Brandon Foreman gives a practical approach to the diagnosis and workup of neuromuscular disease in neuro critical care. Neuromuscular diseases are common and include chronic autoimmune disorders such as myasthenia gravis, acute demyelinating disorders like Guillain Barre, paraneoplastic disorders, and toxidromes such as botulism. The presentation of many neuromuscular diseases can be subtle: diffuse weakness, subtle swallowing difficulty, or double vision. Many patients do not present until its nearly too late, and timely diagnosis can lead to rapid stabilization of airway, autonomics, and other potentially lethal complications and expedited treatment of the underlying cause. Brandon’s first piece of advice pertaining to neuromuscular disease in critical care? You have to recognise it! There are subtle clues littered through the history and physical exam of a patient. A nasal voice indicates oropharyngeal weakness. This is important to recognise and can tip you off to the likely diagnosis. New onset eye complaints or proximal muscle weakness will likewise lead the clinician to consider neuromuscular weakness. If a patient presents with a history of difficulty rising from a chair or double vision think of disorders such as Guillain Barre or myasthenia gravis. A big question in the early management of patients with neuromuscular weakness is the need for intubation. Brandon advises throwing away some of the traditional methods of answering this question that rely on lung function testing and often involve a respiratory physician. Instead, he runs through a handy list of diagnostics, possible at the bedside to determine the need for mechanical ventilation in this population. Brandon discusses clinical pearls to hone in out what a patient is presenting with. Test such as Simpson’s test or the “ice bag test” are useful addition to any clinician’s toolbox. Finally, Brandon takes you through the initial workup of patients presenting with likely neuromuscular weakness, equipping you with the knowledge to start the process before calling the neurology registrar!

1. Brandon Foreman, MD FACNS
DIAGNOSING CRITICAL NEUROMUSCULAR DISEASE

2. www.faketrumptweet.com

3. Source:GoogleImages,Youtube,Giphy

4. The 20-30-40 Rule
• Forced Vital Capacity < 20 ml/kg
• Maximum Inspiratory Pressure/Negative Inspiratory
Force > -30 cmH20
• Maximum Expiratory Pressure < 40 cmH20
MG: Thieben 2005; GBS: Lawn 2001, Sharshar 2003
INTUBATE OR NOT TO INTUBATE?*
*I realize I am your humble Neurology Consultant
The Rule of 20s
RR > 20 or belly dancing
FVC < 20 mg/kg or cannot count > 20 in one breath
PaCO2 > 20mmHg from expected normal

5. DYSAUTONOMIA

6. If your acute neuromuscular weakness
patient is hypoxic…-
Source:GoogleImages

7. HISTORY
HISTORY
HISTORY
SourceGoogleImages;DecisionMakinginEmergencyCriticalCare2015

8. http://www.ebaumsworld.com/pictures/chicks-with-steve-buscemi-eyes/81434620/;
NairIndianJOphthalmol2014;ToykaNeurology2006

9. Source:Berktree.com

10. Neuropathy
Neuromuscular
Junction (MG)
Myopathy
GBSBotulism
Source:http://www.accademia.org/explore-museum/artworks/michelangelos-david/

11. Source:GoogleImages,Youtube,Giphy
• Cr, K
• CBC
• TSH
• LFTs
• Distal Weakness and areflexia? LP
• Proximal Weakness? ESR/CRP, CK
• Oropharyngeal weakness? ABG, UA, CXR
• Respiratory symptoms and oropharyngeal/ocular weakness?
-> MRI Brain
• Respiratory symptoms and hyperreflexia or sensory level?
-> MRI C-spine

12. THANK YOU