Introduction
Multiple sclerosis (MS) can be a confounding disease. We may know of patients we have treated or even members of our own family who have been diagnosed with this disease. MS patient day-to-day presentation may appear to us as us if everything is normal. Nothing is further from the truth. MS is a chronic, unpredictable, and potentially disabling disease of the central nervous system (CNS) characterized by the disruption of the flow of information within the brain and between the brain and body.1
This disease can present various complications that require rapid and accurate responses during emergencies. To treat MS exacerbation effectively, we must understand the disease and how we may effectively manage emergency situations involving MS patients.
Understanding Multiple Sclerosis
MS occurs due to the immune system mistakenly attacking the protective covering of the axons, the myelin sheath in the CNS, causing communication problems between the brain and the rest of the body.2 Over time, this disease can cause permanent damage or deterioration of nerves.
While the specific cause of MS remains unknown, it’s thought to involve a combination of genetic and environmental factors. Symptoms and severity vary widely from person to person but may include fatigue, difficulty walking, numbness or tingling, muscle weakness, and problems with coordination and balance.1
MS can take many forms including Relapsing-Remitting MS, Secondary-Progressive MS, Primary Progressive MS, and Progressive-Relapsing MS. Relapsing-remitting MS may present as “attacks.” In between these attacks MS patients may be referred to as being in remission, but an attack may last weeks to years. In between attacks people return to their baseline level of activity.
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In secondary-progressive MS, patients have a previous diagnosis of MS but then deteriorate in function progressively over time. Primary-progressive MS is less common and is characterized by progressively worsening symptoms from the beginning with no noticeable relapses or exacerbations of the disease.
Progressive-relapsing MS is the rarest form of MS. These patients will have a steady worsening of symptoms from the beginning with acute relapses.3
During an attack patients may present with mental or physical fatigue. Depression or difficulty with emotional control are another sign. Patients may have issues relevant to learning or concentrating. Memory may also become a problem. Muscle weakness, stiffness, and spasms may be severe enough to impede a patient’s ability to walk or stand.
In some cases, MS leads to partial or complete paralysis. The use of a wheelchair is not uncommon, especially in patients who are untreated or have advanced disease. Pain is another sign, though it is rare to be the first sign.
MS patients will describe that their weakness and fatigue are worse when they have a fever or when they are exposed to heat. MS exacerbations may occur following common infections.
Care of MS Patients
Requests for 911 assistance for patients with MS are mostly from acute non-neurological problems. Patients with MS requesting tend to have high levels of disability. As the patient’s disease progresses, they may require a more intensive EMS response.
Emergency situations involving MS patients may be a direct result of the disease itself, a complication of treatment, or an unrelated medical emergency. When responding to an emergency involving an MS patient, it’s essential to remember that pre-existing symptoms like muscle weakness, coordination problems, or altered sensation can complicate the patient’s presentation and management.4
For example, in a patient experiencing an MS exacerbation, presenting symptoms may include severe fatigue, decreased mobility, vision problems, or increased muscle spasticity. Here, initial treatment includes stabilizing the patient, managing acute symptoms, and preparing for transport to the hospital, where corticosteroids may be administered to reduce inflammation and end the exacerbation.5
Due to muscle spasticity and decreased mobility MS patients are more prone to falls. Expect soft tissue injuries, fractures, and depending on circumstances head injuries. Assessment of head injury may be complicated by the fact that a patient has memory or concentration problems related to their primary MS.
Err on the side of caution with these patients. MS patients with severe disability have a greater risk of infectious complications such as pneumonia, UTIs, and pressure ulcers, any one of which could be deadly if left untreated.
Supportive care, oxygen if indicated and IV access are essential. Manage patients symptomatically, treat any injuries that occur as a result of falls, re-assess airway, breathing, and circulation, and be ready to intervene immediately if your patient starts to decline.
Impact on Other Emergencies
The presence of MS can also complicate the management of other emergencies. For instance, during a myocardial infarction (heart attack), the pain and stress of the situation can exacerbate MS symptoms, potentially obscuring typical heart attack symptoms.4 Routinely obtaining a 12-lead EKG in MS patients who may be experiencing an MS flare-up may help identify patients who are having a cardiac event.
MS patients who also have asthma are especially challenging. Asthmatic attacks can be more severe due to an MS patient’s difficulty with muscle control for the forced expiration necessary during the attack.6 MS patients with severe inflammations may require earlier intubation and CPAP may not be indicted if they are the patient is especially fatigued. Similarly, trauma patients with MS might have a higher risk for complications due to impaired mobility and sensory perception, potentially leading to increased injury severity or delayed recovery.7
Conclusion
MS patients require specialized care during emergencies due to the unique challenges posed by their disease. Paramedics and EMTs should approach these patients with an understanding of the pathophysiology of MS and its potential effects on the presentation and management of emergencies.
Prompt recognition, supportive care, monitoring the patients A-B-C’s, and coordinated transport to the hospital are critical to ensure the best possible outcome for these patients.
References
1. Neurology, 84(4), 350-358. National Multiple Sclerosis Society. (2021). What is MS?
2. Compston, A., & Coles, A. (2008). Multiple sclerosis. Lancet, 372(9648), 1502-1517. Global Initiative for Asthma. (2019).
3. Multiple Sclerosis National Institutes of Neurological Disorders and Stroke. https://www.ninds.nih.gov/health-information/disorders/multiple-sclerosis
4. Marrie, R. A., Elliott, L., Marriott, J., Cossoy, M., Blanchard, J., Tennakoon, A., & Yu, N. (2015). Comorbidity increases the risk of hospitalizations in multiple sclerosis.
5. Brownlee, W. J., Hardy, T. A., Fazekas, F., & Miller, D. H. (2017). Diagnosis of multiple sclerosis: progress and challenges. The Lancet, 389(10076), 1336-1346.
6. Glick, T., Union County College Paramedic Program, November, 1984.
7. Bøe Lunde, H. M., Aae, T. F., Indrevåg, W., Aarseth, J., Bjorvatn, B., Myhr, K. M., & Bø, L. (2013). Poor sleep in patients with multiple sclerosis. PLoS One, 8(8), e75042.
