Myasthenic Crisis Checklist - Myasthenia Gravis Evaluation - Chest X-ray and lung ultrasound (exclude other lung disease) - Forced vital capacity (FVC) - Electrolytes (including Ca/Mg/Phos), CBC with differential - Beta-HCG if pregnancy possible - Infectious workup or TSH level if symptoms of infection or thyroid disease Respiratory supp ort - Consider early HFNC or BiPAP if mild-moderate respiratory distress or tachypnea. - Intubation only if clinically indicated. Pyridostigmine - New diagnosis of MG: May initiate at 60 mg q6 - Chronic MG not intubated: Continue prior dose unless extremely high - May add glycopyrrolate to reduce oral secretions (e.g. I mg with each dose) Plasma exchange/lVIG - Plasma exchange is the fastest approach to stabilize disease. - If plasma exchange is contraindicated/unavailable may use IVIG. Monitoring - Most useful: Usual monitoring (vital signs, clinical appearance, subjective dyspnea, etc.) - Forced vital capacity: Monitor 2-3 times daily. DO NOT wake up patient for this. - Do not measure negative inspiratory force (NIF). Drugs to avoid (main ones) - Antibiotics: aminoglycosides, fluoroquinolones, tetracyclines, macrolides - Muscle relaxants: dantrolene, cyclobenzaprine, baclofen, methocarbamol, succinylcholine - Neuro: Lithium, haloperidol, prochlorperazine, phenytoin - Cardiovascular: Beta-blockers, calcium channel blockers, lidocaine, procainamide, statins - Other: Antihistamines, anticholinergics, high-dose magnesium, IV contrast By Dr. Josh Farkas @ https://twitter.com/PulmCrit #Myasthenic #Crisis #MyastheniaGravis #Checklist #Management #CriticalCare
