Skip to main content

Advertisement

SpringerLink
Log in

Emergency Neurological Life Support: Acute Non-Traumatic Weakness

  • Review Article
  • Published:
Neurocritical Care Aims and scope Submit manuscript

Abstract

Acute non-traumatic weakness may be life-threatening if it involves respiratory muscles or is associated with dysautonomia. Most patients presenting with an acute muscle weakness have a worsening neurologic disorder that requires a rapid, systematic approach, and detailed neurologic localization of the findings. In many patients, urgent laboratory tests are needed and may involve neuroimaging. Because acute weakness is a common presenting sign of neurological emergencies, it was chosen as an Emergency Neurological Life Support protocol. An inclusive list of causes of acute weakness is explored, both by presenting complaint and anatomical location, with an outline of the key features of the history, examination, investigations, and treatment for each diagnosis.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Mehta S. Neuromuscular disease causing acute respiratory failure. Respir Care. 2006;51:1016–21 (discussion 1021–1023).

    PubMed  Google Scholar 

  2. Lawn ND, Fletcher DD, Henderson RD, Wolter TD, Wijdicks EF. Anticipating mechanical ventilation in Guillain–Barre syndrome. Arch Neurol. 2001;58:893–8.

    Article  PubMed  CAS  Google Scholar 

  3. Abel M, Eisenkraft JB. Anesthetic implications of myasthenia gravis. Mt Sinai J Med. 2002;69:31–7.

    PubMed  Google Scholar 

  4. Orebaugh SL. Succinylcholine: adverse effects and alternatives in emergency medicine. Am J Emerg Med. 1999;17:715–21.

    Article  PubMed  CAS  Google Scholar 

  5. Novy J, Carruzzo A, Maeder P, Bogousslavsky J. Spinal cord ischemia: clinical and imaging patterns, pathogenesis, and outcomes in 27 patients. Arch Neurol. 2006;63:1113–20.

    Article  PubMed  Google Scholar 

  6. Brinar VV, Habek M, Brinar M, Malojcic B, Boban M. The differential diagnosis of acute transverse myelitis. Clin Neurol Neurosurg. 2006;108:278–83.

    Article  PubMed  Google Scholar 

  7. DeRosa MA, Cryer PE. Hypoglycemia and the sympathoadrenal system: neurogenic symptoms are largely the result of sympathetic neural, rather than adrenomedullary, activation. Am J Physiol Endocrinol Metab. 2004;287:E32–41.

    Article  PubMed  CAS  Google Scholar 

  8. Eddleston M, Buckley NA, Eyer P, Dawson AH. Management of acute organophosphorus pesticide poisoning. Lancet. 2008;371:597–607.

    Article  PubMed  CAS  Google Scholar 

  9. Roberts DM, Aaron CK. Management of acute organophosphorus pesticide poisoning. BMJ. 2007;334:629–34.

    Article  PubMed  CAS  Google Scholar 

  10. White J. Venomous animals: clinical toxinology. EXS. 2010;100:233–91.

    PubMed  CAS  Google Scholar 

  11. Warrell DA. Snake bite. Lancet. 2010;375:77–88.

    Article  PubMed  Google Scholar 

  12. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000;283:897–903.

    Article  PubMed  CAS  Google Scholar 

  13. Gaul C, Dietrich W, Friedrich I, Sirch J, Erbguth FJ. Neurological symptoms in type A aortic dissections. Stroke. 2007;38:292–7.

    Article  PubMed  Google Scholar 

  14. Tsai TT, Nienaber CA, Eagle KA. Acute aortic syndromes. Circulation. 2005;112:3802–13.

    Article  PubMed  Google Scholar 

  15. Aggarwal M, Khan IA. Hypertensive crisis: hypertensive emergencies and urgencies. Cardiol Clin. 2006;24:135–46.

    Article  PubMed  Google Scholar 

  16. Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet. 2000;356:411–7.

    Article  PubMed  CAS  Google Scholar 

  17. Grob D, Brunner N, Namba T, Pagala M. Lifetime course of myasthenia gravis. Muscle Nerve. 2008;37:141–9.

    Article  PubMed  Google Scholar 

  18. Meriggioli MN, Sanders DB. Advances in the diagnosis of neuromuscular junction disorders. Am J Phys Med Rehabil. 2005;84:627–38.

    Article  PubMed  Google Scholar 

  19. Headache Classification Subcommittee of the International Headache, Society. The International Classification of Headache Disorders: 2nd edition. Cephalalgia. 2004;24(Suppl 1):9–160.

    Google Scholar 

  20. Russell MB, Ducros A. Sporadic and familial hemiplegic migraine: pathophysiological mechanisms, clinical characteristics, diagnosis, and management. Lancet Neurol. 2011;10:457–70.

    Article  PubMed  Google Scholar 

  21. Guisado R, Arieff AI. Neurologic manifestations of diabetic comas: correlation with biochemical alterations in the brain. Metabolism. 1975;24:665–79.

