15 Great Posts Related To The Dx And Rx Of Muscle Weakness From emDocs With Links To Two Additional Resources From EMC

Note to myself:6-2-2021: Continue review starting at #11 below.

In this post, I link to the results of a search on Guillain-Barre Syndrome (GBS) from the emDocs site . The search yielded a list of great articles related to muscle weakness.

But the best place to start on the topic of muscle weakness is to first review the two Emergency Medicine Cases podcasts and show notes on the topic and then review the 15 great articles:

• Ep156 ED Approach to Acute Motor Weakness
  • “In this Part 1 of of our 2 part podcast on weakness, Episode 156 – Approach to Acute Motor Weakness, with the help of EM physician Dr. George Porfiris, the winner of many teaching awards and Dr. Roy Baskind, neurologist at North York General, creator of a brand-new neuro podcast The Encephalopod, we turn the assessment of the weak patient into a satisfying, frustration-free, experience for you by laying out a simple approach and feeding you the key clinical pearls that will help you clinch the diagnosis. This is not about generalized malaise or fatigue from dehydration or anemia or sepsis. This is not about hypoglycemia, polypharmacy, or medication side effects. This is not about the details of stroke, traumatic spinal cord injuries or chronic neurodegenerative disorders, all of which can present with the chief complaint of weakness. What we do in this podcast is throw out the word “weakness” and instead, zero in on the specific symptoms of loss of true neuromuscular strength. We dig into the patterns of decreased true neuromuscular strength and how they can narrow our differential. We discuss some key associated symptoms that will narrow our differential even further. We simplify the distinction between UMN and LMN and see how that can narrow our differential even further. And in the next part of this two part podcast we review the key features of the most emergent muscle weakness diagnoses we need to act on in the ED…”
  • Helman, A. Porfiris, G. Baskind, R. Episode 156-Acute Weakness. Emergency Medicine Cases. May, 2021. https://emergencymedicinecases.com/acuteweakness. Accessed 6-5-2021
• Ep157 Neuromuscular Disease for Emergency Medicine
  • “There is a long list of rare neuromuscular diseases. Nonetheless, there are a few that you are likely to see in the ED, that are relevant to Emergency Medicine because they require timely diagnosis and treatment. In this Part 2 of our 2-part series on acute motor weakness with Roy Baskind and George Porfiris, we keep it short and simple by limiting our discussion to the key clinical clues and management strategies of two of the more common acute life-threatening neuromuscular diseases, myasthenia gravis and Guillain Barré syndrome, and how to distinguish them from their mimics…”
  • Helman, A. Baskin, R. Porfiris, G. Neuromuscular Disease for Emergency Medicine. Emergency Medicine Cases. June, 2021. https://emergencymedicinecases.com/neuromuscular-disease. Accessed 6-5-2021.

And now below are the outstanding posts related to muscle weakness from emDocs:

