In this section : Neurology
Cognitive Function
Conscious Level
Stroke Care
Idiopathic Intrancranial Hypertension
Myasthenia Gravis
Serotonin Syndrome
Neuroleptic Malignant Syndrome
Guillain-Barré Syndrome
Acute Vertigo
Transient Global Amnesia
Brain Tumours
Lumbar Puncture
Transient Loss of Consciousness
Other Funny Turns
Haematemesis – ACP
Head and Neck Injury
Severe Headache
Status Epilepsy in Adults
The First Seizure
Multiple Sclerosis
Coma
Guillain-Barré Syndrome
Last updated 29th February 2024
Introduction
- 40% of patients with Guillain-Barré Syndrome (GBS) may have respiratory muscle involvement and up to 30% develop respiratory failure as a result of the muscles of respiration being affected.
- It is essential to establish the extent of respiratory muscle involvement, especially in patients with rapid onset weakness involving the swallowing or shoulder muscles, in order to anticipate the need for intensive care with intubation and ventilation should they become progressively weaker and unable to breathe adequately.
- Assessment and monitoring of ward patients with GBS for clinical and laboratory evidence of impending respiratory failure should inform the timing of consultation for Critical Care Unit admission and management.
Diagnosis
- GBS is defined as progressive motor and sensory deficit commonly ascending in nature without sphincter involvement and without sensory level. Often preceded by gastroenteritis.
- LP is essential for diagnosis (high protein and normal amount of white blood cells).
- In clinically unclear cases electrophysiology (DCN in Edinburgh) is needed.
Autonomic Nervous System
- Changes in the Autonomic Nervous System can occur in 20% of patients with GBS.
- Manifestations of autonomic dysregulation include postural hypotension, sweating, hypertension and potentially life threatening cardiac arrhythmias.
- Signs of autonomic dysfunction may dangerously worsen as the patient develops respiratory failure.
Measuring Forced Vital Capacity (FVC)
- Forced vital capacity (FVC) is the amount of air which can be forcibly exhaled from the lungs after taking the deepest breath possible.
- Bedside measurement of FVC should be used to monitor respiratory muscle function and is useful in guiding decisions to consult Critical Care specialists for consideration of respiratory support.
- Additional factors to guide intubation include duration of onset < 7days), inability to cough, lift head off pillow, secretion clearance, patient age and co morbidities.
Performing the FVC
- The patient takes a deep breath in, as large as possible, and blows out as hard and as fast as possible and keeps going until there is no air left.
- This should be carried out at least three times and two of the FVC readings should be within 100 ml of each other to be obtain a reliable reading.
- Ensure that there is a good seal around the mouth piece during the procedure to avoid mouth leaks.
- This should initially be performed every 4 hours, relaxed if stabilising.
Contraindications to Performing the FVC
- If any of the following have occurred recently, then it may be better to wait until the patient has fully recovered before carrying out the FVC – if in doubt, ask medical staff.
- Haemoptysis of unknown origin
- Pneumothorax
- Unstable cardiovascular status, recent myocardial infarction or pulmonary embolism (within a month)
- Thoracic, abdominal or cerebral aneurysms
- Recent eye surgery
- Acute disorders affecting test performance, such as nausea or vomiting
- Recent thoracic or abdominal surgical procedures
Differential Diagnosis
- Other paralytic illnesses such as myasthenia gravis, flaccid phase of spinal cord lesion, paraneoplastic syndrome, botulism. Polio used to be part of differential but no longer.
Treatment
- Consult Neuro team during working hours/neuromedics at RIE after hours if necessary
- Consider elective ventilation if progressive fall in FVC and patient is tiring
- Treat pain with NSAIDs or opiates
- LMWH to reduce risk of venous thrombosis
- IVIG and Plasma Exchange (PE) have both been shown to be effective in GBS, whereas steroids are not.
- IVIG 2g/kg over five days (0.4g/kg every day), is as effective as PE but has fewer side effects
- Patients with mild GBS who are symptomatic but able to walk unaided can be managed conservatively
- Patients who dont improve or relapse after IVIG or PE are extremely difficult to manage. Anecdotal evidence that steroids may help here. No good evidence that PE followed by IVIG is helpful, while no trial of IVIG followed by PE has been undertaken
Prognosis
- 3 phases to illness – period of deterioration which may be rapid over a matter of hours or up to 4 weeks, followed by plateau phase then period of recovery which is usually gradual over several months
- Rule of thirds – 1/3 make full recovery, 1/3 left with mild disability. 1/3 have moderate to severe disability
Content Updated by Dr Ondrej Dolezal