Not all Myasthenia Gravis patients will present with obvious symptoms, but may still be struggling with rapidly increasing flaccidity that can lead to critical respiratory distress with partial or total diaphragmatic paralyzation. Anxiety may be present but it is not the cause of Mysasthenic emergency. Do NOT assume the patient is exaggerating symptoms in what may appear to be a benign presentation. Myasthenics can rapidly decline within minutes.
Not addressing a Myasthenic in exacerbation or crisis appropriately can lead to fatality.
Do not rely on single criteria assessment. Evaluation should include:
Oxygen can be used on route to the closest emergency facility but is a bandaid and will not address Myasthenic respiratory weakness. Myasthenia Gravis respiratory distress is an issue of ventilatory failure and not oxygenation capability. The lung's tissue maintains it's ability to oxygenate during inspiratory paralyzation in the early stages and oxygen levels can remain falsely elevated. Oxygen supplementation can be used for temporary assistance and comfort. NIV support is preferable and can be used to help assist the diaphragm and potentially avoid mechanical ventilation, although ventilation may be required. Avoid muscle relaxers for intubation if possible.
A patient may be experiencing varying levels of diaphragmatic paralysis and have stable testing outcomes. These do not rule out advancing exacerbation or crisis. Changes and measurable data may not occur until AFTER the patient has crashed.
Maintain calm environment and appropriate ventilatory support. Do not wait for the patient to crash to seek NIV solutions.
Ice packs on the neck, throat and diaphragm can help provide slowed nerve transmission and offer partial, temporary relief. Use as appropriate. Ensure room temperature is also cool and comfortable to allay increased flaccidity.
Cholinergic Crisis Assessment:
SLUDGE syndrome may be helpful in rapid assessment. Both Myasthenic and Cholinergic crisis may see crossover in presentation but these two crisis are very different.
S : Salivation
L : Lacrimation
U : Urination
D : Diarrhea
G : GI Distress
E : Emesis
(M) : Miosis
Cholinergic crisis is an over-stimulation at a neuromuscular junction due to an excess of acetylcholine (ACh), as a result of the inactivity (perhaps even inhibition) of the AChE enzyme, which normally breaks down acetylcholine. Atropine can be used to help reverse Cholinergic crisis. Please assess patient for possible Cholinergic presentation: