Immediate Management of Sudden Onset Paralysis
The immediate management of sudden onset paralysis requires rapid recognition of potential stroke or other neurological emergency, activation of emergency medical services, and transport to the nearest stroke-capable facility for urgent diagnosis and treatment. 1
Initial Assessment and Recognition
Recognition and Activation of Emergency Services
- Immediate activation of emergency response system (9-1-1) is strongly recommended for any patient with sudden onset of neurological symptoms including paralysis 1
- First responders should use stroke recognition and severity tools to identify potential stroke and facilitate rapid transport 1
- Early notification by EMS to the receiving hospital improves time to diagnosis and treatment 1
Presumptive Management
- For any unexpected collapse with unresponsiveness on the field (such as in sports), presume sudden cardiac arrest until proven otherwise 1
- For sudden onset paralysis without loss of consciousness, presume stroke or other acute neurological emergency 1
Hospital-Based Immediate Management
Rapid Diagnostic Approach
History and physical examination to exclude identifiable causes of paralysis 1, 2
- Determine timing of symptom onset (sudden onset is characteristic of stroke, Bell's palsy)
- Assess pattern of paralysis (unilateral vs bilateral, face vs limbs)
- Check for associated symptoms (speech changes, visual disturbances, headache)
Neuroimaging
Condition-Specific Management
For Suspected Stroke
- Rapid transport to a stroke-capable facility with neurocritical care and neurosurgical capabilities 1
- For hemorrhagic stroke:
- Blood pressure management
- Reversal of anticoagulation if applicable
- Potential surgical intervention for hematoma evacuation 1
For Bell's Palsy (Facial Paralysis)
- Oral corticosteroids within 72 hours of symptom onset (prednisolone 50 mg daily for 10 days or prednisone 60 mg daily for 5 days with 5-day taper) 1, 2
- Eye protection for patients with impaired eye closure (lubricating drops, ophthalmic ointment, moisture chamber) 1, 2
- Optional antiviral therapy in addition to steroids (not as monotherapy) 1, 2
For Suspected Spinal Cord Injury
- Immobilization of the spine
- Maintenance of adequate blood pressure to support spinal cord perfusion
- Urgent neurosurgical consultation
For Metabolic Causes (e.g., Thyrotoxic Periodic Paralysis)
- Check electrolytes, particularly potassium levels 3
- Treat underlying electrolyte abnormalities rather than focusing solely on paralysis 3
Special Considerations
Timing Considerations
- For stroke patients, time is critical - treatment outcomes are significantly better with earlier intervention 1, 4
- For Bell's palsy, treatment within 72 hours of symptom onset significantly improves recovery rates 1, 2
- Recovery of walking function after stroke occurs in 95% of patients within the first 11 weeks 5
Prognosis Communication
- For Bell's palsy, approximately 70-94% of patients recover completely without treatment 2
- For stroke-related paralysis, prognosis depends on severity of initial impairment:
- Patients with mild/moderate leg paresis: prognosis can be made within 3 weeks
- Patients with severe leg paresis: prognosis can be made within 6 weeks 5
Follow-up Recommendations
- For Bell's palsy: Reassess or refer to a facial nerve specialist if there are new/worsening neurologic findings, ocular symptoms, or incomplete recovery after 3 months 1, 2
- For stroke: Establish a rehabilitation plan based on deficit severity
Common Pitfalls to Avoid
- Delayed recognition and activation of emergency services - this significantly worsens outcomes 1, 4
- Misdiagnosing Bell's palsy - approximately 30% of facial paralysis cases have other underlying causes 1
- Failure to protect the eye in facial paralysis, which can lead to corneal damage 1, 2
- Overlooking metabolic causes of paralysis such as hypokalemia 3
- Focusing on paralysis rather than the underlying cause - treating the cause (e.g., electrolyte abnormalities) may rapidly resolve symptoms 3