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CC BY-NC-ND 4.0 · J Neuroanaesth Crit Care 2019; 06(03): 236-256
DOI: 10.1055/s-0039-1696061
Review Article
Indian Society of Neuroanaesthesiology and Critical Care

Acute Nontraumatic Muscle Weakness

Kiran Jangra
1   Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
,
Hemant Bhagat
1   Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
,
Aastha Takkar
2   Department of Neurology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
› Author Affiliations
Further Information

Publication History

Received: 24 February 2019

Accepted after revision: 19 June 2019

Publication Date:
11 September 2019 (online)

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Abstract

Acute nontraumatic weakness (ANTW) is defined as acute onset of weakness in any part of the body. The weakness occurs due to interruption at any point along the motor pathway. The motor pathway originates from upper motor neuron cells in the cerebral cortex and traverses through the brainstem till lower motor neurons in the spinal cord. The axon of a lower motor neuron is known as the peripheral motor nerve that synapses with muscle. ANTW is of varied etiology and presentation that may be immediately life-threatening if respiratory muscles or autonomic nervous system is involved. Involvement of respiratory muscles may be associated with respiratory failure that may require mechanical ventilation. The weakness may be localized to one limb or generalized involving several muscle groups. When bulbar muscles are involved, weakness leads to problem in swallowing and coughing that endangers the patient's airway. Similarly, the course of the disease also varies, and these patients may worsen rapidly. Hence, a comprehensive history, systematic evaluation, and a detailed neurological examination are performed to localize the disorder. There are specific clinical features peculiar to the particular location of the lesion in the body. Hence, it is possible to anatomically localize these lesions based on the clinical features. Initial laboratory tests and appropriate neuroimaging should be obtained as indicated by history and examination. The time-sensitive emergencies should be addressed immediately, as the delay in management may lead to either permanent neurological damage or may worsen the overall outcome in such conditions. The initial management should always include care of airway, breathing, and circulation (ABC). The imaging should be obtained only after initial stabilization of ABC. The definitive treatment should be done as per the etiology.

Keywords

acute weakness - neuromuscular weakness - nontraumatic weakness - respiratory failure
 

