Critical Care 2 – Myasthenic Crisis

This is the second case in a series looking at critical care medicine. Patients under the care of the critical care team may develop delayed complications of their illness or injuries. These cases can help individuals and teams prepare to identify and manage these patients who become newly, and sometimes unexpectedly, unstable.

This case comes from Dr. Dominique Piquette, academic Intensivist at Sunnybrook Hospital in Toronto, Ontario with updates from Dr. Sameer Sharif (Hamilton Health Sciences, Hamilton, Ontario) and Dr. Sophie Ramsden (Emergency Medicine Resident, McMaster University, Hamilton, Ontario)

Why it Matters

Patients admitted to a medical or surgical ward may decompensate, overwhelming the resources available. Most hospitals have a critical care outreach or rapid response team that can be activated in these cases. The critical care team must quickly assess the patient and carefully consider how to provide critical care safely and expediciously.

In this case, the team must rapidly identify the respiratory failure secondary to neuromuscular weakness and then develop an intubation plan that accounts for the anatomically difficult airway created by the mediastinal mass.

Clinical Vignette

A 57-year-old female with history of thymoma and myasthenia gravis is currently admitted to a general medical ward for pneumonia develops respiratory distress 48 hours after admission. A respiratory therapist (RT) was paged to assess the patient and then called you urgently because the patient appears unwell.

Case Summary

57-year-old female with known history of myasthenia gravis and thymoma is admitted to hospital 48 hours prior for CAP and started on Ceftriaxone and Azithromycin. Over the last 24 hours, she has developed progressive weakness and bulbar symptoms. RT was paged to assess vital capacity, and finds her in respiratory distress, at which point the Rapid Response Team (sim team) is paged.

The resuscitation team is expected to recognize and manage myasthenic crisis with respiratory failure, with consideration for airway management with an anterior mediastinal mass. The patient will require intubation and pharmacotherapy for myasthenic crisis. Additionally, the team is expected to update the family member, and inform them of medical error.

Download Case Here:

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