An elderly woman presents with a 9 month history of increasing weakness of all four (4) limbs and a two-day history of inability to swallow her saliva, or cough. She is dyspnoeic, hypoxaemic and her Vital Capacity is 400mls. Outline the key features of your management.
This appears to be a chronic problem, and there is probably not time to discuss possible/probable
futility of more active therapy. Key features of management should include:
• clinical assessment to help establish the diagnosis (especially sensation, pattern of weakness
[eg. lower motor neurone, long tract signs etc])
• reasonable to intubate/ventilate (hopefully after a full clinical examination has been performed)
• drugs for intubation – such as the acute risk with suxamethonium, and the potential harm associated with the use of neuromuscular blockade
• establishment of specific diagnosis (from disorders of muscle, neuromuscular junction, peripheral nerves, anterior horn cell disease, cord lesions and central lesions)
• collaboration with neurologists,
• relevant investigations (eg. EMG, LP, CT, MRI etc)
• general supportive care, including consideration of early tracheostomy.
Common problems related to lack of relevant detailed knowledge.
This question brings about another round of differential diagnosis generation, for the question "what is causing this whole-body weakness". The assessment of the critically ill patient with weakness is well discussed elsewhere.
Chapter 51 (pp. 568) Acute cerebrovascular complications by Bernard Riley and Thearina de Beer
Chapter 57 (pp. 617) Neuromuscular diseases in intensive care by George Skowronski and Manoj K Saxena
Yuki, Nobuhiro, and Hans-Peter Hartung. "Guillain–Barré syndrome." New England Journal of Medicine 366.24 (2012): 2294-2304.
Jani, Charu. "Critical Illness Neuropathy." Medicine (2011): 237.
Young, G. Bryan, and Robert R. Hammond. "A stronger approach to weakness in the intensive care unit." Critical care 8.6 (2004): 416.
Mareska, Michael, and Laurie Gutmann. "Lambert-Eaton myasthenic syndrome." Seminars in neurology. Vol. 24. No. 2. [New York]: Thieme-Stratton Inc.,[c1981-, 2004.