Acute Flaccid Paralysis in Adults

SOPs for management of common acute neurological problems. Department of Neurology, JIPMER; 2014 Acute Flaccid Paralysis in Adults Acute Quadriparesi...
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SOPs for management of common acute neurological problems. Department of Neurology, JIPMER; 2014

Acute Flaccid Paralysis in Adults Acute Quadriparesis/plegia

1. General measures  Ensure protection of airway and adequate ventilation (Especially if there is respiratory muscle weakness, shallow respiration, dysphagia, weak gag)  Check and support: BP and Heart Rate  Immobilize neck if history of neck/head trauma  Send electrolytes and get an ECG- to look for hypokalaemia

2. Examination and classification into pattern for example,

SOPs for management of common acute neurological problems. Department of Neurology, JIPMER; 2014

 Flaccid quadriparesis with sensory level (early bladder dysfunction)Transverse myelitis, compressive myelopathy  Flaccid

afebrile

symmetric

Para/quadriparesis

(+/−

bulbar

and

Respiratory involvement) with areflexia and minimal sensory loss (but often sensory symptoms): Acute neuropathy or polyradiculopathy (esp., Guillain Barre Syndrome)  Flaccid, febrile, pure motor, asymmetric, paralysis (no bladder involvement) often with meningismus: Enteroviral, polio, or vaccine associated poliomyelitis  Flaccid motor-sensory lower limb monoparesis after IM injection: Injection neuritis  Ophthalmoplegia, ptosis, bulbar weakness with motor weakness: MillerFischer variant of Guillain Barre Syndrome, Botulism, Myasthenia Gravis  Proximal muscle weakness, muscle tenderness without sensory symptoms or signs and with preserved reflexes: Viral myositis, inflammatory myopathy (e.g., dermatomyositis) 3. Investigations (according to the suspected site of lesion and cause of paralysis)  Neuroimaging (spinal cord) MRI indicated in all cases of myelopathy, suspected transverse myelitis  X- ray spine: suspected atlantoaxial dislocation, vertebral tuberculosis 

Electrophysiological testing (NCV & electromyography/ RNST): Guillain Barre Syndrome, Myasthenic Crisis, Inflammatory Myopathy, Periodic Paralysis (Dyskalemic), acute neuromyositis

 Lumbar puncture (CSF): Guillain Barre syndrome, suspicion of viral myelitis  Biochemistry: Creatine Kinase, Potassium, Magnesium, Phosphate

SOPs for management of common acute neurological problems. Department of Neurology, JIPMER; 2014

 ECG: Hypokalemia  Urine for porpho-bilinogens, toxins: arsenic, lead etc., 4. Management (depends on the underlying aetiology identified) 1) Meticulous supportive care, anticipate and identify  Respiratory, bulbar weakness (except in injection neuritis), shock due to reduced vascular tone (spinal cord disease), Autonomic instability, complications of immobilization and prevention of nosocomial infections. 2) Specific therapy:  Guillain Barre syndrome: IVIG, 2 g/kg over 2–5 d  Transverse myelitis: IV methyl-prednisolone 10–30 mg/kg, daily (max-1 g) for 3–5 d  Compressive myelopathy: spinal immobilization, surgical intervention, steroids (acute traumatic myelopathy)  Dermatomyositis, Myasthenia Gravis: Immunomodulation  Hypokalaemia: Intravenous potassium correction

SOPs for management of common acute neurological problems. Department of Neurology, JIPMER; 2014

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SOPs for management of common acute neurological problems. Department of Neurology, JIPMER; 2014

2010; 81:812–20. 9. Tyler KL. Herpes simplex virus infections of the central nervous System: encephalitis and meningitis, including Mollaret’s. Herpes. 2004; 11:57A–64A. 10. Misra UK, Kalita J. Anterior horn cells are also involved in Japanese encephalitis. Acta Neurol Scand. 1997;96:114–7. 11. Frohman EM, Wingerchuk DM. Clinical practice. Transverse myelitis. N Engl J Med. 2010;363:564–72.

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