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symptom.weakness.ed.v1PRODUCTION
symptom.weakness.ed.v1

Acute weakness (ED workup — focal + generalized + fluctuating)

symptomacuteundifferentiatedadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

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Distribution (focal / generalized / proximal / distal / ascending / descending / fluctuating), onset tempo, progression — anchors phenotype (stroke / GBS / MG / cord / channelopathy / botulism / myopathy) (Powers 2019)

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pattern characterized + tempo anchored

Patient inputs (41)

Age shifts priors: stroke risk doubles each decade after 55; GBS bimodal (young + elderly); MG peaks 20s women, 60s men (Powers 2019; van den Berg 2014; Sanders 2016)

MG women > men in young adulthood; periodic paralysis (thyrotoxic) Asian males; PPM > women for stroke until 75

BP extremes drive stroke vs hypoperfusion; hypertensive urgency in stroke; orthostatic in hypoadrenalism / dehydration

Brady (channelopathy, hypothyroid, MG vagal); tachy (thyrotoxic paralysis, GBS dysautonomia)

Tachypnea early respiratory failure in GBS / MG crisis / botulism — pCO2 lags

Hypoxia from neuromuscular respiratory failure (GBS, MG, botulism) — late finding (FVC drop precedes)

Fever raises infection prior (transverse myelitis post-infectious; epidural abscess); hypothermia → severe hypothyroid

AFib / mechanical valve / recent MI → cardioembolic stroke (CHA2DS2-VASc); raises stroke prior with focal deficit

Atherosclerotic vascular risk factors raise stroke prior; metabolic syndrome → small-vessel disease

Prior stroke/TIA → recurrence risk + ABCD2 prior; chronic deficits may mimic acute deficit

Known MG → crisis trigger search; known myopathy → exacerbation vs new disease

Known cancer + back pain + neuro deficit → epidural cord compression STAT MRI + dexamethasone

Statin / colchicine / chronic steroid → drug-induced myopathy (Stroes EAS 2015 PMID 25694464)

Anticoag/antiplatelet shifts hemorrhagic vs ischemic stroke prior; thrombolysis contraindication if recent anticoag

Hyperthyroid → thyrotoxic periodic paralysis (Asian males) + storm myopathy; hypothyroid → myopathy + myxedema

Facial droop + dysarthria + arm drift = FAST screen for stroke; bulbar findings (dysphagia, dysarthria, dysphonia) raise MG/GBS/botulism prior

Sensory level → cord; stocking-glove → polyneuropathy / GBS; cortical sensory loss → stroke; saddle anesthesia → cauda equina

Urinary retention + saddle anesthesia → cauda equina STAT; bladder dysfunction + sensory level → cord lesion

Diplopia + ptosis + fatigability → MG; fixed dilated pupils + descending → botulism

Back pain + leg weakness + sensory level → cord compression / cauda equina → route symptom.back_pain.ed.v1

Myalgia + cola-colored urine + weakness → rhabdomyolysis (Bosch 2009 PMID 19571284)

Viral illness 1-3 wks prior + ascending weakness + areflexia → GBS (Brighton criteria PMID 24163275)

Focal vs generalized vs proximal vs distal vs ascending vs descending vs fluctuating — anchors phenotype (Powers 2019; van den Berg 2014; Sanders 2016)

Last-known-well + onset tempo (seconds-stroke; hours-cord; days-GBS; weeks-MG; sudden-recurrent-channelopathy) drives thrombolysis window + workup tempo (Powers 2019)

Static (stroke) vs progressive (GBS, cord) vs fluctuating (MG) vs episodic (channelopathy) — anchors mechanism

Leukocytosis with infection (transverse myelitis, abscess); anemia in chronic disease

K (periodic paralysis), Na (hyponatremia weakness/AMS), glucose (hypoglycemia stroke mimic), BUN/Cr (AKI in rhabdo)

CK >5000 → rhabdomyolysis; mild elevation in myopathy; high in MG crisis is rare

Thyroid screen — hyper (thyrotoxic paralysis, storm myopathy), hypo (myopathy, myxedema)

Coagulopathy → hemorrhagic stroke risk; thrombolysis contraindication if INR >1.7 (warfarin)

