foreign [Music] coughing and breathing of one day duration on our initial 10 second assessment patient was conscious oriented and following comments coming to primary survey Airway there were mild pooling of secretions so we did an intermittent suction and a rapid sequence intubation SOS was planned coming to breathing respiratory rate of 35 per minute saturation of 95 percentage with 3 liter of nasal forms 150 bar 80 heart rate of 110 beats per minute all peripheral pulses were equally palpable two large Ivor cannulas were inserted during this point of time coming to disability GCS was 15 by 15 bilateral pupil equally reacting to light coming to exposure temperature was 98.4 degree Fahrenheit grbs plus 140 milligram per deciliter coming to urgents of primary survey ABG was taken showing a pH of 7.350 pco250 put of 88 and bicarb of 24. ECG was taken showing sinus tachycardia CBC CRP point of care showed a total count of 6000 and CRP of 17. coming to sample history this patient YouTube artificial blood gas right what was indication to take article build case in this patient uh so Oneness the patient had is still breathlessness to look at any acidosis assets and the patient also is a known case of myasthenia gravis is what is the saturation of the patient an arrival was 95 percentage with three liter of Nexus okay so from ABG you want to see what what is a specific thing you are looking for in ABG since the patient is we have to look at pco2 retention has to be there yeah for respiratory failure right Myasthenia crisis is what you are looking at right was apparently all right two days back developed history of fever and productive cuffs uh one day back the patient on awake noticed difficulty in eating swallowing and ptosis was also present there was fluctuating weakness and it was increased on activity towards the end of the day the patient developed regurgitation for food on coming to here the patient developed breathlessness coughing bilateral ptosis and multiple episodes of choking there was Associated blurring of vision no history of any trauma seizure vomiting headache or slurring of speech no history of any diaphoresis urinary retention increased secretion abdominal cramps or lacrimation now instead of any allergies drug history the patient was on tap parido stick milk 60 milligram BD stay of similar episodes in the past which how long he is having the problem with the known case what is the duration five years five years initially they started the drugs coming to systemic examination CNS examination of your told the previous history of the patient drug sander what happened now three days back patient had a difficulty in swallowing and noticed doses other than that any other history you want to take a history of any precipitating factors so in this is a medical case presentation right so it's not Amber history you have to say the medical history including history of presiding complaints past history medication so you can put the headings but you need to explain the positive history and negative history also because there's a Pure medical case and there is no acute emergency for this patient and it's not a trauma piece right so explain the medical history fully okay person so what else we can suspect for the increase in the carbon dioxide level you told it a Big E 50 is limited what is do you suspect anything else COPD you have to explore the possibilities of any chronic respiratory problems also and the old age these people are frequently going for there may be chance of aspiration that may be having its impact on the lungs can you believe any findings in the chest yes coming to systemic examination CNS patient was conscious oriented and following comments on both the limbs bilateral doses was present old reflexes were normal Power five by five on both Upper Limb and lower limb single breath test was come to B12 cranial or examination 1 and 2 was normal three four six or extraocular movements were restricted in all directions bilateral doses first person communicate Sensations were felt normally bilaterally cranial seven bilateral facial weakness was noted cleaner 8 9 10 were examined and it was normal normal uvula was there but gag reflex was a sluggish coming to cranial of 12 uh neck turning and flexion was a very weak shoulder strugging was also weak coming to cranial nerve 12 uh no fasciculations were noted coming to respiratory system uh right side minimal collapse was present CVS S1 S2 percent no Mormons and bowel sounds were present so our initial diagnosis was the patient was in Myasthenia crisis which were either precipitated by underlying infections a history of infection yes two days back history of fever and productive okay is there any possibility of without fever also they can exhibit some infection wolded people usually they need not have fever temperature is not minimal temperatures but disproportionately the infection will be persisted okay so your differential diagnosis must any crisis secondary to a LRTA with the patient right so what are the other conditions you will suspect in this patient uh the patient was on top Peridot statement so we have to differentiate between my stenia crisis as well as Coal Energy crisis good so what is the difference sorry so what is the difference between myasthenic crisis and Coal Energy characteristics by symptomatically we can differentiate like in cold energy crisis there will be diaphoresis and acclimation bronchial secretions urination like that by investigations we can give neostigmund test if the patient improves and it is suggestive of mystenia Crisis if still the patient worsens more of suggestive of choline energy crisis okay so basically myasthening crisis is a crisis of under medication and Coroner's crisis is a crisis of over medications so when your body when a mystery patient is not getting adequate amount of protesting men in the body to function normally the patient goes into myasthening crisis which can be precipitated by acute increase in demand secondary like infections or the patient is having a more than adequate amount of product in the body which is causing anticolinergic effects which causes a cold energy crisis so our symptoms with um Myasthenia crisis will be primary symptoms of patients of my skinny crisis will be factorial fluctuating weakness yes fluctuating matching and meaning of weakness associated with the muscle predominantly muscle weakness and this is the major compressed patient will be having along with swallowing difficulty what is the eye finding how will be the pupil people will be normal people can be normal or can be myost it can be myost or it can be normal what other features will be there for the patient patient will have cough because of aspirations or increased cough reflex expression can have cough and in cold energy this