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Acute Peripheral Neurologic Lesions. Peripheral nervous system serves sensory, motor and autonomic functions. On PE the most important finding in a peripheral nerve process is reduction or absence of reflexes.
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Peripheral nervous system serves sensory, motor and autonomic functions. • On PE the most important finding in a peripheral nerve process is reduction or absence of reflexes. • Abnormalities of proprioception, vibratory sensation, andn pain and temp can also be seen.
It is important to determine which part of the peripheral nervous system is involved. • A localized process strongly suggests a focal lesion. • Most muscle related processes result in weakness of large proximal muscles. Difficult getting out of chairs. • May see pain and tenderness of muscles with elevated CK.
Neuropathies frequently affect both the motor and sensory systems, effecting longer nerves and reducing distal muscle power. • Pinpoint the time and course of illness, diurnal fluctuations, a review of meds, and any other illnesses. • In the ED useful tests include serum chem, metabolic profile and CK.
Treatment depends on the specific diagnosis, but neurological consult should be obtained. • Supportive care in the ED for severe, life-threatening neuromuscular diseases should begin in the ED. • Admission for acute peripheral neurological conditions is warranted for respiratory or autonomic compromise.
Myopathies • Polymyositis is an inflammatory myopathy affecting people older than 30, M>F. • Usually presents with proximal symmetric weakness. May progress to dysphagia and resp. failure. • On PE will see reduced proximal strength but no sensory loss, and reflexes should be intact. • Labs may show elevated ESR, leukocytosis, CK
Dermatomyositis can affect kids and affects mostly women. • Clinically similar to polymyositis except a violaceous rash over the hands and face. • A large number of substances including environmental, occupational, and pharmacologic agents can cause myopathies.
Myopathies cause a predominantly proximal pattern of weakness with normal sensation and preserved tendon reflexes. • Viral myositis causes an acute myopathy, occasionally involving the heart, assoc. with febrile illness, myalgia and elevated CK levels.
Disorders of Neuromuscular Junction • Clostridium botulism is an acute disease marked by weakness and GI slowing. • Ingestion of home canned vegetables 1-2 days before symptoms is a hallmark of botulism. • Ingestion of honey by infants can lead to botulism and symptoms present with poor sucking. • Absence of pupillary light reflex distinguishes botulism from myasthenia gravis.
Proximal limb weakness, intact sensation, and normal reflexes are generally found. • Treatment in infants include antibiotics and immune serum. Adults receive immune serum.
Guillain-Barre’ syndrome affects individuals of all ages with the most common form being acute generalized neuropathy. • Pts report a preceding viral illness with numbness and tingling of the lower ext. being the first symptoms with progressive ascending weakness. • Most cases are caused by autoimmune attack on myelinated motor nerves.
Hallmark of GBS is the lack of deep tendon reflexes. • Respiratory failure and lethal autonomic disturbances can occur. • In the acute phase, LP should be performed. CSF protein will be high after one week of symptoms with normal glucose and cell ct.
Lyme disease present similar to GBS but with CSF pleocytosis with a hx of tick bites or with CSF lyme antibodies. • GBS should be admitted to the hospital for plasma exchange or IVIG. • Acute intermittent porphyria is a rare autosomal dominant condition with weakness, psychosis and abd. pain.
Focal Neuropathies • Carpal tunnel syndrome- numbness of first three digits-worse at night. • Reproduced by compression of the median nerve or by tapping on the nerve. • Treat with splints at night and NSAIDS. • Refer to hand surgeon
Ulnar nerve entrapment-occurs most commonly at elbow with numbness of 5th and half of the 4th finger. Wasting of hypothenar muscles occur. • Deep peroneal nerve entrapment at the fibular head can cause footdrop and numbness between the 1st and 2nd toes. Treat conservatively and improves without specific therapy.
Meralgia paresthetica-entrapment of the lateral cutaneous nerve of the thigh. Numbness of the lateral thigh. Occurs after weight loss, OB surgeries or wearing heavy belt (carpenter, police). • Bell’s Palsy-diagnosis of exclusion. Sudden facial weakness (involves forehead), difficulty with articulation, problems keeping eye closed, inablity or keep one side of mouth closed.
Treatments for Bell’s palsy can include 50mg prednisone for 7 days and acyclovir 200mg po 5 times daily for 10 days. • Lyme disease- pathogen Borrelia burgdorferi. Neurologic signs such as 7th nerve palsy may present after fatigue and arthralgias. • Affects the peripheral nerves and nerve roots. May see progression of weakness and sensory loss. There will be a patchy myotomal pattern.
Deep tendon reflexes will be diminshed and lab studies should show CSF lyme antibodies. • 3 weeks of ceftriaxone or doxy IV is treatment • Brachial neuritis-acute condition manifests as shoulder back or arm pain followed by weakness of the arm or shoulder girdle. • Idiopathic • Upper trunk is most affected • Reflexes diminished • Inability to form a pincer with the index finger and thumb
Lumbar plexopathy occurs in diabetic pts and presents with back pain followed by weakness. • Acute onset of ipsilateral back pain, followed by progressive leg weakness. Sensory intact. • Long term muscle wasting • In ED lumbar X rays to screen for degenerative or neoplastic disease.
In late AIDS virus pt may have acute radiculitis caused by CMV infection. • Pts become acutely weak with mainly lower ext involvement with weakness and hyporeflexia, decreased sensation and +/- rectal tone loss.