Heme-positive dipstick without RBCs → myoglobinuria → rhabdo

STAT glucose — hypoglycemia is the #1 stroke mimic; ALWAYS check before thrombolysis

NCCT — rule out hemorrhage before thrombolysis; ASPECTS score for LVO (Powers 2019 PMID 31662037)

AFib detection (cardio-embolic stroke); hyperkalemic peaked T-waves; hypokalemic U-waves; long QT in channelopathy

CTA head/neck — LVO detection within thrombectomy window (Saver NEJM 2019); collateral score

STAT MRI spine with contrast if cord compression / cauda equina / transverse myelitis suspected (Greenberg 2015 PMID 12236201)

Tick attachment 4-7 days → tick paralysis (ascending) — remove tick + observe

Canned food / IV drug use → botulism (food / wound); descending + cranial nerves + autonomic

Canned/home-canned food OR wound + descending weakness + cranial nerves + dilated pupils → botulism (CDC PMID 33956777)

Demand ischemia in stroke / severe weakness + CAD; cardio-embolic source workup

Bedside FVC + NIF — falling FVC <20 mL/kg or NIF less negative than -30 cm H2O → intubation prep in GBS/MG/botulism

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Severity triggers (15)

15 need judgement
  • informationallife_threateningfocal_weakness_acute_stroke_window
    Acute focal weakness / facial droop / dysarthria within 4.5 h of last-known-well — IV alteplase / tenecteplase candidate; activate stroke pathway (Powers AHA/ASA 2019 PMID 31662037)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninglarge_vessel_occlusion_thrombectomy_window
    NIHSS ≥6 OR clinical LVO syndrome (gaze deviation, neglect, aphasia, hemiparesis) — CTA head/neck + endovascular thrombectomy ≤24 h (DEFUSE-3 / DAWN) (Powers 2019; Saver NEJM 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninggbs_ascending_weakness
    Ascending symmetric weakness + areflexia + recent viral illness 1-3 wks prior — Guillain-Barré; LP (albumin-cytologic dissociation) + IVIG 0.4 g/kg/day × 5 d OR PLEX; intubate if FVC<20 (van den Berg 2014 PMID 24163275)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmyasthenic_crisis_bulbar_respiratory
    Fatigable weakness + ptosis / diplopia / dysphagia / dysarthria + falling FVC — myasthenic crisis; IVIG or PLEX + pyridostigmine + steroids; intubate if FVC<20 (Sanders MGFA 2016 PMID 27358333)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcord_compression_or_cauda_equina
    Bilateral leg weakness + sensory level + saddle anesthesia + urinary retention/incontinence — STAT MRI + dexamethasone 10 mg IV + neurosurgery (Greenberg AAN PMID 12236201; Greenhalgh Spine 2015)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningbotulism_descending_with_cranial_nerves
    Descending symmetric weakness + cranial nerves (diplopia, dysphagia, dysarthria, dysphonia) + dilated/fixed pupils + autonomic + canned food/wound — botulism; HBAT from CDC + ICU (Sobel CDC PMID 33956777)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsevere_hyponatremia_with_weakness
    Na <120 with weakness / AMS / seizure — severe symptomatic hyponatremia; 3% saline 100 mL IV bolus × 1-3 (max 4-6 mEq/L correction in 24 h) → syndrome.hyponatremia.core.v1
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretransient_ischemic_attack_resolved
    Focal deficit fully resolved within 24 h (typically <1 h) — TIA; ABCD2 ≥4 → admit + dual antiplatelet (CHANCE/POINT); urgent vascular workup (Johnston Lancet 2007)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretransverse_myelitis_post_infectious
    Subacute bilateral weakness + sensory level + bladder dysfunction over hours-days — transverse myelitis; MRI + LP + IV methylprednisolone 1 g × 3-5 d
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereperiodic_paralysis_channelopathy
    Recurrent episodic generalized weakness sparing respirations + K extremes (<2.5 hypoK or >6.5 hyperK) — channelopathy (hypokalemic, hyperkalemic, thyrotoxic); replete K + treat trigger
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevererhabdomyolysis_with_aki_or_hyperk
    Myalgia + weakness + dark urine + CK >5000 (often >10,000) + heme-positive UA without RBCs → myoglobinuria → AKI risk; aggressive LR + electrolyte correction (Bosch NEJM 2009 PMID 19571284)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehypoglycemia_stroke_mimic
    Focal deficit with glucose <70 mg/dL — #1 stroke mimic; D50 25 g IV bolus + D10 infusion; reassess neuro exam after glucose ≥100
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatedrug_induced_myopathy
    Proximal symmetric weakness + statin / colchicine / steroid / fibrate use + CK elevation — drug-induced myopathy; deprescribe + recheck CK; rhabdo if severe (Stroes EAS 2015 PMID 25694464)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecritical_illness_neuropathy_myopathy
    Generalized weakness in ICU/post-ICU patient + sepsis / prolonged ventilation / steroid / neuromuscular blocker exposure — critical illness polyneuropathy/myopathy; supportive + rehab
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildfunctional_neurologic_weakness
    Weakness inconsistent with anatomy + Hoover sign + give-way weakness + normal workup — functional neurologic disorder (FND); neurology outpatient + physiotherapy + CBT
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