thing we are expecting increased productive mineral spin activity suppressing the ultraving effects in the body right so what are the features a patient will be having uh microlation increased bronchial secretions secretions all our bodily secretions can be increased yes what else if Myasthenia crisis is showing weakness of muscles uh cholinergy crisis will show English fasciculations or muscles you can see fasciculations in it okay what is the pupily finding I use we are having a meiosis in colder prices right endometriosis in my opinion is causes materials because there is less amount of neostimin in the body so pupils will be patriotic dilated out and in coronergy crisis since neoshimins affixes more and laptop in effects are less it will be meiosis fine or what else will be there patient increased activities will cause abdominal pain s will be the pains can be there water can be there anything with heart rate uh patient you know bradycardia in cold energy and in Myasthenia crisis the patients usually will have tactical tachycardia can be attributed to multiple effects in Myasthenia crisis can be due to tachypnea within difficulty can be due to a secondary infection that is happening or it can be directly due to my senior crisis itself but in coronergy crisis their heart rate usually will be dropping down because of loss of atropine effects will be decreased right okay so my thinkors isn't cold energy crisis we need to roll out and diagnostic test will be to give neurotrigment if worsening patient design coordinary crisis if improving Mild improvement itself we can say it is my skinny crisis okay what other condition if this patient is presenting to you with uh previous history is unknown this patient is presenting to you with the progressive muscle weakness with breathing difficulty what are the other differential diagnosis you will think about [Music] so basically we will divide it into unilateral and bilaterally Hemi or bilateral involvement okay so if you are thinking about heavy involvement we will think about brain and brain stimulation isn't it but if you are thinking about bilateral weakness we'll think about ascending or descending type of paralysis or tell me some authentic type of paralysis GPS syndrome then may not be ascending it can be but bilateral acute onset Progressive bilateral is ascending or means high power hyper Calamine periodic paralysis then snake snake bite is asymmetrically paralysis or symmetrical paralysis but in volume bilateral conditions that yeah rabbies rabies usually will not have a paralysis in the initial segments right towards the end only but what are the initial features what other thing which is now getting is now actually eradicated according to official sources is eradicated in India what is one disease which was rampant and is now eradicated acute flaccid paralysis polio polio is usually a descending paralysis isn't it is symmetrical but descending paralysis any torches that can cause paralysis toxicity can cause paralysis any other thoughts in that can cause paralysis any metals barium barium toxicity will cause hypokalemia hypoglycemia causing again so barium toxicity we can think about any other paralysis bilaterally or occur in paralysis we can think about in spinal cords syndromes can have acute element type of paralysis then what are what else is there in the spinal cord any inflammatory condition of spinal cord can cause acute bilateral paralysis may not be ascending but bilateral paralysis transverse Melody transverse myelitis is acute inflammatory condition what else any vascular pathology in spinal cord that can cause acute bilateral flaccid paralysis what is a blood supply to spine enough yes Angela is posterior spinal artery so is there any muscular pathology that can cause acute fluency paralysis um any aneurysm in those arteries in antirespulatory or process find that if there is any aneurysm which is rupturing like sh in the brain If there is an original rupture of spinal arteries you will get uncute fluorescent paralysis it can be a thrombus in the spine lot especially in the anterior respond later which is single and posteriorly we have to spend later so antennas thrombosis can cause accuracy paralysis any infections in the spinal space that can cause facet paralysis TV or TB volatiles TB you should take some time right or progressively acute paralysis maybe in a couple of days one or two days osteomyelity is still possible but then also the history is chronic anything else any collections so our sepsis is not the spinal cord right it's not Inspire court it's the inside the spinal cord we have those patients in ICU epidural lapses the epidural abscess can present with acute fossil paralysis okay so multiple things are there so if a patient presents with bilateral weakness in a mystery crisis patient this patient was obviously very history history is very symptomatic you are getting a precipitating factor patient gives all the history so there is no much things to think about but same patient or a new onset Myasthenia patient can present to you with just paralysis bilateral paralysis in those conditions there should be multiple things that is that has to be thought about here okay now coming to management of the patient how are you going to manage this patient possibly secure the airway how do you want to secure the airway of this patient uh he reasses the patient person patient is maintaining saturation of 94 percentage with three little two okay we give a trilo first through its uh new sequence has been given okay if the patient is improving and reflects everything is coming back to normal if the patient is able to uh productive uh spit down the secretions the saturation in Brew then we will wait if not the patients but is saturation Improvement a criteria for Airway secure the airway does not have saturation right saturation comes in breathing and ventilation right Airway doesn't have such saturation now if you assess the airway of the patient what is the problem here and there is pooling of secretions there is pooling of secretion due to muscle weakness inability of the patient to swallow or inability to spit out due to muscle weakness so what is the main thing you can do to identify whether patients recurs Airway management or not equation and clear out the secretions we can wait and watch but why I told that is if you take saturation what is the problem there if you take saturation as a criteria to intubate what is the problem all right present the saturations on the lower separation yeah but is that due to Myasthenia no it doesn't need to uh aspiration maybe it can be due to aspiration that has happened due to my senior true but you are giving a history of today's history of fever cough and breathing difficulty it can very well be a lot the patient is already