 (40%) vs 9/25 (36%), P = 1). There was no significant difference between groups for the time to onset of pneumonia (P = 0.50, Gray test). During follow-up, there were 16/25 (64%) mechanically ventilated patients in the control group, and 25/25 (100%) in the experimental arm (P < 000·1). The time on ventilator was non-significantly shorter in the experimental arm (14 [7; 29] versus 21.5 [17.3; 35.5], P = 0.10). There were no significant differences between groups for length of hospital stay, neurological scores, the proportion of patients who needed tracheostomy, in-hospital death, or any serious adverse events. Conclusions In the present study including adults with Guillain-Barré syndrome at high risk of respiratory failure, we did not observe a prevention of pneumonia with early mechanical ventilation. Trial registration: ClinicalTrials.gov under the number NCT00167622. Registered 9 September 2005, https://clinicaltrials.gov/ct2/show/NCT00167622?cond=Guillain-Barre+Syndrome&cntry=FR&draw=2&rank=1
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Affiliation(s)
- Marie-Anne Melone
- Respiratory, Thoracic Oncology and Respiratory Intensive Care Department, Rouen University Hospital, Rouen, France.
| | - Nicholas Heming
- Medical Intensive Care Unit, Raymond Poincaré Teaching Hospital, 104 boulevard Raymond Poincaré, 92380, Garches, France
| | - Paris Meng
- Medical Intensive Care Unit, Raymond Poincaré Teaching Hospital, 104 boulevard Raymond Poincaré, 92380, Garches, France
| | - Dominique Mompoint
- Radiology Department, Raymond Poincaré Teaching Hospital, Garches, France
| | - Jerôme Aboab
- Medical Intensive Care Unit, Raymond Poincaré Teaching Hospital, 104 boulevard Raymond Poincaré, 92380, Garches, France
| | - Bernard Clair
- Medical Intensive Care Unit, Raymond Poincaré Teaching Hospital, 104 boulevard Raymond Poincaré, 92380, Garches, France
| | - Jerôme Salomon
- Infectious Diseases Department, Raymond Poincaré Teaching Hospital, Garches, France
| | - Tarek Sharshar
- Medical Intensive Care Unit, Raymond Poincaré Teaching Hospital, 104 boulevard Raymond Poincaré, 92380, Garches, France
| | - David Orlikowski
- Medical Intensive Care Unit, Raymond Poincaré Teaching Hospital, 104 boulevard Raymond Poincaré, 92380, Garches, France
| | | | - Djillali Annane
- Medical Intensive Care Unit, Raymond Poincaré Teaching Hospital, 104 boulevard Raymond Poincaré, 92380, Garches, France
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Italian recommendations for the diagnosis and treatment of myasthenia gravis. Neurol Sci 2019; 40:1111-1124. [PMID: 30778878 DOI: 10.1007/s10072-019-03746-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 01/31/2019] [Indexed: 12/30/2022]
Abstract
Myasthenia gravis is a well-treatable disease, in which a prompt diagnosis and an adequate management can achieve satisfactory control of symptoms in the great majority of patients. Improved knowledge of the disease pathogenesis has led to recognition of patient subgroups, according to associated antibodies, age at onset and thymus pathology, and to a more personalized treatment. When myasthenia gravis is suspected on clinical grounds, diagnostic confirmation relies mainly on the detection of specific antibodies. Neurophysiological studies and, to a lesser extent, clinical response to cholinesterase inhibitors support the diagnosis in seronegative patients. In these cases, the differentiation from congenital myasthenia can be challenging. Treatment planning must consider weakness extension and severity, disease subtype, thymus pathology, together with patient characteristics and comorbidities. Since most subjects with myasthenia gravis require long-term immunosuppressive therapy, surveillance of expected and potential adverse events is critical. For patients refractory to conventional immunosuppression, the use of biologic agents is highly promising. These recommendations are addressed to non-experts on neuromuscular transmission disorders. The diagnostic procedures and therapeutic approaches hereafter described are largely accessible in Italy.
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Prabhakar H, Ali Z. Intensive Care Management of the Neuromuscular Patient. TEXTBOOK OF NEUROANESTHESIA AND NEUROCRITICAL CARE 2019. [PMCID: PMC7120052 DOI: 10.1007/978-981-13-3390-3_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Neuromuscular emergencies are a distinct group of acute neurological diseases with distinct characteristic presentations. Patients who suffer from this group of diseases are at immediate risk of losing protection of their native airway as well as aspirating orogastric contents. This is secondary to weakness of the muscles of the oropharynx and respiratory muscles. Although some neuromuscular emergencies such as myasthenia gravis or Guillain-Barré syndrome are well understood, others such as critical illness myopathy and neuropathy are less well characterized. In this chapter, we have discussed the pathophysiology, diagnostic evaluation, and management options in patients who are admitted to the intensive care unit. We have also emphasized the importance of a thorough understanding of the use of pharmacological anesthetic agents in this patient population.
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Affiliation(s)
- Hemanshu Prabhakar
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Zulfiqar Ali
- Division of Neuroanesthesiology, Department of Anesthesiology, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir India
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Abstract
Acute neurological problems are common, accounting for 10-20% of medical admissions. In the coming years, there will be increased neurology involvement in the acute care of these patients complementing traditional outpatient-based services. Models of acute neurology are reliant on close collaboration between the emergency department, acute medicine and neurology and should integrate with existing hyperacute stroke pathways. In this article the authors briefly describe the two models of acute neurology set up recently in our neuroscience group and suggest a clinical approach that may help non-neurologists involved in acute care settings. The authors emphasise some of the lessons learnt in delivering the service, particularly the importance of focusing on the acute problem and tailoring the examination and investigations to tackling it in the context of the patient's functional level and personal circumstances. Early neurology intervention can reduce admission and hospital length of stay.
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Affiliation(s)
- Kuven K Moodley
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Arani Nitkunan
- St George's University Hospitals NHS Foundation Trust, London, UK and Croydon University Hospital, Croydon, UK
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Hawkes MA, Rabinstein AA. Cervical spine disease: A possible cause of neuromuscular respiratory failure. Neurol Clin Pract 2018; 8:e34-e36. [PMID: 30588386 DOI: 10.1212/cpj.0000000000000507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 07/16/2018] [Indexed: 11/15/2022]
Affiliation(s)
- Maximiliano A Hawkes
- Department of Neurology, Division of Critical Care Neurology, Mayo Clinic, Rochester, MN
| | - Alejandro A Rabinstein
- Department of Neurology, Division of Critical Care Neurology, Mayo Clinic, Rochester, MN
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