Horizontal, forced gaze deviations with seizures are usually contralateral to the seizure focus, and epileptic gaze deviations are seldom sustained for more than a few minutes
A caveat is that temporal and parietal partial seizures don’t produce forced eye version, but can occasionally produce neglect, resulting in a tendency for ipsilateral eye deviation - but not a forced deviation
Guillain-Barre Syndrome (GBS) and myelopathies are frequently heralded by paresthesias of the limbs.
Any patient presenting with bilateral paresthesias, these two entities must be acknowledged in decision making.
The main morbidity ED physicians will encounter with GBS or Myasthenia Gravis is respiratory insufficiency requiring ventilator support.
Any ED patient diagnosed or presumed to have these diagnoses requires assessment of a:
Forced Vital Capacity (FVC)
Negative Inspiratory Force (NIF)
Maximum Expiratory Force (MEF).
Intubation is recommended by the “20/30/40 Rule" (FVC < 20 mL/kg, NIF < -30 cm H2O, or MEF < 40 cm H2O)
Locked–in Syndrome is due to a lesion of the ventral pons and “classically” consists of anarthria and quadriplegia, with preservation of consciousness and vertical eye movement.
This entity must always be considered in patients in a comatose-like state.
Ptosis and diplopia are frequent presenting symptoms of neuromuscular junction pathology (MG and botulism), along with other bulbar signs.
The “bulb” is an archaic term for the medulla oblongata, so the word bulbar refers to the nerves and tracts connected to the medulla, and also by association the muscles thus innervated (i.e. tongue, pharynx and larynx).
Bulbar signs include difficulty with phonation, dysarthria, and dysphagia.
Bulbar signs could also represent a brainstem lesion.