01Approach to the Critical Patient/attcp44

Immediate threats and stabilization

›Time critical priorities

›Airway protection triggers

›Bulbar weakness with inability to handle secretions

›Recurrent aspiration

›Breathing failure triggers

›Rapidly progressive ascending weakness

›Single breath count less than 20

›Circulatory instability triggers

›Labile blood pressure

›Symptomatic bradycardia or tachyarrhythmia

›If impending respiratory failure, early ICU and early intubation pathway

Monitoring and targets

›Monitoring bundle

›Continuous cardiac monitoring for autonomic neuropathy risk

›High grade AV block risk in Guillain Barre syndrome

›Ventricular arrhythmia risk with dysautonomia

›Serial respiratory mechanics

›Forced vital capacity trending

›Negative inspiratory force trending

›Frequent neuro checks

›Progression pattern and tempo

›New cranial nerve deficits

High risk red flags

›Red flags

›Rapid progression over hours to days

›Concern for Guillain Barre syndrome

›Concern for spinal cord or cauda equina process

02History/hx55

Pattern recognition

›Symptom pattern

›Tempo of onset

›Hyperacute minutes

›Acute hours to days

›Subacute days to weeks

›Distribution

›Distal symmetric stocking glove

›Ascending symmetric weakness

›Multifocal asymmetric

›Predominant modality

›Motor weakness

›Sensory loss

›Neuropathic pain

›Autonomic symptoms

Preceding events and exposures

›Triggers and exposures

›Recent infection within 1 to 4 weeks

›Diarrheal illness

›Upper respiratory infection

›Vaccination within 6 weeks

›Temporal association only

›Alternative triggers still prioritized

›New medications and toxins

›Chemotherapy agents

›Nitrofurantoin exposure

›Isoniazid exposure

›Metronidazole exposure

03Physical Exam/exam44

Neurologic localization

›Neuro exam framework

›Strength pattern

›Proximal versus distal weakness

›Symmetric versus asymmetric weakness

›Reflexes

›Generalized hyporeflexia or areflexia

›Preserved reflexes with weakness prompting alternate diagnosis

›Sensory modalities

›Vibration and proprioception

›Pinprick and temperature

›Coordination and gait

›Sensory ataxia

›Foot drop gait

Cranial nerve and bulbar assessment

›Cranial nerve screen

›Facial weakness

›Bilateral facial palsy pattern

›Incomplete eye closure

›Bulbar findings

›Dysphonia

›Weak cough

›Ocular findings

›Ophthalmoplegia concern for Miller Fisher variant

›Ptosis prompting neuromuscular junction differential

Autonomic and cardiorespiratory assessment

›Autonomic findings

›Orthostatic vitals

04Differential Diagnosis/ddx39

Life threatening and time sensitive

›Critical differential

›Guillain Barre syndrome acute inflammatory demyelinating polyradiculoneuropathy ICD 10 G61.0

