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
References 1. Marx A, Glass JD, Sutter RW. Differential diagnosis of acute Flaccid paralysis and its role in poliomyelitis surveillance. Epidemiology Rev. 2000; 22:298–316. 2. Hughes RAC, Rees JH. Clinical and epidemiological features of Guillain-Barre syndrome. J Infect Dis. 1997; 176:S92–8. 3. Paradiso G, Tripoli J, Galicchio S, Fejerman N. Epidemiological, Clinical and electrodiagnostic findings in childhood Guillain-Barre Syndrome: a reappraisal. Ann Neurol. 1999; 46:701–7. 4. Kalra V, Sankhyan N, Sharma S, Gulati S, Choudhry R, Dhawan B. Outcome in childhood Guillain-Barre syndrome. Indian J Pediatr. 2009; 76:795–9. 5. Rantala H, Uhari M, Cherry J, Shields WB. Risk factors of respiratory Failure in children with Guillain Barre Syndrome. Pediatr Neurol. 1995; 13:289–92. 6. Melnick J. Enteroviruses: polioviruses, coxsackieviruses, echoviruses, and newer enteroviruses. In: Field’s BN, Knipe DM, Chanock RM, eds. Field’s virology. Philadelphia: LippincottRaven Publishers; 1996. pp. 655–712. 7. Wadia NH, Wadia PN, Katrak SM, Misra VP. A study of the Neurologic disorder associated with acute haemorrhagic conjunctivitis due to enterovirus 70. J Neurol Neurosurg Psychiatry. 1983; 46:599–610. 8. Gadre G, Satishchandra P, Mahadevan A, et al. Rabies viral Encephalitis: clinical determinants in diagnosis with special Reference to paralytic form. J Neurol Neurosurg Psychiatry.
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.