Elissa’s Story

00:00
11:19

Playback Speed

No me gusta!

The flash player was unable to start. If you have a flash blocker then try unblocking the flash content - it should be visible below.

Nurses Edition Commentary

Mizuho Spangler, DO, Kathy Garvin, RN, and Lisa Chavez, RN
00:00
01:23

Playback Speed

No me gusta!

The flash player was unable to start. If you have a flash blocker then try unblocking the flash content - it should be visible below.

Jonathan W., M.D. -

Sounds like this was Heavy Metal poisoning that got better when the patient was removed from the toxic source.

Jonathan Wasserberger MD

Jess Mason -

Thanks for your comment. The R&D lab was a red herring in real life, so I wanted to include that in the segment. I should have mentioned that Elissa's diagnosis was ultimately confirmed by EMG and I think antibodies as well. Great thought on heavy metals, and important to keep on the ddx!
-Jess

Lars E., M.D. -

Fascinating case. While I appreciate the education about the varied presentations of GBS, I have difficulty accepting the recommendations provided in this chapter. Patients presenting to the ED with multiple non-anatomic neurolologic symptoms (numbness, weakness, paresthesias/dysesthesias) are very common. I think I had 3 of these cases my last shift. The conclusion of this chapter seems to be that GBS should be considered in these patients even when there is a lack of physical signs, i.e., that patients with odd, non-anatomic, atypical neurologic complaints should get an LP to assess for elevated protein. Let's ponder that for a moment: atypical GBS is very rare, perhaps 1 case per 100,000 per year. Lumbar puncture is not free of expense, ED physician time, patient throughput time/ED crowding, patient discomfort, and complications. Also, apparently early in the course of GBS the CSF is initially negative, so it is not clear that increasing the number of patients we LP is going to increase the number of early GBS diagnosis. The United States is not littered with the bodies of weak, nearly paralyzed patients with missed cases of atypical GBS. Are we really missing enough cases of this diagnosis that it justifies increasing the rate at which we perform LP on a patient's initial presentation when there are no objective findings?

Jess Mason -

I think one of the take home points is to increase your workup and level of suspicion when someone has multiple ED visits and isn't getting better. Remember to keep GBS on your differential, that it's not always a classic presentation, and the LP is a necessary part of the workup when GBS is being considered. Of course every emergency provider uses their own clinical acumen to decide when to pursue that workup, and the point is not to LP everyone, but to keep this in mind since it can present quite differently than how it is classically taught.

To join the conversation, you need to subscribe.

Sign up today for full access to all episodes and to join the conversation.

To download files, you need to subscribe.

Sign up today for full access to all episodes.
Shock, Asthma, and Fingertips Full episode audio for MD edition 246:13 min - 343 MB - M4AEM:RAP 2016 June Canadian Edition Canadian 18:39 min - 26 MB - MP3EM:RAP 2016 Junio Resumen Español Español 91:44 min - 126 MB - MP3EM:RAP 2016 Juin Résumé en Francais Français 58:51 min - 81 MB - MP3EM:RAP 2016 June Aussie Edition Australian 32:29 min - 45 MB - MP3EM:RAP 2016 June German Edition Deutsche 122:57 min - 169 MB - MP3EM:RAP 2016 June Board Review Answers 172 KB - PDFEM:RAP 2016 June Board Review Questions 237 KB - PDFEM:RAP 2016 June MP3 300 MB - ZIPEM:RAP 2016 June Written Summary 809 KB - PDF