Recomendados
Más contenido relacionado
La actualidad más candente
La actualidad más candente (20)
Similar a APPROACH TO ACUTE FLACCID PARALYSIS .pptx
Similar a APPROACH TO ACUTE FLACCID PARALYSIS .pptx (20)
Último
Último (20)
APPROACH TO ACUTE FLACCID PARALYSIS .pptx
- 1. Approach to Acute Flaccid Paralysis Facilitator: Prof. Dr. Shiva Shrestha Presenter: Sunil Timilsina 1st year Resident General Practice and Emergency Medicine
- 2. Introduction • WHO- “A clinical syndrome characterized by rapid onset of weakness reaching maximum within days to weeks which many times involves respiratory and bulbar muscles in a child less than 15 years or any age.” Standard Case Definition Any child under 15 years of age with acute flaccid paralysis, Or A patient of any age in whom a clinician suspects polio
- 3. Diagnostic Approach • History • Examination • Assessment and Stabilization • Investigations • Differential Diagnosis
- 4. History Fever at onset • Polio or enteroviral myelitis • Transverse myelitis • Myositis • epidural abscess No fever at onset • GBS Nature of onset Rapid Subacute Delayed • GBS • Trauma • Viral Myositis • Metabolic Abnormalities • Polio • Non-polio infections • Post diptheric neurits • Polymyositis Sensory level • Transverse Myelitis • Compressive Myelopathy
- 5. History Pattern of weakness Ascending Descending Symmetrical Asymmetric al Proximal Distal • GBS • Rabies • Tick bite Paralysi s • Post Diphther ic Polyneur opathy • Botulism • GBS • Transverse Myelitis • Rabies • Botulism • Post Diphtheric Polyneuro pathy • Polio • Nonpolio • Myopat hy • NMJ disease • GBS Radicular pain • Guillian-Barre Syndrome
- 6. History Facial Weakness Guillain Barre syndrome, Myasthenia Gravis, Botulism Exposure drugs, toxins, snake envenomation, dog bite, honey, canned food Sore throat/neck swelling Diphtheritic polyneuropathy Recent IM injection Traumatic Neuritis Early bowel and bladder involvement Compressive Myelopathy, Transverse Myelitis Diurnal variation/ double vision Myasthenia Gravis Muscle tenderness Inflammatory Myopathy, Myositis
- 7. History Spinal tenderness Painful Spinal Movements Spinal trauma, epidural abscess or other extradural compression Recent Respiratory illness or Diarrhea GBS Diarrhea, Inadequate dietry intake Hypokalemic periodic paralysis Difficult labor Erb’s palsy Recent vaccination Post vaccination flaccid paralysis Recent surgery Traumatic Myelopathy, Epidural Abscess Pain Abdomen + Psychiatric Manifestation Acute Intermittent Porphyria
- 8. Examination Findings Level Conditions Flaccid afebrile Paraparesis with sensory level (early bladder dysfunction)- Spinal Cord • Transverse myelitis • Compressive myelopathy Flaccid, febrile, pure motor, asymmetric, paralysis (no bladder involvement) often with meningismus Anterior horn cell • Polio • Enteroviral • Vaccine associated poliomyelitis
- 9. Examination Findings Level Conditions Flaccid afebrile symmetric para/quadriparesis (+/− bulbar and respiratory involvement) with areflexia Roots / Nerve • Guillain Barre Syndrome Flaccid motor-sensory lower limb monoparesis after IM injection Traumatic neuritis
- 10. Examination Findings Level Conditions Early ptosis, preserved reflexes, fluctuating weakness NMJ • Myasthenia Gravis • Botulism • Snake Envenomation Proximal muscle weakness, muscle tenderness without sensory symptoms or signs and with preserved reflexes Muscle • Viral myositis • Inflammatory myopathy (e.g., dermatomyositis)
- 11. Initial Assessment and Stabilization • Detection and Management of Respiratory muscles weakness • Detection and Management of Bulbar Weakness • Evaluation of cardiovascular instability • Ruling out Dyselectrolytemia or Toxemia • To rule out spinal cord compression
- 12. Investigations Test Findings Conditions CSF examination • CSF Pleocytosis 1. Polio and Non-polio enteroviral Myelitis 2. Rabies • Albuminocytological dissociation 1. Guillian Barre Syndrome 2. Post Diphtheric Polyneuropathy Serum Electrolytes • K: Low or raised • Mg: raised Periodic Paralysis Creatinine Kinase • Raised 1. Viral Myositis 2. Inflammatory Myopathy
- 13. Investigations Test Findings Conditions Nerve Conduction Test • conduction block • Multifocal motor slowing • GBS MRI with or without contrast • Hyperintense lesion • Compression • Ring Enhancing lesion • Transverse Myelitis • Compressive Myelopathy • Epidural Abscess Nasopharyngeal swab • Demonstration of viral RNA • Enteroviruses Stool sample • Demonstration of viral RNA • Isolation • Poliomyelitis Urine for porphobilinogen • Positive • Acute Intermittent Porphyria
- 14. Acute Flaccid Paralysis Feature of spinal cord compression or sensory involvement? CEMRI as soon as possible Compressive Myelopathy Non Compressive Myelopathy Spine stabilization + Surgical Decompression Acute Transverse Myelitis Yes DTRs No ↓/+ - Ocular/bulbar involvement? Symmetrical? • Myasthenia • Botulism CPK K/Mg Myoglobin • Polio • GBS • Traumatic Neuritis - + - • Viral Myositis • Periodic Paralysis + • GBS NCV ABC stabilization Differentials
- 15. References • Sunit C Singhi, Ravi Shah, Naveen Sankhyan, Pratibha Singhi (July 2012); Approach to a child with Acute Flaccid Paralysis; Ind Jour Ped, 2012 available from www.researchgate.net/publication/229082372 • Field Guide for Supplementary Activities Aimed at Achieving Polio Eradication, WHO, 2015 • Vinod K Paul, Arvind Bagga; Ghai Essential Pediatrics, 8th Edition; CBS Publishers, New Delhi, ISBN: 978- 81-239-2334-5 • UpToDate
Notas del editor
- As per Global Polio Eradication Initiative Acute: Rapid progression of paralysis, (from onset to maximum paralysis) Flaccid: Loss of muscle tone, “floppy” (as opposed to spastic or rigid) Paralysis: Weakness, loss or diminution of motion
- Fever,rashes,arthralgia,conjunctivitis-= Adeno 70, 71 Trivial trauma may lead to spinal compression in patients with cervical vertebral instability (Patients with Downs syndrome, congenital cervicovertebral anomalies or juvenile idiopathic arthritis)
- Drugs: Aminoglycosides, Phenytoin @NMJ Lead, Mercury, Arsenic@ peripheral neuropathy Snake/OP@NMJ
- MMR, td, Flu, Meningococcal