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



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