ed playbook — drug actions (12)

  1. 1. D50 IV (or D10 infusion)
    25 g (50 mL D50W) IV bolus then D10 infusion at 100 mL/hr • IV • once + maintenance
    trigger: Glucose <70 mg/dL (or symptomatic <80) — #1 stroke mimic
    ALWAYS correct hypoglycemia before any stroke decision; ADA 2026 — repeat glucose q15 min until ≥100
  2. 2. alteplase IV (or tenecteplase)
    Alteplase 0.9 mg/kg (10% bolus over 1 min, 90% over 60 min, max 90 mg); tenecteplase 0.25 mg/kg IV bolus (max 25 mg) • IV • once
    trigger: Acute ischemic stroke within 4.5 h of last-known-well + no contraindications + NIHSS ≥4 (or disabling deficit) + BP <185/110 + glucose corrected
    Powers AHA/ASA 2019 PMID 31662037 — Class I; tenecteplase non-inferior (EXTEND-IA TNK 2018); route to neuro.ischaemic-stroke.v1
  3. 3. labetalol IV (or nicardipine infusion)
    Labetalol 10-20 mg IV q10 min PRN (max 300 mg); nicardipine 5 mg/h titrate by 2.5 mg/h q5 min (max 15 mg/h) • IV • titrate
    trigger: Pre-tPA BP ≥185/110 OR post-tPA BP ≥180/105
    Powers 2019 — strict BP control during/after thrombolysis; avoid sublingual nifedipine
  4. 4. dexamethasone IV
    10 mg IV bolus then 4 mg IV q6h • IV • q6h
    trigger: Suspected epidural spinal cord compression (malignancy + back pain + leg weakness) OR transverse myelitis
    Loblaw NEJM 2003 + Greenberg AAN PMID 12236201 — high-dose dex pending STAT MRI + neurosurgery / RT
  5. 5. IVIG (or PLEX)
    IVIG 0.4 g/kg/day IV × 5 days OR PLEX 5 sessions over 7-14 days • IV • daily
    trigger: GBS with progression OR myasthenic crisis
    Hughes Cochrane + van den Berg 2014 PMID 24163275 — IVIG and PLEX equally effective in GBS; route to neuro.gbs.core.v1 or neuro.mg-crisis.core.v1
  6. 6. pyridostigmine PO/IV
    60-90 mg PO q4h (oral) OR 1-2 mg IV/IM q2-3h if NPO • PO/IV • q4h
    trigger: Confirmed myasthenic crisis (may be paused if cholinergic crisis suspected)
    Sanders MGFA 2016 PMID 27358333 — symptomatic acetylcholinesterase inhibitor; combine with IVIG/PLEX + steroids
  7. 7. botulinum equine antitoxin (HBAT — CDC)
    HBAT 1 vial IV (adult); request from state health dept / CDC 770-488-7100 • IV • once
    trigger: Suspected botulism (descending paralysis + cranial nerves + autonomic + history of canned food/wound)
    CDC Sobel 2015 PMID 33956777 — HBAT covers serotypes A-G; treat empirically while awaiting toxin assay; route to ICU for ventilation
  8. 8. calcium gluconate IV
    1-2 g IV over 5 min • IV • q5-10 min PRN
    trigger: Hyperkalemia with paralysis OR ECG changes (peaked T, widened QRS)
    KDIGO + ACEP — membrane stabilization first in hyperK with ECG changes; route to syndrome.hyperkalemia.core.v1
  9. 9. insulin + D50 IV
    Regular insulin 10 units IV + D50 25 g IV bolus • IV • once + repeat q15-30 min
    trigger: Hyperkalemia with paralysis (intracellular K shift)
    KDIGO — shifts K into cells; pairs with calcium for stabilization + kayexalate / lokelma / patiromer for total-body K removal
  10. 10. KCl IV / PO
    10-20 mEq IV over 1 h via central line (max 40 mEq/L peripheral); PO 40-80 mEq q4-6h • IV/PO • titrate
    trigger: Hypokalemic periodic paralysis (K <2.5 + weakness)
    Replete with caution — too-fast IV → arrhythmia; treat trigger (thyrotoxic / familial); telemetry mandatory
  11. 11. normal saline OR LR (rhabdo)
    1-2 L LR IV bolus then 1.5-2 mL/kg/h titrate to urine output 200-300 mL/h • IV • continuous
    trigger: Rhabdomyolysis with CK >5000 OR myoglobinuria OR AKI
    Bosch NEJM 2009 PMID 19571284 — aggressive IVF reduces AKI; LR preferred to avoid hyperchloremic acidosis; bicarbonate use controversial; route to renal.aki.intrinsic.atn.v1
  12. 12. methylprednisolone IV (transverse myelitis)
    1 g IV daily × 3-5 days • IV • daily
    trigger: Confirmed transverse myelitis (idiopathic or MS-related)
    Greenberg AAN PMID 12236201 — high-dose pulse steroids first-line; PLEX if refractory; route to neuro.transverse-myelitis.v1