›Rapidly progressive symmetric weakness

›Areflexia

›Acute spinal cord compression ICD 10 G95.20

›Sensory level

›Hyperreflexia or Babinski

›Cauda equina syndrome ICD 10 G83.4

›Saddle anesthesia

›Urinary retention

›Epidural abscess ICD 10 G06.1

›Fever

›Back pain

›Tick paralysis SNOMED CT 409622000

›Rapid ascending paralysis

›Exposure to tick habitats

Peripheral nerve and root disorders

›Peripheral neuropathy etiologies

›Toxic neuropathy ICD 10 G62.2

›Chemotherapy induced

›Heavy metals

›Nutritional deficiency neuropathy

›Thiamine deficiency ICD 10 E51.9 with neuropathy manifestations

›Vitamin B12 deficiency ICD 10 E53.8

›Vasculitic neuropathy ICD 10 G63

›Painful asymmetric deficits

›Systemic vasculitis features

05Laboratory Tests/lt49

Core labs for acute neuropathy

›Baseline evaluation

›Complete blood count for infection or anemia

›Leukocytosis supporting infection

›Eosinophilia supporting allergic or parasitic process

›Electrolytes and renal function

›Sodium for severe hyponatremia weakness mimic

›Potassium for periodic paralysis

›Glucose

›Severe hyperglycemia and dehydration

›Hypoglycemia neuro mimic

›Liver enzymes

›Alcohol related disease clues

›Medication toxicity clues

Neuropathy focused labs

›Etiology directed labs

›Thyroid stimulating hormone

›Hypothyroidism neuropathy association

›Myopathy mimic consideration

›Vitamin B12 with methylmalonic acid if borderline

›Macrocytosis support

›Posterior column signs support

›Thiamine level when available

›Alcohol use risk

›Malnutrition risk

›Creatine kinase for myopathy mimic

›Marked elevation supporting myositis or rhabdomyolysis

›Normal value supporting neuropathic process

06Diagnostic Tests/dt54

Scoring Systems

›Risk and severity tools

›GBS Disability Scale

›Grade 0 healthy

›Grade 1 minor symptoms able to run

›Grade 2 able to walk 10 meters unaided unable to run

›Grade 3 able to walk 10 meters with aid

›Grade 4 bed or chair bound

›Grade 5 requires assisted ventilation

›Grade 6 death

›Medical Research Council sum score

›Six muscle groups bilateral scoring 0 to 5

›Total score 0 to 60

›EGRIS Erasmus GBS Respiratory Insufficiency Score

›Time from onset to admission

›Facial or bulbar weakness

›MRC sum score at admission

Electrodiagnostics

›Nerve conduction and EMG

›Indications

›Diagnostic confirmation of demyelinating versus axonal process

›Localization when focal deficits

›Early test limitations

›Normal results possible in first week of Guillain Barre syndrome

›Repeat testing at 1 to 2 weeks if high suspicion

›Demyelinating features

›Prolonged distal motor latencies

›Conduction block

07Disposition/dispo28

Level of care selection

›Admission pathway

›ICU indications

›Forced vital capacity decline trend

›Bulbar dysfunction

›Dysautonomia with arrhythmia or labile blood pressure

›Step down or monitored bed indications

›Suspected Guillain Barre syndrome without respiratory compromise

›Significant neuropathic pain requiring parenteral therapy

›Ward admission indications

›Stable non progressive deficits with inpatient workup need

›Functional decline needing PT and OT planning

Transfer and escalation

›Transfer criteria

›Need for plasma exchange capability

›Suspected severe Guillain Barre syndrome

›Rapidly progressive weakness

›Need for neurosurgical capability

›Imaging evidence of compression

›Cauda equina syndrome concern

Discharge criteria

›Discharge only when low risk

›Stable symptoms without progression over 24 to 48 hours

›No bulbar symptoms

›Normal respiratory mechanics when measured

›Safe ambulation plan

›Gait aid provided if needed

›Reliable supervision at home

08Treatment/t83

Supportive care and prevention

›Supportive bundle

›Airway and breathing support

›If declining respiratory mechanics, early noninvasive support trial only with close monitoring

›If bulbar dysfunction or rapid decline, intubation strategy with experienced operator