  • References

  • 1 Gerard T, Bryan D. Principles of Anatomy & Physiology. 14th ed. New Jersey: John Wiley & Sons, Inc; 2014. 406, 502, 541
  • 2 Gillian P, Christopher R. Human Physiology: The Basis of Medicine. 3rd ed. Oxford: Oxford University Press; 2006: 151-153
  • 3 Caulfield AF, Flower O, Pineda JA, Uddin S. Emergency neurological life support: acute non-traumatic weakness. Neurocrit Care 2017; 27 (Suppl 1) 29-50
    CrossrefPubMedGoogle Scholar
  • 4 Mehta S. Neuromuscular disease causing acute respiratory failure. Respir Care 2006; 51 (09) 1016-1021, discussion 1021–1023
    PubMedGoogle Scholar
  • 5 Lawn ND, Fletcher DD, Henderson RD, Wolter TD, Wijdicks EF. Anticipating mechanical ventilation in Guillain-Barré syndrome. Arch Neurol 2001; 58 (06) 893-898
    CrossrefPubMedGoogle Scholar
  • 6 Coplin WM, Pierson DJ, Cooley KD, Newell DW, Rubenfeld GD. Implications of extubation delay in brain-injured patients meeting standard weaning criteria. Am J Respir Crit Care Med 2000; 161 (05) 1530-1536
    CrossrefPubMedGoogle Scholar
  • 7 Ropper AH. The Guillain-Barré syndrome. N Engl J Med 1992; 326 (17) 1130-1136
    CrossrefPubMedGoogle Scholar
  • 8 Seneviratne U. Guillain-Barré syndrome. Postgrad Med J 2000; 76 (902) 774-782
    PubMedGoogle Scholar
  • 9 Sagarin MJ, Barton ED, Chng YM, Walls RM. National Emergency Airway Registry Investigators. Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts. Ann Emerg Med 2005; 46 (04) 328-336
    CrossrefPubMedGoogle Scholar
  • 10 Li J, Murphy-Lavoie H, Bugas C. Martinez J, Preston C. Complications of emergency intubation with and without paralysis. Am. J Emerg Med 1999; 17 (02) 141-143
    PubMedGoogle Scholar
  • 11 Sakles JC, Laurin EG, Rantapaa AA, Panacek EA. Airway management in the emergency department: a one-year study of 610 tracheal intubations. Ann Emerg Med 1998; 31 (03) 325-332
    CrossrefPubMedGoogle Scholar
  • 12 Walls RM. Rapid-sequence intubation in head trauma. Ann Emerg Med 1993; 22 (06) 1008-1013
    CrossrefPubMedGoogle Scholar
  • 13 Abel M, Eisenkraft JB. Anesthetic implications of myasthenia gravis. Mt Sinai J Med 2002; 69 (01) (02) 31-37
    PubMedGoogle Scholar
  • 14 Orebaugh SL. Succinylcholine: adverse effects and alternatives in emergency medicine. Am. J Emerg Med 1999; 17 (07) 715-721
    PubMedGoogle Scholar
  • 15 Rajajee V, Riggs B, Seder DB. Emergency neurological life support: airway, ventilation, and sedation. Neurocrit Care 2017; 27 (Suppl 1) 4-28
    CrossrefPubMedGoogle Scholar
  • 16 Jan MM, Al-Buhairi AR, Baeesa SS. Concise outline of the nervous system examination for the generalist. Neurosciences (Riyadh) 2001; 6 (01) 16-22
    PubMedGoogle Scholar
  • 17 Florman JE, Duffau H, Rughani AI. Lower motor neuron findings after upper motor neuron injury: insights from postoperative supplementary motor area syndrome. Front Hum Neurosci 2013; 7: 85
    PubMedGoogle Scholar
  • 18 Folks DG, Ford CV, Regan WM. Conversion symptoms in a general hospital. Psychosomatics 1984; 25 (04) 285-289, 291, 294–295
    CrossrefPubMedGoogle Scholar
  • 19 Zuccoli G, Panigrahy A, Bailey A, Fitz C. Redefining the Guillain-Barré spectrum in children: neuroimaging findings of cranial nerve involvement. Am J Neuroradiol 2011; 32 (04) 639-642
    CrossrefPubMedGoogle Scholar
  • 20 Pidcock FS, Krishnan C, Crawford TO, Salorio CF, Trovato M, Kerr DA. Acute transverse myelitis in childhood: center-based analysis of 47 cases. Neurology 2007; 68 (18) 1474-1480
    CrossrefPubMedGoogle Scholar
  • 21 Chen L, Li J, Guo Z, Liao S, Jiang L. Prognostic indicators of acute transverse myelitis in 39 children. Pediatr Neurol 2013; 49 (06) 397-400
    CrossrefPubMedGoogle Scholar
  • 22 Wolf VL, Lupo PJ, Lotze TE. Pediatric acute transverse myelitis overview and differential diagnosis. J Child Neurol 2012; 27 (11) 1426-1436
    CrossrefPubMedGoogle Scholar
  • 23 Bernard TJ, Rivkin MJ, Scholz K. et al. Thrombolysis in Pediatric Stroke Study. Emergence of the primary pediatric stroke center: impact of the thrombolysis in pediatric stroke trial. Stroke 2014; 45 (07) 2018-2023
    CrossrefPubMedGoogle Scholar
  • 24 DeAngelis LM. Brain tumors. N Engl J Med 2001; 344 (02) 114-123
    CrossrefPubMedGoogle Scholar
  • 25 Muzumdar D, Jhawar S, Goel A. Brain abscess: an overview. Int J Surg 2011; 9 (02) 136-144
