What are the next steps in managing a patient with acute flaccid quadriparesis after establishing airway, breathing, and circulation (ABCs)?

Next Steps After Stabilizing ABCs in Acute Flaccid Quadriparesis

After securing airway, breathing, and circulation, immediately check blood glucose with point-of-care testing and perform a rapid focused neurological examination to assess the level of consciousness, pattern of weakness, and presence of respiratory compromise. 1, 2

Immediate Priorities (D and E of ABCDE)

Disability Assessment

• Rapidly assess neurological status using the Glasgow Coma Scale to quantify level of consciousness 1
• Check blood glucose immediately via finger stick or point-of-care testing, as hypoglycemia can mimic neurological emergencies and cause focal deficits 3, 1, 2
• Correct hypoglycemia immediately with intravenous glucose if blood glucose is low 2
• Control seizures if present with appropriate anticonvulsants 1
• Assess for signs of increased intracranial pressure or impending herniation 1

Exposure and Environmental Control

• Completely undress the patient to facilitate thorough examination of all extremities and skin 1
• Remove wet clothing to prevent hypothermia 1
• Implement warming measures as needed to maintain normothermia 1

Critical Respiratory Monitoring

Because acute flaccid quadriparesis can rapidly progress to respiratory failure, continuous monitoring for respiratory compromise is essential. 4

• Monitor respiratory rate, depth, and effort continuously 4
• Assess vital capacity and negative inspiratory force if available 4
• Any child or adult suspected of having Guillain-Barré syndrome (the most common cause of acute flaccid quadriparesis) needs immediate hospitalization due to potential for acute respiratory compromise 4
• Prepare for possible intubation and mechanical ventilation 4

Urgent Diagnostic Workup

Laboratory Testing

• Obtain immediate serum potassium level, as hyperkalemia is a rare but rapidly reversible cause of acute flaccid quadriparesis 5
• Complete blood count 2
• Comprehensive metabolic panel including electrolytes, renal function 2
• Serum osmolality 2
• Consider toxicology screen if drug toxicity suspected 2

Neuroimaging

• Obtain urgent non-contrast CT scan of the brain to exclude hemorrhage, stroke, or other structural causes 2
• Consider MRI with diffusion-weighted imaging if CT is negative but clinical suspicion remains 2

Electrodiagnostic Studies

• Nerve conduction studies to differentiate demyelinating from axonal neuropathy (can help confirm Guillain-Barré syndrome) 6, 4
• Consider lumbar puncture for cerebrospinal fluid analysis showing albuminocytologic dissociation typical of Guillain-Barré syndrome 4

Key Differential Diagnoses to Consider

The following conditions must be rapidly evaluated:

• Guillain-Barré syndrome (most common cause in children and adults) 4
• Hyperkalemia (rare but rapidly reversible) 5
• Hypoglycemia (rapidly reversible with IV glucose) 2
• Transverse myelitis 4
• Toxic neuropathies 4
• Tick paralysis 4
• Infantile botulism 4
• Myasthenia gravis 4
• Hypertensive encephalopathy 2

Monitoring and Supportive Care

Cardiovascular Monitoring

• Monitor cardiac rhythm via electrocardiogram to detect arrhythmias, especially if hyperkalemia is suspected 1, 5
• Measure blood pressure and assess for signs of shock 1
• Initiate IV fluid resuscitation for hypotension with isotonic fluids (0.9% saline) 1, 2

Blood Pressure Management

• Treat significant hypertension cautiously if present, as it may indicate hypertensive encephalopathy or posterior reversible encephalopathy syndrome 2, 6
• Avoid precipitous drops in blood pressure 3

Common Pitfalls to Avoid

• Do not delay hospitalization in any patient with suspected Guillain-Barré syndrome due to risk of rapid respiratory decompensation 4
• Do not use hypotonic fluids as they may exacerbate cerebral edema in metabolic encephalopathy 2
• Do not miss hyperkalemia as a reversible cause—check potassium urgently 5
• Do not assume stroke without excluding metabolic causes and obtaining neuroimaging 2
• In younger children, be aware that severe pain syndrome may present as pseudo-encephalopathy, masking the true diagnosis 4

Treatment Considerations Based on Etiology

If Guillain-Barré Syndrome Confirmed

• Immunomodulating treatment should be used for any patient who loses the ability to walk 4
• Consider plasmapheresis or intravenous immunoglobulin 4
• Intensive care monitoring for those with severe illness or requiring intubation 4

If Hyperkalemia Identified

• Treat with antihyperkalemic measures immediately, as power can improve dramatically as potassium normalizes 5

If Posterior Reversible Encephalopathy Syndrome Develops

• Administer antiepileptic drugs to control seizures 6
• Administer antihypertensive drugs to control blood pressure 6