This document discusses different types of movement disorders that can occur in critically ill patients, including involuntary movements (seizures), weak or ineffective movements (neuromuscular weakness), and no movements (neuromuscular blockers). It provides details on the causes, presentation, evaluation, and treatment of various movement disorders like seizures, myasthenia gravis, Guillain-Barré syndrome, and critical illness myopathy/polyneuropathy. Complications of prolonged seizures as well as disadvantages of prolonged neuromuscular paralysis are also reviewed.
2. Introduction
Three general types of movement disorders
encountered in critically ill patients
1. Involuntary movements (Seizures)
2. Weak or ineffective
movements(neuromuscular weakness)
3. No movements (neuromuscular blockers)
3. Types of movements
a) Tonic contractions
b) Atonic contractions
c) Clonic contractions
d) Myoclonic contractions
e) Automatisms
Post –ictal period : Time immediately following a
seizure and transient impairment of
mentation and sensorium.
4. Drug Related Seizures in the PICU
Drug Intoxication Drug Abuse Drug Withdrawal
Pharmaceuticals: Amphetamines Barbiturates
Ciprofloxacin Cocaine Benzodiazepines
Imipenem Phencyclidine Ethanol
Isoniazid Opiates
Lidocaine
Meperidine
Penicillins
Theophylline
Tricyclics
5. Etiology for seizures
• Drug intoxication
• Drug withdrawal
• Infections
• Head trauma
• Ischemic injury
• Space occupying lesions
• Hemorrhage
• Systemic metabolic derrangements
• Uremic encephalopathy
• Cerebrovascular diseases
• Non compliance of Anti-epileptic drug therapy
7. Intravenous drug therapy for
convulsive seizures in the PICU
• Inj Lorazepam 0.1 mg/kg/dose
• Inj Fosphenytion 15mg/kg loading f/b 5 mg/kg
• Inj Phenytoin 20 mg/kg loading f/b 5 mg/kg
• Inj Phenobarbital 20 mg/kg f/b 5 to 8 mg/kg
• Inj Propofol infusion
• Inj Midazolam infusion
• Phenobarbital coma
8. Anticonvulsant hypersensitivity
syndrome
• Idiosyncrytic reaction to phenytoin or
phenobarbital associated with triad of fever ,
rash, hypotension and lymphadenopathy .
• Lab features include Increased liver enzymes,
Leucocytosis, Thrombocytosis or
Thrombocytopenia.
• Associated with Abnormal EEG.
9. Comparative Features of Myasthenia
Gravis and GBS
Features Myasthenia Gravis GBS
Ocular Findings Yes No
Fluctuating weakness Yes No
Bulbar weakness Yes Yes
DTR Intact Depressed
Autonomic instability No Yes
Nerve Conduction Normal Slowed
10. Comparative Features of Conditions Associated
with Picu Acquired Neuromuscular weakness
Critical Illness
Polyneuropathy
Residual
Neuromuscular Block
Critical illness
Myopathy
Sensory Mod to severe Normal Normal
Motor Systemic weakness,
Respiratory failure
Systemic weakness,
Respiratory failure
Systemic weakness,
Respiratory failure
Creatine Kinase Normal Normal Mild elevation in 50%
Elecrodiagnostic
studies
Motor and sensory
axonal degeneration,
Normal conduction
velocity
Fatigue at NM
Junction
Myopathic changes,
normal conduction
velocity
Muscle biopsy Denervation Atrophy Normal Muscle atrophy , loss
of thick filaments
11. Respiratory consequences of
Neuromuscular Weakness
Consequences Management
Normal respiratory muscle strength Observe
Impaired cough with difficulty clearing
secretions
Chest physiotherapy
Accumulation of secretions, with risk of
infection and airway obstruction
Intubation and mechanical ventilation
Atelectasis and progressive hypoxemia Supplemental oxygen
Alveolar hypoventialtion and hypercapnia Mechanical ventilation