1. Guillain-Barré Syndrome – Third time’s the charm
   MAY 22ND, 2017 SREE NATESAN
   1. “Base: 60 year-old male PMH of Htn, DM, presents to the ED with complaints of generalized weakness and fatigue.  His family states you are the third provider he has seen in the last week.  He was seen by the primary care doctor for fever and cough 5 days prior and started on Azithromycin for bronchitis and was seen at the Urgent care for fatigue and weakness 1 day prior to presentation where he was treated with IVF.  Despite antibiotics and IVF, he reports continued symptoms of generalized weakness.  He denies focal weakness, headache or neck stiffness and has an otherwise negative ROS.  Vital signs are within normal limits on arrival.  PE reveals a normal exam except for the neurologic component which identifies decreased strength in bilateral LE with areflexia.  What is your next step?”
2. Urinary Retention in Kids
   DEC 11TH, 2020 SEAN M. FOX
   1. “Once again the Ped EM Morsels will address a topic that accentuates the fact that children are not aliens to be feared, but rather a special population of humans. Yes, children can be afflicted with conditions traditionally considered in adults (ex, Pulmonary Embolism, A-Fib, and Kidney Stones), but kids will often have different risk factors and associated conditions. Another entity that fits this description I encountered just this week. Let’s take a minute to review (what I had to review) on Urinary Retention in Kids:”
3. Infectious Diarrhea
   JAN 24TH, 2020 SEAN M. FOX
   1. “Diarrhea is no joking matter (although it can be the butt of many jokes – see what I did there?). It causes a large burden to patients (ex, dehydration), care providers, and the healthcare system. Fortunately, more often than not, it is a self-limited process that requires focusing on maintaining hydration status.  There are occasions, however, that may spur one on toward considering antibiotic administration for that “infectious diarrhea.”  Recently, the Infectious Disease Society of America (IDSA) published guidelines related specifically to this.  So, let’s take a brief moment to review their recommendations on management of Infectious Diarrhea:”
4. ToxCard: Paralysis Mimics – Toxicologic Causes of Paralysis
   AUG 20TH, 2019 JENNA PALLANSCH
   1. “Case:A 6-year-old female presents to the Emergency Department (ED) for weakness and difficulty walking. Vitals on arrival: HR 105 bpm, RR 20 breaths/min, BP 114/72 mmHg, 95% SpO2 on room air, T 99.7F.On exam, she has 3/5 strength in bilateral lower extremities and subjective paresthesias in her bilateral lower extremities and hands. She appears to have trouble swallowing with intermittent coughing but has a normal voice. She is unable to walk on her own without falling.
      

      Questions:

      1. What is the toxicologic differential for acute onset paralysis?
      2. What features are most important in your history and exam?
      3. Which toxins have specific antidotes?
5. The Patient Acutely Can’t Walk: Pearls and Pitfalls
   MAY 23RD, 2019 KELSEY MARTIN
   1. “Case 1A 65-year-old male presents with sudden weakness and pain in the left leg. He denies trauma. He states that this weakness began suddenly two hours ago, but he was able to ambulate normally without any assistance earlier this morning before his symptoms began. He is now unable to ambulate, which brought him to the ED. What is the most likely cause of his inability to walk?
      

      Introduction

      A patient may be unable to walk for many reasons. The patient may not be able to walk because of severe pain in an extremity that may be due to a fracture or dislocation or other muscle-skeletal problem, or because of weakness. Weakness is a common complaint in the ED, and a most challenging one. The first priority with a patient presenting with acute weakness should be to evaluate and stabilize, if necessary, the patient’s airway, breathing, and circulation. Even if initially the patient appears to be stable, the patient’s underlying etiology of the acute weakness may cause the weakness to be progressive and eventually interfere with the patient’s airway and/or breathing. Therefore, the ABCs of these patients must be closely monitored, reevaluated, and stabilized as necessary.

      Once the patient is stabilized, an accurate and thorough history of the present illness is needed (1). If the patient states that the main problem is weakness, what does the patient mean by weakness?

6. Influenza in the ED: The Basics and Why is my patient so sick?
   APR 29TH, 2019 CAROLINA MENDOZA
   1. “Case A 40-year-old male with no past medical history presents from home with cough, congestion, shortness of breath, and fever for the past six days. His fever is subjective, and the shortness of breath is progressively worsening. He has been taking over the counter cold medicine and NSAIDs with little relief. Initial vital signs show a temperature of 103 degrees Fahrenheit, pulse of 120 beats per minute, blood pressure of 128/70 mm Hg, respiratory rate of 28, and an oxygen saturation of 89% on room air. On exam, patient appears diaphoretic with an increased work of breathing. He is placed on a non-rebreather mask, and O2 saturation improves to 100%.
      