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Focal weakness (hemiparesis / monoparesis / facial droop / dysarthria) — stroke until proven otherwise (Powers AHA/ASA 2019 PMID 31662037; Saver NEJM 2019); Generalized symmetric weakness, often ascending — GBS / myopathy / electrolyte / botulism (van den Berg Brighton GBS PMID 24163275); Fatigable / fluctuating weakness + ptosis / diplopia / dysphagia / dysarthria — myasthenic crisis (Sanders MGFA 2016 PMID 27358333).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute weakness (ED workup — focal + generalized + fluctuating)** (symptom.weakness.ed.v1).
Phenotype framing: Focal: ischemic stroke (LVO vs small vessel) ~75%, hemorrhagic stroke ~15%, mass/abscess ~5%, post-ictal (Todd) ~5%. Generalized: GBS (post-infectious ascending areflexic), MG crisis (fatigable + bulbar), botulism (descending + autonomic), channelopathy (recurrent), rhabdo, severe electrolyte derangement, hypoglycemia (stroke mimic), functional neurologic disorder, critical illness polyneuropathy in admitted/ICU patients. Cord: TM / cord compression (mass, abscess, hematoma), cauda equina
Scope: Distribution (focal / generalized / proximal / distal / ascending / descending / fluctuating), onset tempo, progression — anchors phenotype (stroke / GBS / MG / cord / channelopathy / botulism / myopathy) (Powers 2019)

No severity triggers fired against current inputs.

Plan

No regimen axis selected (engine has no regimen_axes or could not match).

