Rosen & Barkin's 5-Minute Emergency Medicine Consult (532 page)

See Also (Topic, Algorithm, Electronic Media Element)

• Dacryoadenitis
  
• Dacryocystitis
  
• Hyperthyroidism
  
• Hordeolum and Chalazion
  
• Pseudotumor Cerebri
  

CODES

• 373.13 Abscess of eyelid
  
• 682.0 Cellulitis and abscess of face
  

BASICS

Peripheral neuropathy is a general term for peripheral nerve disorders that may affect motor, sensory, or vasomotor nerve fibers and presents with marked muscle weakness, atrophy pain and numbness

Variable, depending on presentation of symptoms; refer to Differential Diagnosis

DIAGNOSIS

• Sensory nerve dysfunction:
  
  • Numbness
    
  • Localized tingling
    
  • Paresthesias
    
  • Dysesthesias
    
  • Vibration and position sensations are decreased with large-fiber neuropathy
    
  • Pain and temperature sensation are decreased with small-fiber neuropathy
    
  • Deep tendon reflexes are decreased secondary to decreased sensation of afferent limb
    
• Motor nerve dysfunction:
  
  • Weakness:
    
    • Distal > proximal
      
    • Occasionally fasciculations
      
  • Muscle atrophy, diminished tone with long-standing motor nerve involvement
    
  • Loss of reflexes secondary to slowing of conduction along motor nerve efferent limb
    
• Autonomic nerve dysfunction:
  
  • Orthostasis
    
  • Constipation
    
  • Urinary retention
    
  • Impotence
    

• Duration of symptoms
  
• Symmetric or asymmetric symptoms
  
• Distal or proximal symptoms
  
• Motor, sensory, or mixed
  

• Thorough head-to-toe physical exam
  
• Focus on neurologic exam:
  
  • Motor weakness
    
  • Sensory loss typically in stocking-glove distribution
    

• Studies based on acuteness, severity of neuropathy, and most likely diagnosis
  
• Neurologic consult early if acute and severe symptoms
  

• Basic metabolic panel
  
• CBC
  
• Liver function tests
  
• Urinalysis
  
• Thyrotropin-stimulating hormone
  
• HIV or vitamin B
  ₁₂
  based on individual presentations
  
• Electrocardiogram
  

• CXR if indicated
  
• Head CT if indicated
  

• Electromyographic studies, nerve conduction studies, and nerve biopsy per neurologic consult on admission or outpatient follow-up
  
• Lumbar puncture as appropriate for AIDP
  

• Focal:
  
  • Entrapment
    
  • Common sites of compression:
    
    • Carpal, ulnar tunnel
      
    • Tarsal tunnel
      
    • Peroneal
      
  • Myxedema
    
  • Rheumatoid arthritis
    
  • Amyloidosis
    
  • Acromegaly
    
  • Trauma
    
  • Ischemic lesions
    
  • Diabetes mellitus (DM)
    
  • Vasculitis
    
  • Leprosy
    
  • Sarcoidosis
    
  • Neoplastic infiltration or compression
    
• Multifocal (mononeuropathy multiplex):
  
  • DM
    
  • Vasculitis:
    
    • Polyarteritis nodosa
      
    • Systemic lupus erythematosus
      
    • Sjögren syndrome
      
  • Sarcoidosis
    
  • Leprosy
    
  • Malignancy related
    
  • HIV/AIDS
    
  • Hereditary predisposition to pressure palsies
    
• Symmetric:
  
  • Endocrine:
    
    • Most common is DM
      
    • Hypothyroidism
      
  • Medications:
    
    • Isoniazid
      
    • Lithium
      
    • Metronidazole
      
    • Phenytoin
      
    • Cimetidine
      
    • Hydralazine
      
    • Amitriptyline
      
    • Amiodarone
      
  • Nutritional diseases:
    
    • Alcoholism
      
    • B
      ₁₂
      /folate deficiency
      
    • Thiamine
      
  • Critical illness neuropathy
    
  • Hypophosphatemia
    
  • Guillain–Barré syndrome (AIDP)
    
  • Toxic neuropathy:
    
    • Carbon monoxide
      
    • Acrylamide
      
    • Carbon disulfide
      
    • Ethylene oxide
      
    • Organophosphate esters
      
    • Lead
      
• Myelopathy mimicking peripheral neuropathy
  
• Back pain
  
• Saddle anesthesia
  
• Lower extremity weakness
  

TREATMENT

• Pain control as needed
  
• Airway protection as indicated
  

Establish airway protection with severe acute peripheral neuropathy, such as Guillain–Barré syndrome

• Variable depending on acuity of symptoms
  
• Discontinuation offending toxin or agent
  
• Treatment underlying systemic disease
  

• Variable depending on underlying diagnosis
  
• Opioid analgesics
  
• Gabapentin 300 mg PO daily then BID on day 2, then TID on day 3 up to 1,800 mg/d div. TID
  
• Carbamazepine 100 mg PO BID for trigeminal neuralgia
  
• IV immunoglobulin for Guillain–Barré syndrome (AIDP)
  

FOLLOW-UP

• Respiratory distress or acute gait disturbance
  
• Intractable pain
  

Stable respiratory and gait status with outpatient follow-up

Neurology—based on duration, severity of presentation

Primary care or neurology depending on etiology and severity of symptoms

Failure to diagnose Guillain–Barré syndrome (AIDP)

• Azhary H, Farooq MU, Bhanushali M, et al. Peripheral neuropathy: Differential diagnosis and management.
  Am Fam Physician.
  2010;81:887–892.
  
• Gilron I, Watson CP, Cahill CM, et al. Neuropathic pain: A practical guide for the clinician.
  CMAJ
  . 2006;175:265–275.
  
• Marx JA, Hockberger RS, Walls RM, et al.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice
  . 7th ed. St. Louis, MO: Mosby; 2009.
  
• Pascuzzi RM. Peripheral neuropathy.
  Med Clin North Am
  . 2009;93:317–342.