      Background

      Influenza is an acute upper respiratory infection that typically occurs during the winter months (November to March) caused by the influenza A and B viruses. The Centers for Disease Control and Prevention (CDC) defines influenza as an illness with a fever of greater than 100°F and either a sore throat or cough in the absence of other known causes (1). However, a patient’s clinical presentation can vary by age, and there are a wide variety of symptoms associated with influenza infection. Studies have attempted to distinguish the clinical presentations of patients with influenza, but there has been no clinical finding with a sensitive or specific enough positive likelihood ratio to rule out or rule in influenza (2-4). Among those with influenza fever, cough, sore throat, headache, myalgia, and rhinitis appear to be the most common symptoms (1). Cough and fever within 48 hours of symptoms onset has the best positive predictive value (79%) of influenza (4). Vomiting and diarrhea are more frequently seen in the pediatric population, but these symptoms are far less likely than the typical upper respiratory symptoms (5). Additionally, numerous complications can occur after an infectious with influenza including acute bronchitis, secondary bacterial pneumonia, otitis media, myocarditis, pericarditis, myoglobinuria, renal failure, encephalitis, and toxic shock syndrome (3).                                                                                                                                                                           “In the United States, about 20% of the population is infected with the influenza virus during the winter season (1). Transmission of the virus occurs through large droplets and direct contact with small particle aerosols (3). A higher prevalence occurs in school children given close proximity in confined spaces. Viral shedding occurs 24 to 48 hours before onset of illness and ceases 6 to 7 days later. Periods of shedding are longer in children and elderly with studies showing up to a mean of 19 days after start of symptoms (3). Those at higher risk for complications include children and adults with pre-existing respiratory diseases like asthma and chronic obstructive pulmonary disease, morbid obesity, children under 2 years of age, and elderly patients (particularly those > 75 years old) (7). Studies have shown that children younger than 6 months of age and children with chronic medical conditions also have a high risk of mortality related to influenza (1, 5). In the adult population, about 90% of the deaths occur in people greater than 65 years of age (6, 8).”

7. Journal Feed Weekly Wrap-Up
   DEC 8TH, 2018 CLAY SMITH

   1. #2: Acute Flaccid Myelitis – Could You Make the Diagnosis?

      Spoon Feed
      There has been a surge of acute flaccid myelitis (AFM) cases this year, similar to poliomyelitis. The etiology is unknown. Here is how to recognize and treat it based on what we know at this point.

      Why does this matter?
      If someone or their child has sudden onset weakness, where will they come? They will come to the ED. We need to be aware of this clinical presentation and know how to recognize and manage it.

      Don’t be weak – learn about acute flaccid myelitis

      • There have been 386 confirmed cases of AFM across the US
      • Eighty confirmed cases in 2018, as of November 2.
      • Most have occurred in children.
      • It’s still rare, one in a million.