    Article  PubMed  CAS  Google Scholar 

  22. Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32:1335–43.

    Article  PubMed  CAS  Google Scholar 

  23. Gallmetzer P, Leutmezer F, Serles W, Assem-Hilger E, Spatt J, Baumgartner C. Postictal paresis in focal epilepsies—incidence, duration, and causes: a video-EEG monitoring study. Neurology. 2004;62:2160–4.

    Article  PubMed  CAS  Google Scholar 

  24. Rolak LA, Rutecki P, Ashizawa T, Harati Y. Clinical features of Todd’s post-epileptic paralysis. J Neurol Neurosurg Psychiatry. 1992;55:63–4.

    Article  PubMed  CAS  Google Scholar 

  25. DeAngelis LM. Brain tumors. N Engl J Med. 2001;344:114–23.

    Article  PubMed  CAS  Google Scholar 

  26. Muzumdar D, Jhawar S, Goel A. Brain abscess: an overview. Int J Surg. 2011;9:136–44.

    Article  PubMed  Google Scholar 

  27. Sayer FT, Vitali AM, Low HL, Paquette S, Honey CR. Brown–Sequard syndrome produced by C3–C4 cervical disc herniation: a case report and review of the literature. Spine. 2008;33:E279–82.

    Article  PubMed  Google Scholar 

  28. Antich PA, Sanjuan AC, Girvent FM, Simo JD. High cervical disc herniation and Brown–Sequard syndrome. A case report and review of the literature. J Bone Joint Surg Br. 1999;81:462–3.

    Article  PubMed  CAS  Google Scholar 

  29. Bruno MA, Pellas F, Schnakers C, et al. Blink and you live: the locked-in syndrome. Rev Neurol (Paris). 2008;164:322–35.

    Article  Google Scholar 

  30. Puetz V, Sylaja PN, Coutts SB, et al. Extent of hypoattenuation on CT angiography source images predicts functional outcome in patients with basilar artery occlusion. Stroke. 2008;39:2485–90.

    Article  PubMed  Google Scholar 

  31. Ropper AH. The Guillain–Barre syndrome. N Engl J Med. 1992;326:1130–6.

    Article  PubMed  CAS  Google Scholar 

  32. Seneviratne U. Guillain–Barre syndrome. Postgrad Med J. 2000;76:774–82.

    Article  PubMed  CAS  Google Scholar 

  33. Meena AK, Khadilkar SV, Murthy JM. Treatment guidelines for Guillain–Barre Syndrome. Ann Indian Acad Neurol. 2011;14:S73–81.

    Article  PubMed  CAS  Google Scholar 

  34. Alshekhlee A, Hussain Z, Sultan B, Katirji B. Guillain–Barre syndrome: incidence and mortality rates in US hospitals. Neurology. 2008;70:1608–13.

    Article  PubMed  Google Scholar 

  35. Ropper AH. Further regional variants of acute immune polyneuropathy. Bifacial weakness or sixth nerve paresis with paresthesias, lumbar polyradiculopathy, and ataxia with pharyngeal-cervical-brachial weakness. Arch Neurol. 1994;51:671–5.

    Article  PubMed  CAS  Google Scholar 

  36. Hughes RA, Swan AV, van Koningsveld R, van Doorn PA. Corticosteroids for Guillain–Barre syndrome. Cochrane Database Syst Rev. 2006;CD001446.

  37. Varma JK, Katsitadze G, Moiscrafishvili M, et al. Signs and symptoms predictive of death in patients with foodborne botulism—Republic of Georgia, 1980–2002. Clin Infect Dis. 2004;39:357–62.

    Article  PubMed  Google Scholar 

  38. Long SS. Infant botulism. Pediatr Infect Dis J. 2001;20:707–9.

    Article  PubMed  CAS  Google Scholar 

  39. Chalk C, Benstead TJ, Keezer M. Medical treatment for botulism. Cochrane Database Syst Rev. 2011;CD008123.

  40. Graeme KA, Pollack CV Jr. Heavy metal toxicity, part I: arsenic and mercury. J Emerg Med. 1998;16:45–56.

    Article  PubMed  CAS  Google Scholar 

  41. Graeme KA, Pollack CV Jr. Heavy metal toxicity, part II: lead and metal fume fever. J Emerg Med. 1998;16:171–7.

    Article  PubMed  CAS  Google Scholar 

  42. Marx A, Glass JD, Sutter RW. Differential diagnosis of acute flaccid paralysis and its role in poliomyelitis surveillance. Epidemiol Rev. 2000;22:298–316.

    Article  PubMed  CAS  Google Scholar 

  43. Venance SL, Cannon SC, Fialho D, et al. The primary periodic paralyses: diagnosis, pathogenesis and treatment. Brain. 2006;129:8–17.

    Article  PubMed  CAS  Google Scholar 

  44. Iorizzo LJ III, Jorizzo JL. The treatment and prognosis of dermatomyositis: an updated review. J Am Acad Dermatol. 2008;59:99–112.