›Autonomic instability management

›Continuous telemetry

›Bedside atropine availability for symptomatic bradycardia

›Venous thromboembolism prophylaxis

›Pharmacologic prophylaxis unless contraindicated

›Mechanical prophylaxis when anticoagulation contraindicated

Disease specific immunotherapy

›Guillain Barre syndrome therapy

›First line immunotherapy

›Intravenous immunoglobulin total dose 2 g per kg

›0.4 g per kg per day for 5 days

›Infusion reaction monitoring

›Thrombosis risk assessment

›Plasma exchange

›4 exchanges over 7 to 14 days

›Typical exchange volume 40 to 50 mL per kg per session

›Central access complication monitoring

›Timing principles

›Benefit greatest when started within 2 weeks of onset

›Consider within 4 weeks for ongoing progression

›Corticosteroids

›Not recommended as monotherapy in Guillain Barre syndrome

›No functional outcome benefit in trials

09Special Populations/sp30

Pregnancy

›Pregnancy considerations

›Diagnostic adjustments

›MRI preferred over CT when feasible for spine evaluation

›Ionizing radiation minimization strategy

›Therapy considerations

›IVIG acceptable when indicated for Guillain Barre syndrome

›Plasma exchange feasible with obstetric and ICU coordination

›Maternal fetal monitoring triggers

›Autonomic instability

›Respiratory compromise

Geriatric

›Older adult considerations

›Higher complication risk

›Aspiration pneumonia risk with bulbar dysfunction

›Delirium risk with sedating analgesics

›Medication safety

›Lower starting doses for gabapentinoids

›Avoid tricyclics when high fall risk or conduction disease

›Alternate diagnoses prevalence

›Spinal stenosis and radiculopathy overlap

›Nutritional deficiency risk with low intake

Pediatrics

›Pediatric considerations

›Weight based respiratory thresholds

›Age appropriate forced vital capacity interpretation

›Close monitoring with rapid progression

›Pediatric Guillain Barre syndrome therapy

10Background/b33

Epidemiology

›Epidemiology facts

›Guillain Barre syndrome incidence

›Approximately 1 to 2 per 100000 per year

›Incidence increases with age

›Common acute neuropathy categories in ED

›Immune mediated polyradiculoneuropathy

›Toxic and metabolic neuropathies

›Prognosis overview

›Majority recover ambulation over months

›Subset require mechanical ventilation

Pathophysiology

›Mechanisms

›Demyelinating polyradiculoneuropathy

›Immune attack on peripheral myelin

›Conduction slowing and block

›Axonal variants

›Immune mediated axonal injury

›Slower recovery with severe deficits

›Dysautonomia mechanisms

›Small fiber involvement

›Labile sympathetic and parasympathetic output

Therapeutic Considerations

›Treatment principles

›IVIG and plasma exchange efficacy in Guillain Barre syndrome

›Faster recovery when started early

›Similar efficacy between modalities in many studies

›Combination therapy

11Patient Discharge Instructions/pdi18

copy discharge instructions

›Discharge instructions for acute peripheral neuropathy

›Diagnosis uncertainty and follow up plan

›Neurology or primary care follow up within 72 hours

›Lab and test results review plan

›Return to ED immediately for red flags

›New or worsening weakness

›Trouble breathing

›Trouble swallowing or choking

›New facial droop or trouble speaking

›New fainting or severe dizziness

›Chest pain or palpitations

›New loss of bladder or bowel control

›Safety and function

›No driving until cleared if weakness or numbness affects pedals

›Fall prevention at home

›Medication counseling

›Sedation risk with gabapentin or pregabalin

›Avoid alcohol with sedating medications

12References/r14

Clinical guidelines and consensus

›Guideline sources

›American Academy of Neurology practice parameter for Guillain Barre syndrome immunotherapy

›IVIG or plasma exchange recommended for non ambulatory patients

›Corticosteroids not recommended as monotherapy

›European Federation of Neurological Societies and Peripheral Nerve Society guidance on GBS diagnosis and management

›Respiratory and autonomic monitoring emphasis

›Early immunotherapy for progressive weakness

Evidence based sources

›Key evidence

›Randomized trials and meta analyses comparing IVIG and plasma exchange in Guillain Barre syndrome

›Similar functional outcomes in many comparisons

›Earlier treatment associated with better recovery trajectories

›Cohort studies on dysautonomia complications in Guillain Barre syndrome

›Arrhythmia risk support for telemetry

›Labile blood pressure risk support for ICU monitoring

Evidence & Review

Evidence & Review