      Clinical Presentation

      • Here is the standard case definition.
      • It is similar to poliomyelitis.
      • There is rapid onset of flaccid weakness in one or more limbs over hours to days.
      • “Cranial nerve abnormalities, resulting in facial weakness, ophthalmoplegia, and bulbar signs such as dysarthria and dysphagia, may be variably present.”
      • This year, 99% of confirmed cases had a viral illness (respiratory or, less often, GI) or fever (81%) in the 4 weeks prior to onset of weakness.
      • MRI shows characteristic spinal cord gray matter edema, predominantly affecting the anterior horn or central cord; “also notable signal abnormality and enhancement of ventral nerve roots in some patients, as well as variable lesions noted in the brainstem, particularly the dorsal pons.”
      • CSF pleocytosis with >5 WBCs is often seen. But there is no, “cytoalbuminologic dissociation (elevated CSF protein in the absence of pleocytosis) as seen in Guillain Barré syndrome.”
8. Generalized Non-Focal Weakness in the Elderly
   JUN 28TH, 2018 JOSHUA KIM
   1. Just prior to shift change, you see a 74-year-old male who presents with generalized weakness that started about a month ago. He says he has noticed that he has been feeling much more tired and that he feels like he can’t do as much as he used to. He does not focalize his weakness but notices that he wakes up in the morning just feeling exhausted. He has a prior history of hypertension and type 2 diabetes and he reports he is taking all of his medications and there are no recent changes in his medications. He states he used to work as a factory worker for 40 years but has recently moved to a new apartment. He is a regular smoker and has been drinking more, denies any illicit drug use.”VS include BP 139/87, HR 84, RR 13, O2 Saturation 97%, T 98.7.”What are the next steps? How should we approach an elderly patient with generalized weakness?”
9. Influenza and Considerations Regarding Infectious Mimics
   MAR 2ND, 2017 ERICA SIMON
   1. “A 57-year-old male with a previous medical history of hypertension and hyperlipidemia presents to the emergency department (ED) with the chief complaint of chills, headache, cough, and generalized malaise.  The patient reports the onset of his symptoms 48 hours prior with temperatures peaking at 102.2°F.  Review of systems is notable for a sick contact – a granddaughter with “the flu.”  The patient denies nausea, vomiting, diarrhea, and abdominal pain.  He denies recent travel and reports an inability to obtain an influenza vaccination secondary to a lack of health insurance.Triage Vital Signs:  T103.1°F, HR 126, RR 18, SpO2 95% RAWhen approaching this patient, what life threatening conditions that you should be considering?  While a diagnosis of influenza is likely high on your list, what clues should you be looking for during the physical examination that might suggest the need for an alternative evaluation and treatment?Let’s take a minute to review influenza mimics.
10. Undifferentiated Weakness: ED-Focused Approach and Management
    MAR 11TH, 2016 LARYSSA PATTI
    1. “You are three-quarters of the way through your shift in the emergency department (ED) and your next patient has one of the most dreaded chief complaints. The triage note states that your patient is a 75-year-old female with three days of WEAKNESS. Even the most experienced provider would want to sneak that triage note back in the rack without anyone noticing. Weakness can be a sign of any pathology and this article attempts to provide some steps toward evaluating and managing the weak patient.”
11. Bell’s Palsy: Pearls and Pitfalls in Evaluation and Management
    FEB 24TH, 2016 DREW A. LONG
    1. “A 32 year-old man presents to the Emergency Department complaining of facial drooping. He states that over the past two days, he has had increasing difficulty moving the right side of his face. He first noticed his mouth drooping on the right side along with difficulty closing his right eye. He has no history of any previous episode like this, no past medical history, and no history of trauma. His vitals are normal. Physical exam reveals complete paralysis of the right side of his facial muscles, though the rest of the neurologic exam is normal. What conditions are important to rule out? How do you treat this patient? What do you tell him when he asks if and how soon he will regain normal function?”
12. Zika Virus: What do you need to know?
    FEB 13TH, 2016 BRIT LONG
    1. “IntroductionIn January 2016, the U.S. and European Centers for Disease Control and Prevention advised that pregnant women postpone travel to any area where Zika virus transmission was currently occurring.^1-3 Just a year prior, the majority of the public had never heard of Zika virus. This little-known virus currently dominates headlines and has created public fear unseen since the Ebola virus in 2014. Due to public perception of this virus and potential complications, emergency providers must know when to be concerned for this virus and what conditions to consider.Zika virus was first discovered in the Zika Forest of Uganda in 1947.⁴ Until the early 2000s, it was largely confined to Africa and Asia. Since 2014, it has been reported in South America, Central America, the Caribbean, Mexico, and Puerto Rico.⁵ Transmission has occurred in travelers returning from the infected regions to non-endemic countries, such as the United States and Western Europe.⁶
13. D-List Superbugs: Clostridium botulinum
    APR 23RD, 2015 MANPREET SINGH

    1. Case #1:

       An 8 week-old male infant brought in by parents for decreased PO intake and increased fussiness x 2 days. He was born at term after an uncomplicated pregnancy, was exclusively breastfed and developing appropriately. Vitals were stable and patient was afebrile. On exam infant had a strong cry but noted to not hold head up well when picked up and eye movements were delayed. Reflexes were intact.  He would not feed with breast or formula in the ED with multiple attempts noted to have a weak suck response. Workup was initially targeted to sepsis and dehydration based on the concerning findings. Urinalysis, chest x-ray, and spinal fluid were negative for infectious etiology. IV antibiotics and IV fluids were started and admission to PICU.