Setting playbook (ed) — Pattern-anchored triage (focal vs generalized vs fluctuating vs cord/cauda); rule out stroke (NIHSS / tPA window / LVO) + cord compression / cauda equina (STAT MRI) + myasthenic crisis / GBS with respiratory failure (FVC<20) + botulism (descending + cranial) + severe electrolyte paralysis + rhabdomyolysis with AKI; activate downstream engine (Powers AHA/ASA 2019 PMID 31662037; van den Berg Brighton GBS 2014 PMID 24163275; Sanders MGFA 2016 PMID 27358333; Bosch NEJM 2009 PMID 19571284; CDC botulism PMID 33956777)
1. D50 IV (or D10 infusion) 25 g (50 mL D50W) IV bolus then D10 infusion at 100 mL/hr IV once + maintenance — Glucose <70 mg/dL (or symptomatic <80) — #1 stroke mimic (ALWAYS correct hypoglycemia before any stroke decision; ADA 2026 — repeat glucose q15 min until ≥100)
2. alteplase IV (or tenecteplase) Alteplase 0.9 mg/kg (10% bolus over 1 min, 90% over 60 min, max 90 mg); tenecteplase 0.25 mg/kg IV bolus (max 25 mg) IV once — Acute ischemic stroke within 4.5 h of last-known-well + no contraindications + NIHSS ≥4 (or disabling deficit) + BP <185/110 + glucose corrected (Powers AHA/ASA 2019 PMID 31662037 — Class I; tenecteplase non-inferior (EXTEND-IA TNK 2018); route to neuro.ischaemic-stroke.v1)
3. labetalol IV (or nicardipine infusion) Labetalol 10-20 mg IV q10 min PRN (max 300 mg); nicardipine 5 mg/h titrate by 2.5 mg/h q5 min (max 15 mg/h) IV titrate — Pre-tPA BP ≥185/110 OR post-tPA BP ≥180/105 (Powers 2019 — strict BP control during/after thrombolysis; avoid sublingual nifedipine)
4. dexamethasone IV 10 mg IV bolus then 4 mg IV q6h IV q6h — Suspected epidural spinal cord compression (malignancy + back pain + leg weakness) OR transverse myelitis (Loblaw NEJM 2003 + Greenberg AAN PMID 12236201 — high-dose dex pending STAT MRI + neurosurgery / RT)
5. IVIG (or PLEX) IVIG 0.4 g/kg/day IV × 5 days OR PLEX 5 sessions over 7-14 days IV daily — GBS with progression OR myasthenic crisis (Hughes Cochrane + van den Berg 2014 PMID 24163275 — IVIG and PLEX equally effective in GBS; route to neuro.gbs.core.v1 or neuro.mg-crisis.core.v1)
6. pyridostigmine PO/IV 60-90 mg PO q4h (oral) OR 1-2 mg IV/IM q2-3h if NPO PO/IV q4h — Confirmed myasthenic crisis (may be paused if cholinergic crisis suspected) (Sanders MGFA 2016 PMID 27358333 — symptomatic acetylcholinesterase inhibitor; combine with IVIG/PLEX + steroids)
7. botulinum equine antitoxin (HBAT — CDC) HBAT 1 vial IV (adult); request from state health dept / CDC 770-488-7100 IV once — Suspected botulism (descending paralysis + cranial nerves + autonomic + history of canned food/wound) (CDC Sobel 2015 PMID 33956777 — HBAT covers serotypes A-G; treat empirically while awaiting toxin assay; route to ICU for ventilation)
8. calcium gluconate IV 1-2 g IV over 5 min IV q5-10 min PRN — Hyperkalemia with paralysis OR ECG changes (peaked T, widened QRS) (KDIGO + ACEP — membrane stabilization first in hyperK with ECG changes; route to syndrome.hyperkalemia.core.v1)
9. insulin + D50 IV Regular insulin 10 units IV + D50 25 g IV bolus IV once + repeat q15-30 min — Hyperkalemia with paralysis (intracellular K shift) (KDIGO — shifts K into cells; pairs with calcium for stabilization + kayexalate / lokelma / patiromer for total-body K removal)
10. KCl IV / PO 10-20 mEq IV over 1 h via central line (max 40 mEq/L peripheral); PO 40-80 mEq q4-6h IV/PO titrate — Hypokalemic periodic paralysis (K <2.5 + weakness) (Replete with caution — too-fast IV → arrhythmia; treat trigger (thyrotoxic / familial); telemetry mandatory)
11. normal saline OR LR (rhabdo) 1-2 L LR IV bolus then 1.5-2 mL/kg/h titrate to urine output 200-300 mL/h IV continuous — Rhabdomyolysis with CK >5000 OR myoglobinuria OR AKI (Bosch NEJM 2009 PMID 19571284 — aggressive IVF reduces AKI; LR preferred to avoid hyperchloremic acidosis; bicarbonate use controversial; route to renal.aki.intrinsic.atn.v1)
12. methylprednisolone IV (transverse myelitis) 1 g IV daily × 3-5 days IV daily — Confirmed transverse myelitis (idiopathic or MS-related) (Greenberg AAN PMID 12236201 — high-dose pulse steroids first-line; PLEX if refractory; route to neuro.transverse-myelitis.v1)