    Article  PubMed  Google Scholar 

  45. Anderson KE, Bloomer JR, Bonkovsky HL, et al. Recommendations for the diagnosis and treatment of the acute porphyrias. Ann Intern Med. 2005;142:439–50.

    PubMed  Google Scholar 

  46. Grattan-Smith PJ, Morris JG, Johnston HM, et al. Clinical and neurophysiological features of tick paralysis. Brain. 1997;120(Pt 11):1975–87.

    Article  PubMed  Google Scholar 

  47. Edlow JA, McGillicuddy DC. Tick paralysis. Infect Dis Clin North Am. 2008;22:397–414.

    Article  PubMed  Google Scholar 

  48. Kuncl RW. Agents and mechanisms of toxic myopathy. Curr Opin Neurol. 2009;22:506–15.

    Article  PubMed  CAS  Google Scholar 

  49. Wirtz PW, Smallegange TM, Wintzen AR, Verschuuren JJ. Differences in clinical features between the Lambert–Eaton myasthenic syndrome with and without cancer: an analysis of 227 published cases. Clin Neurol Neurosurg. 2002;104:359–63.

    Article  PubMed  Google Scholar 

  50. Keogh M, Sedehizadeh S, Maddison P. Treatment for Lambert–Eaton myasthenic syndrome. Cochrane Database Syst Rev. 2011;CD003279.

  51. Barohn RJ, Sahenk Z, Warmolts JR, Mendell JR. The Bruns-Garland syndrome (diabetic amyotrophy). Revisited 100 years later. Arch Neurol. 1991;48:1130–5.

    Article  PubMed  CAS  Google Scholar 

  52. Tracy JA, Dyck PJ. The spectrum of diabetic neuropathies. Phys Med Rehabil Clin N Am. 2008;19:1–26.

    Article  PubMed  Google Scholar 

  53. Davies L, Spies JM, Pollard JD, McLeod JG. Vasculitis confined to peripheral nerves. Brain. 1996;119(Pt 5):1441–8.

    Article  PubMed  Google Scholar 

  54. Mathew L, Talbot K, Love S, Puvanarajah S, Donaghy M. Treatment of vasculitic peripheral neuropathy: a retrospective analysis of outcome. QJM. 2007;100:41–51.

    Article  PubMed  CAS  Google Scholar 

  55. London Z, Albers JW. Toxic neuropathies associated with pharmaceutic and industrial agents. Neurol Clin. 2007;25:257–76.

    Article  PubMed  Google Scholar 

  56. Fox IK, Mackinnon SE. Adult peripheral nerve disorders: nerve entrapment, repair, transfer, and brachial plexus disorders. Plast Reconstr Surg. 2011;127:105e–18e.

    Article  PubMed  Google Scholar 

  57. Neal S, Fields KB. Peripheral nerve entrapment and injury in the upper extremity. Am Fam Physician. 2010;81:147–55.

    PubMed  Google Scholar 

  58. Racaniello VR. One hundred years of poliovirus pathogenesis. Virology. 2006;344:9–16.

    Article  PubMed  CAS  Google Scholar 

  59. Riggs JE. Neurologic manifestations of electrolyte disturbances. Neurol Clin. 2002;20:227–39.

    Article  PubMed  Google Scholar 

  60. Schrier RW, Bansal S. Diagnosis and management of hyponatremia in acute illness. Curr Opin Crit Care. 2008;14:627–34.

    Article  PubMed  Google Scholar 

  61. Ravid M, Robson M. Proximal myopathy caused by latrogenic phosphate depletion. JAMA. 1976;236:1380–1.

    Article  PubMed  CAS  Google Scholar 

  62. Sebastian S, Clarence D, Newson C. Severe hypophosphataemia mimicking Guillain–Barre syndrome. Anaesthesia. 2008;63:873–5.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Intensive Care, Royal North Shore Hospital, Sydney, NSW, Australia

    Oliver Flower

  2. Department of Emergency Medicine, Royal North Shore Hospital, Sydney, NSW, Australia

    Christine Bowles

  3. Department of Neurology, Mayo Clinic Rochester, Rochester, MN, USA

    Eelco Wijdicks

  4. Division of ED Critical Care, Mount Sinai School of Medicine, New York, NY, USA

    Scott D. Weingart

  5. Department of Neurology, University of California, San Francisco, CA, USA

    Wade S. Smith

Authors
  1. Oliver Flower
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Christine Bowles
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Eelco Wijdicks
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Scott D. Weingart
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Wade S. Smith
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Oliver Flower.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Flower, O., Bowles, C., Wijdicks, E. et al. Emergency Neurological Life Support: Acute Non-Traumatic Weakness. Neurocrit Care 17 (Suppl 1), 79–95 (2012). https://doi.org/10.1007/s12028-012-9752-7

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12028-012-9752-7

Keywords

Search

Navigation