Evaluation of the adult with acute weakness in the emergency department
- Andrew W Asimos, MD
Andrew W Asimos, MD
- Adjunct Associate Professor, Department of Emergency Medicine
- University of North Carolina School of Medicine
- Section Editor
- Robert S Hockberger, MD, FACEP
Robert S Hockberger, MD, FACEP
- Section Editor — Adult Signs and Symptoms
- Emeritus Professor of Medicine
- David Geffen School of Medicine at UCLA
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Weakness is a common, nonspecific emergency department (ED) complaint that encompasses a broad differential diagnosis. Causes include neurologic ailments and a range of non-neurologic conditions. The diagnosis of potentially life-threatening neurologic and neuromuscular processes requires a systematic, anatomic approach based upon a careful history, physical examination, and in some cases, imaging studies.
Particularly in the elderly, infection, cardiovascular disease, and dehydration must be considered as possible causes of weakness. However, such conditions cause generalized malaise rather than true neuromuscular weakness and will not be discussed here, except to mention them as important considerations in the differential diagnosis.
The approach to the diagnosis and initial management of patients presenting to the ED with acute, nontraumatic neurologic and neuromuscular weakness will be reviewed here. Medical conditions characterized by general malaise or chronic weakness is discussed separately.
DIFFERENTIAL DIAGNOSIS OF ACUTE WEAKNESS
Although this topic reviews the approach to the patient with acute weakness from nontraumatic neurologic or neuromuscular disease, a broad differential diagnosis, including causes of generalized weakness (or malaise), is presented here to assist clinicians looking for additional information about these conditions.
Life-threatening central causes of unilateral weakness
●Ischemic stroke – Sudden loss of focal brain function is the core feature of the onset of ischemic stroke. This may manifest as acute, focal, unilateral weakness or paralysis in the face, upper extremity, or lower extremity, or as difficulty with coordination and gait. Other medical illness can mimic stroke (table 1), and symptoms of stroke can vary widely based upon the cause and the artery involved (table 2 and table 3). (See "Overview of the evaluation of stroke" and "Initial assessment and management of acute stroke".)
- Hughes RA, Cornblath DR. Guillain-Barré syndrome. Lancet 2005; 366:1653.
- McGillicuddy DC, Walker O, Shapiro NI, Edlow JA. Guillain-Barré syndrome in the emergency department. Ann Emerg Med 2006; 47:390.
- Skiendzielewski JJ, Martyak G. The weak and dizzy patient. Ann Emerg Med 1980; 9:353.
- Medical Research Council. Aids to the Investigation of Peripheral Nerves, Crown Publishing, London 1976.
- Yang KL, Tobin MJ. A prospective study of indexes predicting the outcome of trials of weaning from mechanical ventilation. N Engl J Med 1991; 324:1445.
- Juel VC, Bleck TP. Neuomuscular disorders in critical care. In: Textbook of Critical Care, Grenvik A, Ayres SM, Holbrook PR, Shoemaker WC. (Eds), WB Saunders, Philadelphia 2000. p.1886.
- Orebaugh SL. Succinylcholine: adverse effects and alternatives in emergency medicine. Am J Emerg Med 1999; 17:715.
- Tobey RE, Jacobsen PM, Kahle CT, et al. The serum potassium response to muscle relaxants in neural injury. Anesthesiology 1972; 37:332.
- Fisher CM, Curry HB. Pure motor hemiplegia. Trans Am Neurol Assoc 1964; 89:94.
- Gan R, Sacco RL, Kargman DE, et al. Testing the validity of the lacunar hypothesis: the Northern Manhattan Stroke Study experience. Neurology 1997; 48:1204.
- Massicotte EM, Montanera W, Ross Fleming JF, et al. Idiopathic spinal cord herniation: report of eight cases and review of the literature. Spine (Phila Pa 1976) 2002; 27:E233.
