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
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".)
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- 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