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A N E V I D E N C E - B A S E D A P P ROAC H T O E M E RG E N C Y M E D I C I N E
December 2002
Weakness: A Systematic Volume 4, Number 12
Andrew W. Asimos, MD
Non-traumatic, Neurologic Associate Medical Director, Stroke Program,
Carolinas Medical Center, Charlotte, NC; Clinical
The chief complaint box on the chart says it all: “Weak and tingling, desires second Peer Reviewers
opinion.” To compound your dilemma, an emergency medicine physician across Diane M. Birnbaumer, MD, FACEP
town who saw the patient earlier in the day told her that she was just “anxious.” Professor of Medicine, UCLA; Associate Program
The patient says she is anxious because her legs are “buckling.” You hope that your Director, Department of Emergency Medicine, Harbor-
neurologic examination will provide some obvious findings, since neuro never was UCLA Medical Center, Torrance, CA.
your forte. Pinprick sensation is normal. Maybe she is “a little weak,” but she Stephen Karas, Jr., MD, FACEP
doesn’t seem to be making much of an effort. You have trouble “getting reflexes,” Clinical Professor, UCSD Department of Medicine,
San Diego, CA.
but you have trouble interpreting the reflex exam on lots of your patients. By the
time you finish examining the patient, your stomach feels as weak as the patient’s Sid M. Shah, MD, FACEP
knees. She probably is just anxious, and you are certain that no diagnostic test or Assistant Clinical Professor, Michigan State University;
Sparrow/MSU Emergency Medicine Residency
fancy neurologic examination will prove otherwise….But maybe an MRI of the
Program; Ingham Regional Medical Center,
brain or spinal cord or a scan of something would help. Lansing, MI.
Editor-in-Chief Center School of Medicine, Emergency Medicine, Morristown Professor and Chief of the Division Medical Service, Orlando, FL.
Albuquerque, NM. Memorial Hospital. of Family Medicine, Mount Sinai Alfred Sacchetti, MD, FACEP,
Stephen A. Colucciello, MD, FACEP, School of Medicine, New York, NY. Research Director, Our Lady of
W. Richard Bukata, MD, Clinical Michael A. Gibbs, MD, FACEP, Chief,
Assistant Chair, Department of Professor, Emergency Medicine, Department of Emergency John A. Marx, MD, Chair and Chief, Lourdes Medical Center, Camden,
Emergency Medicine, Carolinas Los Angeles County/USC Medical Medicine, Maine Medical Center, Department of Emergency NJ; Assistant Clinical Professor
Medical Center, Charlotte, NC; Center, Los Angeles, CA; Medical Portland, ME. Medicine, Carolinas Medical of Emergency Medicine,
Associate Clinical Professor, Director, Emergency Department, Center, Charlotte, NC; Clinical Thomas Jefferson University,
Department of Emergency Gregory L. Henry, MD, FACEP,
San Gabriel Valley Medical Professor, Department of Philadelphia, PA.
Medicine, University of North CEO, Medical Practice Risk
Center, San Gabriel, CA. Emergency Medicine, University Corey M. Slovis, MD, FACP, FACEP,
Carolina at Chapel Hill, Chapel Assessment, Inc., Ann Arbor,
Francis M. Fesmire, MD, FACEP, MI; Clinical Professor, Department of North Carolina at Chapel Hill, Professor of Emergency Medicine
Hill, NC. Chapel Hill, NC.
Director, Chest Pain—Stroke of Emergency Medicine, and Chairman, Department of
Associate Editor Center, Erlanger Medical Center; University of Michigan Medical Emergency Medicine, Vanderbilt
Michael S. Radeos, MD, MPH,
Assistant Professor of Medicine, School, Ann Arbor, MI; President, University Medical Center;
Attending Physician, Department
Andy Jagoda, MD, FACEP, Professor UT College of Medicine, American Physicians Assurance Medical Director, Metro Nashville
of Emergency Medicine,
of Emergency Medicine; Director, Chattanooga, TN. Society, Ltd., Bridgetown, EMS, Nashville, TN.