    CrossrefPubMedGoogle Scholar
  • 26 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 (12) 2160-2164
    CrossrefPubMedGoogle Scholar
  • 27 Rolak LA, Rutecki P, Ashizawa T, Harati Y. Clinical features of Todd’s post-epileptic paralysis. J Neurol Neurosurg Psychiatry 1992; 55 (01) 63-64
    CrossrefPubMedGoogle Scholar
  • 28 Aggarwal M, Khan IA. Hypertensive crisis: hypertensive emergencies and urgencies. Cardiol Clin 2006; 24 (01) 135-146
    CrossrefPubMedGoogle Scholar
  • 29 Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet 2000; 356 9227 411-417
    CrossrefPubMedGoogle Scholar
  • 30 Headache Classification Subcommittee of the International Headache. Society. The International Classification of Headache Disorders: 2nd edition. Cephalalgia 200;424 (Suppl 1): 9–160
  • 31 Russell MB, Ducros A. Sporadic and familial hemiplegic migraine: pathophysiological mechanisms, clinical characteristics, diagnosis, and management. Lancet Neurol 2011; 10 (05) 457-470
    CrossrefPubMedGoogle Scholar
  • 32 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 (08) 1113-1120
    CrossrefPubMedGoogle Scholar
  • 33 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 (07) 897-903
    CrossrefPubMedGoogle Scholar
  • 34 Gaul C, Dietrich W, Friedrich I, Sirch J, Erbguth FJ. Neurological symptoms in type A aortic dissections. Stroke 2007; 38 (02) 292-297
    CrossrefPubMedGoogle Scholar
  • 35 Tsai TT, Nienaber CA, Eagle KA. Acute aortic syndromes. Circulation 2005; 112 (24) 3802-3813
    CrossrefPubMedGoogle Scholar
  • 36 Sayer FT, Vitali AM, Low HL, Paquette S, Honey CR. Brown-Sèquard syndrome produced by C3-C4 cervical disc herniation: a case report and review of the literature. Spine 2008; 33 (09) E279-E282
    CrossrefPubMedGoogle Scholar
  • 37 Antich PA, Sanjuan AC, Girvent FM, Simó JD. High cervical disc herniation and Brown-Sequard syndrome. A case report and review of the literature. J Bone Joint Surg Br 1999; 81 (03) 462-463
    PubMedGoogle Scholar
  • 38 Brinar VV, Habek M, Brinar M, Malojcić B, Boban M. The differential diagnosis of acute transverse myelitis. Clin Neurol Neurosurg 2006; 108 (03) 278-283
    CrossrefPubMedGoogle Scholar
  • 39 Rowland LP, Shneider NA. Amyotrophic lateral sclerosis. N Engl J Med 2001; 344 (22) 1688-1700
    CrossrefPubMedGoogle Scholar
  • 40 Kiernan MC, Vucic S, Cheah BC. et al. Amyotrophic lateral sclerosis. Lancet 2011; 377 (9769) 942-955
    CrossrefPubMedGoogle Scholar
  • 41 Miller RG, Jackson CE, Kasarskis EJ. et al. Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter update: the care of the patient with amyotrophic lateral sclerosis: multidisciplinary care, symptom management, and cognitive/behavioral impairment (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2009; 73 (15) 1227-1233
    CrossrefPubMedGoogle Scholar
  • 42 Meena AK, Khadilkar SV, Murthy JM. Treatment guidelines for Guillain-Barré Syndrome. Ann Indian Acad Neurol 2011; 14 (Suppl 1) S73-S81
    CrossrefPubMedGoogle Scholar
  • 43 Alshekhlee A, Hussain Z, Sultan B, Katirji B. Guillain-Barré syndrome: incidence and mortality rates in US hospitals. Neurology 2008; 70 (18) 1608-1613
    CrossrefPubMedGoogle Scholar
  • 44 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 (07) 671-675
    CrossrefPubMedGoogle Scholar
  • 45 Hughes RA, Swan AV, van Koningsveld R, van Doorn PA. Corticosteroids for Guillain-Barré syndrome. Cochrane Database Syst Rev 2006; 19 (02) CD001446
    PubMedGoogle Scholar
  • 46 Davies L, Spies JM, Pollard JD, McLeod JG. Vasculitis confined to peripheral nerves. Brain 1996; 119 (Pt 5) 1441-1448
    CrossrefPubMedGoogle Scholar
  • 47 Mathew L, Talbot K, Love S, Puvanarajah S, Donaghy M. Treatment of vasculitic peripheral neuropathy: a retrospective analysis of outcome. QJM 2007; 100 (01) 41-51
    PubMedGoogle Scholar
  • 48 London Z, Albers JW. Toxic neuropathies associated with pharmaceutic and industrial agents. Neurol Clin 2007; 25 (01) 257-276
    CrossrefPubMedGoogle Scholar
  • 49 Graeme KA, Pollack CV. Jr Heavy metal toxicity, part I: arsenic and mercury. J Emerg Med 1998; 16 (01) 45-56
    CrossrefPubMedGoogle Scholar
  • 50 Graeme KA, Pollack CV. Jr Heavy metal toxicity, part II: lead and metal fume fever. J Emerg Med 1998; 16 (02) 171-177
    CrossrefPubMedGoogle Scholar
