emDOCs Podcast – Episode 112: Guillain-Barré Syndrome Part 2

Episode 112: Guillain-Barré Syndrome Part 2

ED treatment:

• IVIG and plasma exchange are the main treatment modalities. 
  • Both seem equally effective, but combining them does not improve outcomes.
  • Get neurology involved early to help you decide which one to use.
• Dysautonomia:
  • Generally occurs in patients with more severe disease.
  • Can present as a sustained tachyarrhythmia or hypertension or can oscillate between episodes of parasympathetic hyperactivity and sympathetic hyperactivity. 
  • Only persistent or sustained abnormalities should be treated. If the patient is oscillating between parasympathetic and sympathetic episodes, avoid aggressive treatment when possible, as the oscillations are usually short-lived.
  • For sustained hypotension, start with fluids and then low-dose norepinephrine if needed.
  • Persistent severe hypertension (MAP > 100-120 mmHg or evidence of end-organ damage) should be treated with short-acting medication such as nicardipine or clevidipine.
    • Only treat with antihypertensive agents after pain and agitation have been controlled.
    • Avoid beta blockers as this may worsen bradycardia. 
  • Other autonomic issues, such as urinary retention, incontinence, or gastroparesis, can occur.
    • Urinary symptoms can be treated with a Foley or straight cath.
    • Gastroparesis can be treated with a prokinetic agent like metoclopramide.
    • If ileus or pseudo-obstruction occurs, the patient needs a bowel regimen and potentially a rectal tube for decompression.
• Airway:
  • Findings that suggest intubation may ultimately be needed:   facial or bulbar weakness; abnormal single breath test; poor cough strength; multiple muscle groups are affected; inability to handle secretions 
  • If you suspect ventilation issues, you can check a negative inspiratory force (NIF) or a forced vital capacity (FVC), although no clear data supports these for GBS.
    • Long suggests the single-breath test, in which the patient takes as deep a breath as possible and counts in a regular voice. Normally, you should be able to get to 20.
  • Rocuronium is the preferred paralytic.
    • Succinylcholine can cause hyperkalemia due to muscle denervation.
  • Ketamine is a great choice for induction.
  • Have push dose epinephrine at the bedside as induction can remove sympathetic tone and result in a vagal episode.
  • Ventilator settings are the same as you would normally use.

Disposition:

• If the patient has only distal paresthesias, no weakness, and no progression of symptoms, they can be discharged to follow up with their primary care provider or with instructions to return to the ER if symptoms progress.
• Anyone with progressive symptoms or more findings on exam than paresthesias alone should be admitted to the hospital, likely to an ICU setting, due to the risk of decompensation.

Outcomes:

• Many patients make full recoveries. However, ~20% cannot walk without assistance at one year, and ~30% have continued respiratory failure.
• Mortality is ~5%.

Please see Part 1 on the presentation and evaluation of GBS.

References:

1. Madden J, Spadaro A, Koyfman A, Long B. High risk and low prevalence diseases: Guillain-Barré syndrome. Am J Emerg Med. 2024 Jan;75:90-97. Epub 2023 Oct 28. PMID: 37925758