Non-pharmacologic actions:
- Two large-bore IVs; central line if vasopressors / IV K replacement needed
- NPO until dysphagia screen completed (aspiration risk in stroke, MG, GBS, botulism)
- Aspiration precautions; HOB ≥30°
- STAT neuro consult for any focal deficit + tPA decision
- STAT neurosurgery / spine consult for cord/cauda compression
- STAT IR / endovascular team for LVO
- Bedside FVC + NIF q2-4h if neuromuscular concern (intubation prep at FVC<20, NIF >-30)
- Telemetry for hyperK / hypoK / channelopathy / GBS dysautonomia / MG crisis
- Foley if urinary retention (cauda) or for I/O tracking in rhabdo / shock
- Pressure ulcer prevention + DVT prophylaxis (pneumatic compression in acute stroke / cord)

Monitoring

Setting (ed) monitoring:
- NIHSS q1h × 24 h then q4h post-stroke
- BP q15 min × 2 h post-tPA then q30 min × 6 h then q1h × 16 h
- Bedside FVC + NIF q2-4h in GBS / MG / botulism (intubation trigger)
- Continuous SpO2 + telemetry
- Serial neuro exams q15-30 min × 4 h then per disposition
- Repeat glucose q15 min if hypoglycemic until ≥100
- CK + BMP q4-6h in rhabdo until trending down + K stable
- I/O monitoring; urine output ≥200 mL/h in rhabdo
- Repeat ECG for evolving hyperK changes / channelopathy

Follow-up plan: Stroke: secondary prevention (antiplatelet OR anticoag for AFib, statin, BP control, dysphagia screen, rehab); dual-antiplatelet for high-risk TIA (CHANCE/POINT). GBS: outpatient neuro + rehab. MG: chronic immunosuppression + crisis prevention. Cord/cauda: spine surgery + radiation; rehab. Rhabdo: cause workup + electrolyte monitoring. Channelopathy: chronic K replacement + trigger avoidance
- Close-out criterion: discharge bundle prescribed + follow-up scheduled

Monitoring phase: Stroke: NIHSS q1h × 24 h then q4h; BP q15 min post-tPA × 2 h; serial neuro exams. GBS/MG/botulism: FVC + NIF q2-4h; arrhythmia monitoring (dysautonomia); aspiration precautions. Rhabdo: CK q6h; BMP q4-6h until K + Cr stable. Cord: serial neuro + dexamethasone taper plan

Disposition

Current setting: ed — Pattern-anchored triage (focal vs generalized vs fluctuating vs cord/cauda); rule out stroke (NIHSS / tPA window / LVO) + cord compression / cauda equina (STAT MRI) + myasthenic crisis / GBS with respiratory failure (FVC<20) + botulism (descending + cranial) + severe electrolyte paralysis + rhabdomyolysis with AKI; activate downstream engine (Powers AHA/ASA 2019 PMID 31662037; van den Berg Brighton GBS 2014 PMID 24163275; Sanders MGFA 2016 PMID 27358333; Bosch NEJM 2009 PMID 19571284; CDC botulism PMID 33956777)

Disposition criteria:
- Discharge: resolved TIA with ABCD2 <4 + workup negative + dual antiplatelet started + 24-h follow-up; hypokalemic periodic paralysis resolved with K replacement and trigger identified
- Observation: NIHSS 0-1 with stroke workup negative + repeat imaging negative + reliable follow-up; isolated channelopathy with K corrected
- Stroke unit / stepdown: NIHSS 1-5 with confirmed ischemic stroke without tPA; secondary prevention + rehab consult
- NSICU: post-tPA stroke; post-thrombectomy LVO; ICH; SAH; hemorrhagic transformation
- ICU: GBS with progression / autonomic; MG crisis (intubated or near-intubation); botulism; severe rhabdo with AKI; severe hyperK with paralysis
- OR direct: epidural cord compression with neurosurgical lesion (acute hematoma, abscess, spine fracture)
- Floor: rhabdo with stable CK trending + IVF; transverse myelitis post-steroids; resolved channelopathy admitted for workup