Lincoln Medical and Mental
International Studies Program, Barbados, West Indies; Past Health Center, Bronx, NY; Mark Smith, MD, Chairman,
Valerio Gai, MD, Professor and Chair,
Mount Sinai School of Medicine, President, ACEP. Assistant Professor in Emergency Department of Emergency
Department of Emergency
New York, NY. Medicine, University of Turin, Italy. Jerome R. Hoffman, MA, MD, FACEP, Medicine, Weill College of Medicine, Washington Hospital
Professor of Medicine/Emergency Medicine, Cornell University, Center, Washington, DC.
Michael J. Gerardi, MD, FACEP,
Medicine, UCLA School of New York, NY.
Editorial Board Clinical Assistant Professor, Charles Stewart, MD, FACEP,
Medicine; Attending Physician, Colorado Springs, CO.
Medicine, University of Medicine Steven G. Rothrock, MD, FACEP, FAAP,
UCLA Emergency Medicine Center;
Judith C. Brillman, MD, Residency and Dentistry of New Jersey; Associate Professor Thomas E. Terndrup, MD, Professor
Co-Director, The Doctoring
Director, Associate Professor, Director, Pediatric Emergency of Emergency Medicine, University and Chair, Department of
Program, UCLA School of Medicine,
Department of Emergency Medicine, Children’s Medical of Florida; Orlando Regional Emergency Medicine, University
Los Angeles, CA.
Medicine, The University of Center, Atlantic Health System; Medical Center; Medical Director of of Alabama at Birmingham,
New Mexico Health Sciences Vice-Chairman, Department of Francis P. Kohrs, MD, MSPH, Associate Orange County Emergency Birmingham, AL.
life-threatening ventilatory insufficiency from Guillain- graphic testing (e.g., ACR Appropriateness Criteria™ for
Barré syndrome. Myelopathy, Class III). Other guidelines dictate specific
This article focuses on non-traumatic neurologic and diagnostic or surgical criteria for specific diagnoses that
neuromuscular causes of acute weakness due to pathol- can cause weakness (e.g., Carpal Tunnel Syndrome by the
ogy of one of the neuroanatomic subunits listed in Table American Society of Plastic Surgeons, Class III). The
1. Lesions occurring in any one of these subunits, from algorithms are largely consensus statements based on
the cerebral hemispheres to the innervated muscle(s), can Class II or Class III evidence.
lead to weakness. This article does not cover primary
medical conditions in which weakness is a component Definitions And Anatomical Subunits
(e.g., adrenal insufficiency, hypothyroidism) and non-
categorical causes of weakness, such as fibromyalgia or True weakness is medically defined as an inability to carry
chronic fatigue syndrome. out a desired movement with normal force because of a
While recognizing the exact lesion may not always reduction in strength of the muscles.1 Patients often use
be possible, a focus on the neuroanatomic subunits will the word “weak” when a physician might use “malaise.”
narrow the search for pathology. Certainly, if an emer- The terms malaise and listlessness are most appropriately
gency physician is going to convince a radiologist that an reserved for the perceived weakness that accompanies a
emergent MRI is warranted, it will help to know whether broad spectrum of illnesses, from a benign viral process
the neuropathology is confined to the lower spine or the to congestive heart failure. Indeed, most patients who
cerebral cortex. present to the ED with the complaint of weakness will
ultimately have such a systemic (non-neurologic) illness.
Critical Appraisal Of The Literature Alternatively, fatigue can be distinguished from the more
indiscriminate term weakness, when diminution of
Despite the prevalence of the complaint, there is a strength with repetitive actions occurs. In its purest
paucity of Class I literature relating to the general sense, fatigable weakness should be considered pathog-
evaluation of weakness. Professional organizations such nomonic for a neuromuscular junction (NMJ) process.
as the American College of Radiology (ACR) provide However, patients are more likely to describe fatigue
consensus opinions to help direct appropriate radio- with a more generalized medical condition, such as
➤
Cranial nerve signs ±
Brainstem Combination of:
hemiparesis (ipsilateral
YES ➤ process • right-sided hemiparesis?
