Emergency Neurological Life Support: Acute Non-Traumatic Weakness
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REVIEW ARTICLE
Emergency Neurological Life Support: Acute Non-Traumatic Weakness Oliver Flower • Christine Bowles • Eelco Wijdicks Scott D. Weingart • Wade S. Smith
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Published online: 13 September 2012 Neurocritical Care Society 2012
Abstract Acute non-traumatic weakness may be lifethreatening 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.
O. Flower (&) Department of Intensive Care, Royal North Shore Hospital, Sydney, NSW, Australia e-mail: [email protected] C. Bowles Department of Emergency Medicine, Royal North Shore Hospital, Sydney, NSW, Australia E. Wijdicks Department of Neurology, Mayo Clinic Rochester, Rochester, MN, USA S. D. Weingart Division of ED Critical Care, Mount Sinai School of Medicine, New York, NY, USA W. S. Smith Department of Neurology, University of California, San Francisco, CA, USA e-mail: [email protected]
Keywords Neuromuscular failure Hemiparesis Tetraparesis Neurological exam Respiratory failure ENLS
Introduction The differential diagnosis of acute non-traumatic weakness ranges from the imminently life-threatening to the trivial. The approach to this problem necessarily comprises synchronous resuscitation with investigations and management tailored to the individual patient. Assessment of the airway is the initial priority. During resuscitation, consideration should be given to a several other time-critical diagnoses that require specific management. These are discussed in connection with tables that include the main features of the history, examination, investigations, and treatment for each diagnosis. Trauma is neither discussed here nor is weakness that is not acute in onset. The ENLS suggested algorithm for the initial management of acute weakness is shown in Fig. 1. Suggested items to complete within the first hour of evaluating a patient with acute weakness are shown in Table 1.
Assessing Ventilation and the Need for Urgent Intubation When breathing becomes compromised in patients with neurological weakness, the usual cause is collapse of the oropharyngeal muscles. Diaphragmatic weakness is another significant cause, the diaphragm being responsible for two thirds of respiratory effort. Poor gas exchange may also occur but is less common.
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Fig. 1 ENLS acute non-traumatic weakness protocol Table 1 Acute weakness checklist for the first hour
Table 2 Fact
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