01 12 / 2011

Detect subtle weakness with:

  • Heel Rise Test: Stand on one foot and rise heel
  • Squat Test: Have them squat and then try to stand

Botulism (Descending)

  • Presynaptic ACh toxin-mediated inhibition
  • Irreversible until new NM junctions are made
  • Wound botulism from IVDU
  • Descending paralysis/CN palsies
    • Proptosis, diplopia, facial weakness, speech changes, ptosis, double vision
  • In infants, weak suck and cry, floppy baby
  • Admit to ICU for observation
  • Give antitoxin
    • Test for hypersensitivity first before given (made from horse serum)
    • Do not give to infants
    • Can instead get HBIG (human botulism immunoglobulin), call 510.231.7600.

Guillan-Barre (Ascending)

  • Assoc with campylobacteria diarrhea
  • Weakened reflexes
  • Peripheral polyneuropathy
  • 1–4 week prodrome
  • Can be confused with Transverse Myelitis or Epidural Abscess/Compression
    • Usually GBS has less sensory deficits than the others
    • No clonus in GBS, Babinski negative in GBS
  • Having pain with sensory deficits does NOT rule out GBS
  • Miller-Fisher Variant: Ophthalmoplegia, areflexia, ataxia
  • Descending paralysis instead of ascending
  • Pure Sensory GBS: Ascending sensory loss with absent reflexes
  • Autonomic-Only GBS
  • LP can diagnose: high protein, few WBCs (albumincytologic dissociation).
    • Can be normal in first week
  • To assess disposition, check FVC.
    • FVC normal = 65ml/kg
    • If less than 1/2 predicted, admit to ICU
  • High Risk GBS for Respiratory Compromise:
    • Onset to admission < 7 days
    • Inability to lift elbows/head above bed
    • Inability to stand
    • Ineffective cough
    • Elevated LFTs
  • Treatment is either IVIG or Plamapheresis
  • No benefit to steroids

28 11 / 2011

Ask About:

  • Alcohol
  • Diabetes
  • HIV
  • Heavy Metals
  • Syphillis

Carpal Tunnel

  • Association with pregnancy, hypothyroid, DM, renal failure, acromegaly, steroid use
  • Weakness of thumb adduction, thenar atrophy
  • Median nerve distribution pain
  • Place in splint with NSAIDs

From Critical Decisions June 2010