- Borges LF, Zervas NT, Lehrich JR. Idiopathic spinal cord herniation: a treatable cause of the Brown-Sequard syndrome--case report. Neurosurgery 1995; 36:1028.
- Wada E, Yonenobu K, Kang J. Idiopathic spinal cord herniation: report of three cases and review of the literature. Spine (Phila Pa 1976) 2000; 25:1984.
- Rumana CS, Baskin DS. Brown-Sequard syndrome produced by cervical disc herniation: case report and literature review. Surg Neurol 1996; 45:359.
- Truumees E, Herkowitz HN. Cervical spondylotic myelopathy and radiculopathy. Instr Course Lect 2000; 49:339.
- Argoff CA, Wheeler AH. Spinal and radicular pain disorders. Neurol Clin 1998; 16:833.
- Chad DA, Recht LD. Neuromuscular complications of systemic cancer. Neurol Clin 1991; 9:901.
- Newton HB. Neurologic complications of systemic cancer. Am Fam Physician 1999; 59:878.
- Bell HS. Paralysis of both arms from injury of the upper portion of the pyramidal decussation: "cruciate paralysis". J Neurosurg 1970; 33:376.
- Ladouceur D, Veilleux M, Levesque RY. Cruciate paralysis secondary to C1 on C2 fracture-dislocation. Spine (Phila Pa 1976) 1991; 16:1383.
- Marano SR, Calica AB, Sonntag VK. Bilateral upper extremity paralysis (Bell's cruciate paralysis) from a gunshot wound to the cervicomedullary junction. Neurosurgery 1986; 18:642.
- Patterson JR, Grabois M. Locked-in syndrome: a review of 139 cases. Stroke 1986; 17:758.
- Wijdicks EF, Nichols DA, Thielen KR, et al. Intra-arterial thrombolysis in acute basilar artery thromboembolism: the initial Mayo Clinic experience. Mayo Clin Proc 1997; 72:1005.
- Dawson DM, Potts F. Acute nontraumatic myelopathies. Neurol Clin 1991; 9:585.
- Helweg-Larsen S. Clinical outcome in metastatic spinal cord compression. A prospective study of 153 patients. Acta Neurol Scand 1996; 94:269.
- Portenoy RK, Lipton RB, Foley KM. Back pain in the cancer patient: an algorithm for evaluation and management. Neurology 1987; 37:134.
- Massey JM. Acquired myasthenia gravis. Neurol Clin 1997; 15:577.
- DIFFERENTIAL DIAGNOSIS OF ACUTE WEAKNESS
- Life-threatening central causes of unilateral weakness
- Life-threatening and other serious causes of bilateral weakness
- - Brainstem stroke
- - Spinal cord disease
- - Peripheral nerve disease
- - Neuromuscular junction disease
- - Muscle disease
- Life-threatening medical causes with focal findings
- Life-threatening causes of generalized weakness
- Other neurologic causes of acute weakness
- Other medical causes of generalized weakness
- Elderly patients
- Defining weakness
- Approach to the history
- Unilateral weakness
- Bilateral weakness
- PHYSICAL EXAMINATION
- Motor neuron findings
- Strength testing
- Reflex testing
- Sensation testing
- ANCILLARY STUDIES
- General approach
- Pulmonary function testing
- Chest radiography
- Cerebral spinal fluid (CSF) analysis
- Tensilon test
- Other serologic testing
- ASSESSMENT OF LIFE THREATENING ILLNESS
- Airway and breathing
- Airway management
- Critical diagnoses
- Algorithmic approach
- Unilateral weakness
- - Cortical findings
- - Lacunar syndromes and basal ganglia lesions
- - Brainstem processes
- - Brown-Sequard syndrome
- - Radiculopathies
- - Plexopathies
- - Peripheral nerve injuries
- Bilateral Weakness
- - Cortical or brainstem lesions
- - Myelopathies
- - Polyneuropathy
- - Neuromuscular junction processes
- - Myopathies
- SUMMARY AND RECOMMENDATIONS