01 12 / 2011
Paralyses Ascending and Descending
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
Peripheral Neuropathy
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
