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: Miller-
Fischer 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

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Department of Neurology, JIPMER; 2014

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