having a alert here and you are saying the lrti precipitated Myasthenia why can't the desaturation be a part of type 1 respiratory failure of LRTA in this case since p02 is elevated we can we have to say type 2 but if mycenae was not there this desaturation can very well be attributed to a LRTA in that case will you intubate this patient no so here the question is whether Airway management is needed you say Airway the patient can clear or not saturation should not play a role here it should be separations gag reflex and capture flux these are the things you need to look into fine so you given your new streaming test UK patient improved yes single blood test was initially 12 would come to 24 24 but these patients gag reflex and cough reflex maintained patient improved but still if you suspected aspiration because there was a pollen saturation but if this patient didn't have desaturation or had 98 percentage without oxygen support uh what we do man how will you manage the patient [Music] but still patient has increased respiratory effort how will you manage yes you have you can put a Navy because here's the only the muscle fatigue is there you can see whether with the Navy your CO2 levels can be managed in that case NIV is adequate here you don't have to go for a integration unless patient worsens so with a good follow-up and observation you can see whether patient is a candidate or not okay or else you will individ now how would you in debate what are the things you'll think about since the patient is a case of myosin address we have to be take care of the muscle relaxants or the paralytic age and speaking usually there is depolarizing muscle relaxant and non depolarizing muscle relaxant we should not give depolarizing muscle relaxant like success even if we are giving non depolarizing muscle relaxant it has to be in the minimal therapeutic dose to the way you should not use suction equally success it causes for a long blockage of the in two receptors so if you are administering success it has a prolonged effect on the body and the available sites or style calling is will be again reduced good what about that muscle relaxants apart from broken we can go with other muscle extracurium this is [Music] and what is the main advantage of disadvantage of rochrony [Music] see all the muscle relaxers deforesting and non-demolarizing there will be resistance to the depolarizing muscle relaxants what is the pathology in Western colon receptor antibodies destroy the receptors so the number of receptors are existed so what is the mechanism of action of the depolarizing license persistent deep polarization so they are not having enough receptors to act so we have to increase the dose of suction coding but as you told there may be chance that reaction may be prolonged because the patient is on drugs where the choline stress level they will be trying to destroy so that will destroy even the pseudocore industries the soda Korean distance is the enzyme which will metabolize the successful so there may be chances so depolarizing increase the dosage but prolonged action will be there and a non-depotation very sensitive you can reduce to either off or even to third or one third as an initial dose and see the response an ideal is if the peripheral nerve stimulator we are telling us the main advantages and this one we can reverse it in case any difficulty were to maintain longer period that we don't want what is that we can use this sugar Maddox and then foreign weakness is there everything will be absent or reduced there may be chance of aspiration any type you knock down the level of Consciousness and make the patient Prius during the resources so this one you have to keep in mind and already there is lot of secretions so during before starting pre-oxidation clear all the situations always whatever oxygen you are giving it will not completely reach that that is should be so in case necessary during the conscious level is that we can't able to continue we can keep the patient left later and also so that there will be possibilities of minimizing the aspiration so these are all things you have to keep it then coming to the serial tutorials see what is the thing they will be careful so already there is a skeletal muscle weakness including the respiratory muscles so most of this almost all the senator drugs will further depress the respiration and respect to the efforts so we have to judiciously is in smaller quantities and individual titration and the action will be much prolonged also so in such cases we have to select the short acting least hemodynamic and respiratory alteration so fentanyl for energy purpose you can use it in smaller tools were longer acting better term s all these things should be avoided these are things you have to keep in mind and anything you should anticipate the procedure reciprocities for a procedural solution or anything procedure is over after that also they may need intellectic support so you have to constantly observe the patient for any need arises Okay so how you told you give Neo stigma for the patient right can you explain how do you do nearest mean test ing meal in animal illness and you will immediately flush and with 10 minutes we will ask us the response like improvementosis single breath count and the Agri flux and arm abduction does everything and there is Improvement and it is a positive new statement test so if you give new streaming is the effect permanent no the short duration action then yes we will go with uh Tap radio statement another short term that are PSP will initiate we'll increase the dosage right so you told you take on them and dilute it into 9 MMS and make a 10 normal solution and inject the patient any other complications are you expecting in this test so patient might go into bradycardia yes so you should make sure that you have at least a drop in with you right so near stigmund test in this condition you are in emergency department but the neurologist uh initially diagnosis Myasthenia they give a Tropic they give a tropin the knowledge they give new Stickman because when you are pushing in your stream in IV it can significantly cause bradycardia so dropping precursions for the test should be explained along with the test so dropping should be either given if you because in my skin crisis we told that patient will be having but if it is not there you should always keep drop it with you in case patient goes into radically okay Baseline pulse rate before thinking of giving administing new statement check the purchase it is normal rate or already bracket so initially if it is [Music] [Music] per day for five days we will give a long-term treatment based on the pathology there is a Time Moma then we'll go with timectomy if not a trial of zeroids is also vegan that is no not good okay thank you sir