YES ➤ Left (dominant)
face/contralateral body, cerebral
upper motor neuron signs)? (Class II-III) • right-sided sensory deficit?
hemisphere
• right visual field deficit?
NO • left gaze preference? process
• aphasia? (Class II-III)
➤
Hemiplegia or monoplegia, NO
Brown-Séquard
➤
➤
ipsilateral loss of vibration/ YES Right
syndrome
proprioception, contralateral
(Class II-III)
Combination of: YES ➤ (nondominant)
loss of pain and temperature • left-sided cerebral
(most likely after hemiparesis?
penetrating trauma)?
hemisphere
• left-sided sensory loss?
• left visual field deficit? process
NO • right gaze preference? (Class II-III)
➤
• left-sided neglect?
Myotomal weakness
(weakness associated with Radiculopathy The evidence for recom-
an isolated spinal nerve),
YES ➤ (Class II-III) mendations is graded using
the following scale. For
dermatomal sensory involving complete definitions, see
(usually pain)? back page. Class I: Definitely
recommended. Definitive,
NO Brachial plexopathy
excellent evidence provides
Shoulder, back, or arm pain, followed by weakness of the arm
➤
Weakness of the anterior tibial and gastrocnemius muscles this publication may
(Class II-III) be reproduced in any
Consider somatoform Entrapment of the common or deep peroneal nerve format without
disorder Footdrop; sensory findings in web space between the great written consent of EB
(Class II-III) and second toes (Class II-III) Practice, LLC.
➤
associated with
an acute illness?
YES ➤ (Class II-III)
All limbs, no sensory Myopathy vs.
NO involvement, proxi- YES ➤ pure motor
➤
➤
mental status?
brainstem process
(Class II-III)
NO Involvement of
Neuromuscular
oculomotor muscles,
➤
➤
eyelids, jaw, face, YES ➤ junction disorder
pharynx, or tongue; (Class II-III)
Tetraparesis (upper
motor neuron signs) Brainstem process fatigable weakness?
plus cranial
YES ➤ (Class II-III)
NO
nerve signs?
➤
➤
NO
Intestinal
➤
Consider symptoms
somatoform or infant?
All four limbs (spastic Mid- or upper-
tetraparesis, upper disorder
cervical myelopathy
motor neuron signs), YES ➤ (Class II-III)
(Class II-III)
sensory level,
bladder dysfunction?
NO YES NO
➤
➤
➤
Legs (spastic
Thoracic myelopathy
paraparesis), upper YES ➤ (rarely may be caused by
motor neuron signs?
a parasagittal lesion)
NO (Class II-III)
The evidence for recommendations is graded using the following
➤
EB Practice, LLC.
➤ ➤
➤
➤
(Avoid succinylcholine if
neuromuscular process Non-contrast
present for more than
Suspected cortical
or subcortical
YES ➤ head CT
three days) (Class II) (Class II-III)
process?
NO
➤
➤ ➤
➤
NO
➤
NO
➤
➤
The evidence for recommendations is graded using the following scale. For complete definitions, see back page. Class I: Definitely
recommended. Definitive, excellent evidence provides support. Class II: Acceptable and useful. Good evidence provides support. Class III:
May be acceptable, possibly useful. Fair-to-good evidence provides support. Indeterminate: Continuing area of research.
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending
upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright ©2002 EB Practice, LLC. 1-800-249-5770. No part of this publication may be reproduced in any
format without written consent of EB Practice, LLC.
Suspected spinal
Conservative treatment
nerve, nerve plexus, YES ➤ (Neuroimaging, electromyography, nerve conduction velocity testing by consultant as
or peripheral nerve
process? indicated) (Class II-III)
NO
➤
➤
➤
Signs of
Suspected Consider acetylcholine ➤ YES ➤ Cardiac monitoring
neuromuscular
YES ➤ receptor antibody testing
autonomic
and appropriate
instability?
junction disorder? or botulism testing supportive care
(Class II-III) (Class II-III)
NO
➤
NO
➤
➤
Suspected
myopathy?