  • 51 Marx A, Glass JD, Sutter RW. Differential diagnosis of acute flaccid paralysis and its role in poliomyelitis surveillance. Epidemiol Rev 2000; 22 (02) 298-316
    CrossrefPubMedGoogle Scholar
  • 52 Fox IK, Mackinnon SE. Adult peripheral nerve disorders: nerve entrapment, repair, transfer, and brachial plexus disorders. Plast Reconstr Surg 2011; 127 (05) 105
    CrossrefPubMedGoogle Scholar
  • 53 Neal S, Fields KB. Peripheral nerve entrapment and injury in the upper extremity. Am Fam Physician 2010; 81 (02) 147-155
    PubMedGoogle Scholar
  • 54 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 (03) 357-362
    CrossrefPubMedGoogle Scholar
  • 55 Long SS. Infant botulism. Pediatr Infect Dis J 2001; 20 (07) 707-709
    CrossrefPubMedGoogle Scholar
  • 56 Chalk C, Benstead TJ, Keezer M. Medical treatment for botulism. Cochrane Database Syst Rev 2011; 16 (03) CD008123 00
    PubMedGoogle Scholar
  • 57 Grattan-Smith PJ, Morris JG, Johnston HM. et al. Clinical and neurophysiological features of tick paralysis. Brain 1997; 120 (Pt 11) 1975-1987
    CrossrefPubMedGoogle Scholar
  • 58 Edlow JA, McGillicuddy DC. Tick paralysis. Infect Dis Clin North Am 2008; 22 (03) 397-413, vii
    CrossrefPubMedGoogle Scholar
  • 59 Eddleston M, Buckley NA, Eyer P, Dawson AH. Management of acute organophosphorus pesticide poisoning. Lancet 2008; 371 9612 597-607
    CrossrefPubMedGoogle Scholar
  • 60 Roberts DM, Aaron CK. Management of acute organophosphorus pesticide poisoning. BMJ 2007; 334 (7594) 629-634
    CrossrefPubMedGoogle Scholar
  • 61 Grob D, Brunner N, Namba T, Pagala M. Lifetime course of myasthenia gravis. Muscle Nerve 2008; 37 (02) 141-149
    CrossrefPubMedGoogle Scholar
  • 62 Meriggioli MN, Sanders DB. Advances in the diagnosis of neuromuscular junction disorders. Am J Phys Med Rehabil 2005; 84 (08) 627-638
    CrossrefPubMedGoogle Scholar
  • 63 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 (04) 359-363
    CrossrefPubMedGoogle Scholar
  • 64 Keogh M, Sedehizadeh S, Maddison P. Treatment for Lambert-Eaton myasthenic syndrome. Cochrane Database Syst Rev 2011; 00
    PubMedGoogle Scholar
  • 65 Iorizzo III LJ. Jorizzo JL. The treatment and prognosis of dermatomyositis: an updated review. J Am Acad Dermatol 2008; 59 (01) 99-112
    CrossrefPubMedGoogle Scholar
  • 66 Guisado R, Arieff AI. Neurologic manifestations of diabetic comas: correlation with biochemical alterations in the brain. Metabolism 1975; 24 (05) 665-679
    CrossrefPubMedGoogle Scholar
  • 67 Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN. Hyperglycemic crises in adult patients with diabetes. Diabetes Care 2009; 32 (07) 1335-1343
    CrossrefPubMedGoogle Scholar
  • 68 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 (01) E32-E41
    CrossrefPubMedGoogle Scholar
  • 69 Reynolds RM, Padfield PL, Seckl JR. Disorders of sodium balance. BMJ 2006; 332 (7543) 702-705
    PubMedGoogle Scholar
  • 70 Adrogué HJ, Madias NE. Hypernatremia. N Engl J Med 2000; 342 (20) 1493-1499
    CrossrefPubMedGoogle Scholar
  • 71 Riggs JE. Neurologic manifestations of electrolyte disturbances. Neurol Clin 2002; 20 (01) 227-239
    CrossrefPubMedGoogle Scholar
  • 72 Ravid M, Robson M. Proximal myopathy caused by latrogenic phosphate depletion. JAMA 1976; 236 (12) 1380-1381
    CrossrefPubMedGoogle Scholar
  • 73 Sebastian S, Clarence D, Newson C. Severe hypophosphataemia mimicking Guillain-Barré syndrome. Anaesthesia 2008; 63 (08) 873-875
    CrossrefPubMedGoogle Scholar
  • 74 Venance SL, Cannon SC, Fialho D. et al. CINCH investigators. The primary periodic paralyses: diagnosis, pathogenesis and treatment. Brain 2006; 129 (Pt 1) 8-17
    CrossrefPubMedGoogle Scholar
  • 75 White J. Venomous animals: clinical toxinology. EXS 2010; 100: 233-291
    PubMedGoogle Scholar
  • 76 Warrell DA. Snake bite. Lancet 2010; 375 (9708) 77-88
    CrossrefPubMedGoogle Scholar
  • 77 Bruno MA, Pellas F, Schnakers C. et al. [Blink and you live: the locked-in syndrome]. Rev Neurol (Paris) 2008; 164 (04) 322-335
    CrossrefPubMedGoogle Scholar
  • 78 Anderson KE, Bloomer JR, Bonkovsky HL. et al. Recommendations for the diagnosis and treatment of the acute porphyrias. Ann Intern Med 2005; 142 (06) 439-450
    CrossrefPubMedGoogle Scholar
  • 79 Tracy JA, Dyck PJ. The spectrum of diabetic neuropathies. Phys wwMed Rehabil Clin N Am 2008; 19 (01) 1-26, v
    PubMedGoogle Scholar