       Upon consultation with PICU attending and his exam there was immediate concern for infantile botulism. Mother was unemployed and father worked as a construction worker. BIG-IV was ordered and administered within 7 hours of suspicion for infection. Patient within 10 hours of PICU admission was noted to have poor respiratory effort and was intubated for ventilator support. Remained in ICU for 6 days and was extubated on day 4.

       Case #2:

       A 2-month-old female presented with a 5-day history of lethargy, poor feeding, constipation, and rhinorrhea. Her older siblings had concurrent upper respiratory tract infections. She was born at term, following an uncomplicated pregnancy. She was previously well. She is formula fed.

       On examination, she appeared lethargic, had a weak cry and was noted to have droopy eyelids. There were no other significant clinical findings. She was started on intravenous antibiotics for suspected sepsis following a full septic work-up. Due to poor respiratory effort patient was intubated and transferred to a tertiary care hospital with a high concern for infantile botulism. Upon arrival to pediatric intensive care unit patient was continued on IV antibiotics and BIG-IV was given 5 hours after arrival. Patient went on to stay in PICU for 5 days then was extubated and began to have good oral intake. Transferred to ward bed for 3 days and went on to be discharged with full recovery on day 9 of hospitalization.

       Most common admitting diagnosis: Bronchiolitis with dehydration and sepsis 

14. Unlocking Common ED Procedures – The Impossible Space: Lumbar Punctures
    JAN 24TH, 2019 ANTHONY DEVIVO
    1. “emDocs is proud to introduce a new series focused on emergency medicine procedures! This series will provide key information on procedural steps, indications, contraindications, pearls, and pitfalls. Today, the lumbar puncture!
       1. “Check out our new downloadable procedure card with QR code link to the article. [Link is to the PDF LP procedure] Print them out and be ready to go over it with your learners.
    2. “CaseA 22-year-old male with no significant past medical history presents to the Emergency Department for 8 hours of a bitemporal headache which woke him from sleep this morning. He says the headache is very severe and the worst he’s had. He affirms the headache has mildly improved from its onset but since then has developed nausea, light sensitivity, and neck stiffness. He denies fever, chills, weakness or numbness of the extremities, or syncope. He has no recent travel, sick contacts, history of headaches in the past, or any history of IV drug use.
       

       Background

       This presentation is well known to emergency medicine physicians as a classic story concerning for subarachnoid hemorrhage. The workup generally begins with a noncontrast CT of the head to assess for blood in the subarachnoid space, which is nearly 100% sensitive if performed within 6 hours of symptoms onset. However, after 6 hours, the sensitivity begins to decline and quickly becomes inadequate for ruling out a subarachnoid hemorrhage.¹ A CT angio may also be performed order to assess for any venous malformations that might be the potential source of bleeding. However, in cases of high clinical suspicion, a CT angio without evidence of vascular malformation is controversial in its ability to rule out SAH. Inevitably, even with all the technology and current literature at our fingertips, a subarachnoid hemorrhage in a patient with this timeframe and high clinical suspicion must be ruled out with a lumbar puncture.

       Lumbar puncture is the primary means by which physicians gain access to the cerebrospinal fluid (CSF) for analysis for a variety of suspected conditions. This procedure is performed by introducing a hollow 20-22 gauge needle into the cerebrospinal space beneath the lower lumbar vertebra.^2-3 Below we will further discuss indications, contraindications, performing the procedure, and complications of a lumbar puncture and their management.

15. EM in 5: Mumps
    NOV 1ST, 2018 ANNA PICKENS
    1. “Welcome to this week’s edition of EMin5 by Dr. Anna Pickens. Today we are focusing on Mumps!”
16. EM Boards Survival Guide: Neurology 1
    OCT 25TH, 2018 ALEX KOYFMAN
    1. “Welcome back to the EM Boards Survival Guide! [Link is to a list of all the Guides to date] This emDocs series will provide you with regular tips and must-know items for EM boards and inservice.* Each post will feature several key takeaways on a specific organ system. This week we cover neurology.”

*The EM Boards Survival Guide series is an awesome learning resource for all primary care clinicians.