Escalation triggers (move to higher acuity):
- NIHSS ≥6 OR clinical LVO suspicion → CTA + endovascular thrombectomy team activation → neuro.ischaemic-stroke.v1
- Hemorrhagic stroke on NCCT → reverse anticoag + BP control + neurosurgery consult → neuro.ich.core.v1
- Suspected SAH (worst-headache + weakness) → NCCT + LP if NCCT negative → neuro.sah.core.v1
- Cord compression / cauda equina signs (sensory level, saddle anesthesia, urinary retention, malignancy + back pain) → STAT MRI + dexamethasone + neurosurgery → neuro.transverse-myelitis.v1 or spine surgery consult
- Bedside FVC <20 mL/kg OR NIF less negative than -30 cm H2O OR clinical respiratory distress → intubate + ICU → neuro.gbs.core.v1 or neuro.mg-crisis.core.v1
- Suspected botulism (descending + cranial + dilated pupils + canned food / wound) → HBAT from CDC + ICU + ventilatory support
- Hyperkalemia with paralysis + ECG changes → calcium + insulin/D50 + kayexalate/lokelma + dialysis prep → syndrome.hyperkalemia.core.v1
- Severe hyponatremia (Na <120) with weakness/AMS/seizure → 3% saline 100 mL bolus → syndrome.hyponatremia.core.v1
- Rhabdomyolysis with CK >5000 OR AKI OR hyperK → aggressive LR + electrolyte correction → renal.aki.intrinsic.atn.v1
- TIA with ABCD2 ≥4 OR crescendo → admit for workup + dual antiplatelet (CHANCE/POINT) → neuro.tia.v1
- Hypoglycemia <70 → D50 + cause workup; if persistent → endocrine consult
- Functional weakness (Hoover sign, give-way) with normal workup → neurology outpatient + psychiatry liaison

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Acute focal weakness / facial droop / dysarthria within 4.5 h of last-known-well — IV alteplase / tenecteplase candidate; activate stroke pathway (Powers AHA/ASA 2019 PMID 31662037)
- [LIFE_THREATENING] NIHSS ≥6 OR clinical LVO syndrome (gaze deviation, neglect, aphasia, hemiparesis) — CTA head/neck + endovascular thrombectomy ≤24 h (DEFUSE-3 / DAWN) (Powers 2019; Saver NEJM 2019)
- [LIFE_THREATENING] Ascending symmetric weakness + areflexia + recent viral illness 1-3 wks prior — Guillain-Barré; LP (albumin-cytologic dissociation) + IVIG 0.4 g/kg/day × 5 d OR PLEX; intubate if FVC<20 (van den Berg 2014 PMID 24163275)

Citations

- 2019 AHA/ASA Stroke Guideline (Powers) + 2018-19 DEFUSE-3/DAWN endovascular trials + 2014 van den Berg Brighton GBS + 2016 Sanders MGFA myasthenia + 2009 Bosch NEJM rhabdomyolysis + 2015 CDC Sobel botulism + 2015 Greenberg AAN transverse myelitis + 2015 Stroes EAS statin myopathy + 2007 Johnston Lancet ABCD2 + 2013 CHANCE / 2018 POINT DAPT for TIA [PMID:33218656](https://pubmed.ncbi.nlm.nih.gov/33218656/)
- Cited evidence (PMID 9255135) [PMID:9255135](https://pubmed.ncbi.nlm.nih.gov/9255135/)

Last reconciled with current guidelines: 2026-05-30.
References
  • 2019 AHA/ASA Stroke Guideline (Powers) + 2018-19 DEFUSE-3/DAWN endovascular trials + 2014 van den Berg Brighton GBS + 2016 Sanders MGFA myasthenia + 2009 Bosch NEJM rhabdomyolysis + 2015 CDC Sobel botulism + 2015 Greenberg AAN transverse myelitis + 2015 Stroes EAS statin myopathy + 2007 Johnston Lancet ABCD2 + 2013 CHANCE / 2018 POINT DAPT for TIA — PMID:33218656
  • Cited evidence (PMID 9255135) — PMID:9255135