YES ➤ Serum electrolytes
Signs of
and creatinine
impending
YES ➤ Close observation
phosphokinase of respiratory status
respiratory failure?
(Electromyography, nerve or intubate
conduction velocity NO (Class II-III)
testing, muscle biopsy by
➤
consultant as indicated)
(Class II-III) Forced vital capacity Intubate
(FVC) less than 12 cc/ (Avoid succinylcholine if
kg OR negative YES ➤ neuromuscular process
inspiratory flow (NIF) present for more than
less than 20 cmH2O? three days) (Class II)
NO
➤
Close observation
of respiratory status
(Class II-III)
The evidence for recommendations is graded using the following scale. For complete definitions, see back page. Class I: Definitely
recommended. Definitive, excellent evidence provides support. Class II: Acceptable and useful. Good evidence provides support. Class III:
May be acceptable, possibly useful. Fair-to-good evidence provides support. Indeterminate: Continuing area of research.
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending
upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright ©2002 EB Practice, LLC. 1-800-249-5770. No part of this publication may be reproduced in any
format without written consent of EB Practice, LLC.
syndrome or signs of a significant myelopathy needs 8. “The patient told me his vision was blurred. Lots of
steroids and a stat MRI. When such neuroimaging cannot patients complain of blurry vision. How was I supposed to
be obtained, document the reason, institute empiric steroid know he meant he was experiencing double vision?”
therapy, and consult immediately. Blurred vision is a complaint that must be differentiated
from double vision. If diplopia is described, cranial nerve
6. “That woman had so much psychosocial stuff going on, dysfunction and bulbar signs must be explored to rule out
her weakness had to be psychosomatic.” a brainstem stroke or neuromuscular junction process. Do a
The reason the patient was anxious was because she detailed examination of the extraocular muscles and
could no longer climb the steps of her home. Non- specifically ask the patient about double vision.
categorical or somatoform disorders are a diagnosis of
9. “The parents said that their infant was lethargic and not
exclusion when evaluating a weak patient. Only after
feeding well, but the kid was afebrile. I ruled out sepsis and
organic causes are excluded should patients be labeled
dehydration. What was the problem?”
with a somatoform disorder.
A good history is necessary in all cases of acute weakness.
In this case, the child had infantile botulism. It was later
7. “The patient was comatose when I saw her.”
found out that the parents had been mixing raw honey
When the neurologist evaluated the patient 10 hours later,
with their child’s formula to “help him out with his
he immediately recognized the patient to be “locked-in.”
bowel movements.”
Unfortunately, even though the patient was taken to the
catheterization lab at that point, her basilar artery 10. “Every geriatric patient I see complains of weakness.
thrombus did not respond to intra-arterial lysis. Although Her oral temperature was normal. How was I to know she
patients with the locked-in syndrome due to a posterior was uroseptic?”
circulation stroke may appear comatose, careful In an elderly patient, weakness may be the chief complaint
examination will identify that their consciousness is for a broad range of diseases. Medical conditions such as
preserved. The only way such a patient may be able to congestive heart failure and infection must be explored as
communicate with anyone is via vertical eye movements. potential etiologies to the patient’s presentation. ▲
toms, in addition to positive thumb adduction Needs Assessment: The need for this educational activity was determined by a
survey of medical staff, including the editorial board of this publication; review
and hand elevation tests. of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and
evaluation of prior activities for emergency physicians.
This test concludes the July through December 2002 Date of Original Release: This issue of Emergency Medicine Practice was published
semester testing period of Emergency Medicine Practice. The December 1, 2002. This activity is eligible for CME credit through December
1, 2005. The latest review of this material was November 8, 2002.
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disclosure statement. The information received is as follows: Dr. Birnbaumer
receives consultation fees from GlaxoSmithKline and Aventis. Dr. Asimos, Dr.
Class Of Evidence Definitions Karas, and Dr. Shah report no significant financial interest or other relationship
with the manufacturer(s) of any commercial product(s) discussed in this
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