Myasthenic Crisis

Admission Plan

Drugs Contraindicated in Myasthenia

Respiratory Support

An example of an admission note of myasthenic crisis patient to the ICU: 
Assessment:
1. Myathenic Crisis:

• Manifestations: ***
• Home MG meds: ***
• Etiology of Crisis: ***

Plan
Neurological:
– Neuro checks q4h
– Low threshold for intubation if increased work of breathing (MG patients can maintain good sats), Will follow PFT (FVC/NIF/MEF) q6h.
– Avoid medications that worsens myasthenia
– Meds:
Will start on IVIG 0.4gm/kg daily for 5 days
Continue pyridostigmine at dose ***
Continue home prednisone dose ***
___________________
Respiratory:
– FVC/NIF/MEF Q4h
– Aspiration precautions, head of bed above 30 degrees
– PRN O2
– Baseline CXR
– Suctioning q1-2 hours
– Meds:
None
_______________________________________________
Cardiology:
– Continuous cardiac telemetry
– Meds:
None
________________________________________________
Renal:
– Renal function normal
– Monitor daily BMP, Mg, Phos while on IVIG
– Meds:
IVFs NS @ 75/hr
_______________________________________________
Gastrointestinal:
– NPO for now till speech evaluation
– Meds:
________________________________________________
Endocrinology:
– FSBS q6hr
– Meds:
– Insulin SS
________________________________________________
Hematology:
– Monitor CBC daily
– SCDs for prophylaxis; enoxaparin 40mg SC daily
– Meds:
enoxaparin 40mg SC daily
________________________________________________
Infectious Disease:
– Current access: PIVs
– Meds:
none
_______________________________________________
Prophylaxis:
DVT: SCDs, enoxaparin 40mg SC daily
____________________________________________________________________________________________
Discharge Planning:
Patient requires *** (ICU or Step down) level of care for monitoring of respiratory functions.

Important Issues for Myasthenic patients

      Drugs contraindicated with myasthenia:

      Antibiotics: Quinolones – Monobactams – Lactams – Macrolides – Aminoglycozides

      Antiarrythmics: Quinine – Quinidine – Procainamide

      BP medications: Beta blockers (including timolol eye drops) – Calcium channel blockers

      CNS medications: Antiepileptic drugs – Lithium

      Local anasthetics: Procainamide

      Neuromuscular blocking agents: Succinylcholine – Curare medications

      Others: Penicillamine – Steroids (needs supervision) – Iodinated contrast agents – Magnesium containing medications

Patient Friendly List of Medications to Avoid

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Pulmonary function tests for MG/GBS:

– The 20/30/40 role: alarming values if FVC < 20ml/kg or NIF < 30cmH2O or MEP < 40cmH2O. These measures help to guide the level of admission (ICU/step down/floor), not to guide the decision for intubation. If FVC < 20ml/kg –> ICU admission is preferred.

– FVC is the most sensitive measure, NIF/MEP are effort dependent and less reproducible compared to FVC. Moreover NIF/MEP are unreliable if the face mask is leaking.

– Don’t depend on the numbers only for intubation. Patient should be either in respiratory distress while resting in bed without activity or hypercapnic to consider intubation.

Steps for respiratory support:

– No respiratory distress –> no need for respiratory support –> admit to step down

– Mild/Moderate respiratroy distress –> consider BIPAP or Hiflow nasal cannula if BIPAP is contraindicated (secretions – nausea – vomiting). It must be done in ICU for lose monitoring of respiratory distress, if didn’t improve (RR decrease, less use of accessory muscles) –> intubate.

– Severe respiratory distress –> intubation and mechanical ventillation.