nk day 1. facial palsy
DESCRIPTION
Spinal Cord Injury TJOKORDA GB MAHADEWA, M.D., M.Med., SFNS(jpn), Ph.D.Presented in Block Neuroscience 22th April 2015Suspect Spine Injury ExaminationHigh-Speed CrashUnconscious patient Multiple injuries Neurologic deficit Spinal pain / tendernessExclude other injuries. Palpate all spinous processes. Ask patient to move spine within the pain limits. Inspect motor and sensory function. Look for Horner's syndrome. Torticollis. Screening for Spine and Spinal Cord Injury Conscious PatientPresence of paraplegia/quadriplegia /pentaplegiaPresume spinal instabilityIdentify bony Early neurosurgicalFracture subluxation consult Screening for Spine and Spinal Cord injuryAlert,sober, neurologically normal patient :① If no neck or spine pain or tenderness to palpation or voluntary movement ② If no painful distracting injury ③ Remove C-colar If still no pain or tenderness with voluntary movementNo further spine evaluation or c-spine x-ray necessary ATLS 2014Screening for Spine and Spinal Cord InjuryATLS 2014Alert, sober, neurologically normal patient :Neck or spine pain or tenderness to palpation or voluntary movement ?After removal of c- collar ?If “ yes” to any question Protect c-spine Obtain necessary x-ray examsSensory ExaminationATLS 2014Motor ExaminationATLS 2014 Neurologic Assessment ATLS 2014Neurogenic Shock Hypotension associated with cervical /high thoracic spine injury Bradycardia Treatment : Maintenance fluids, atropine and occasionally vasopressors Spinal “Shock”Neurologic Not hemodynamic phenomenon Occurs shortly after cord injury Flaccidity Loss of reflexes Classification of Injury ATLS 2014Incomplete Any sensation Position sense Voluntary movement in lower extremity Sacral sparing CompleteNo motor / sensory functionNo sacral sparingMay have reflexes Classifications of InjuryATLS 2014 Spinal Cord Syndromes Central cord Posterior cordAnterior cord Brown – SequardComplete transectionMorphology Fracture or fracture / dislocation Spinal cord injury without radiographic abnormality (SCIWORA)Spinal Cord Injury without radiographic evidence of Trauma (SCIWORET)Penetrating Classification of InjuryATLS 2014Morphology Consider unstable if : X-ray evidence of injury Neurologic deficitSevere pain on spine movement or palpation C Spine X-ray GuidelinesATLS 2014 Adequacy Alignment Bony abnormality Base of skull Cartilage , Contours Disc space Soft tissue C – Spine X-rays 10% of patients with a C-spine fracture have a 2nd, associated noncontiguous vertebral column fracture Indentify one abnormality ? Look for another!Radiographic screening of entire spine required in this instance Crosstable lateral film exludes 85% of fracture Additional 2 views exludes most fractures Also may require Swimmers view Ct scan for bony detail Flexion extension views MRI/CT myelogram Other spine X –ray GuidelinesAdequacy Alignment Bony abnormalityCartilage, Contours Disc Space Soft tissue ManagementImmobilization Entire Patient Proper padding Maintain until spine injury excludedAvoid prolonged use of backboard!MANAGEMENTTreat life threatening injuries first Immobilize Appropriate spine imagingDocument examination Definitive treatmentOccipito-Cervical FusionOccipito-Cervical FusionCervical FracturesThoracic FracturesThoracic FracturesStab WoundThoracolumbal FracturesLumbosacral FracturesSacrococcygeal FracturesMedical ManagementEnsure adequate ventilation especially for high level (c-4) quadriplegic Maintain blood pressure Atropine as needed Methylprednisolone (NASCIS III)SteroidsIV Methylprednisolone Proven spinal cord injury Starts within 1st 8 hours from injury only 30TRANSCRIPT
FACIAL PALSY
PERIPHERAL FACIAL PALSY
the most common cranial neuropathy and may originate from various kinds of damage to the seventh nerve
The facial nerve plays a crucial role in emotional expression
Bells palsy
an abrupt onset of unilateral weakness or paralysis of the face due to acute
peripheral facial nerve dysfunction, with no readily identifiable cause, and with some
recovery of function within 6 months
Axelsson S, 2013
Epidemiology
70% of all cases of peripheral facial palsy
the annual incidence is about 30/100 000 population
a peak incidence between the second and fourth decades of life
no difference in gender
No difference side of the face,
and no seasonal clustering
Axelsson S, 2013
Etiology
have not yet been clarified despite extensive research.
Immunological reactions, viral infections, ischaemia and genetic theories have been postulated
So far the aetiology of Bells palsy is still unclear.
Axelsson S, 2013
Clinical Presentation
weakness or complete paralysis of all the muscles on one side of the face.
The facial creases and nasolabial fold disappear, the forehead unfurrows, and the corner of the mouth droops.
The eyelids will not close and the lower lid sags;
on attempted closure, the eye rolls upward (Bells phenomenon).
Tiemstra, Khatkhate, 2007
8
Eye irritation often results from lack of lubrication and constant exposure. Tear production decreases;
Food and saliva can pool in the affected side of the mouth and may spill out from the corner.
feeling of numbness from the paralysis, but facial sensation is preserved
Tiemstra, Khatkhate, 2007
Diagnosis
The first step in diagnosis is to determine whether facial weakness is due to a problem in the central nervous system or one in the peripheral nervous system.
This is done rapidly with observation and a few questions
Grading
It is fundamental to have a reliable and valid method of evaluating facial palsy and be able to assess the course of recovery and the effect of treatment over time.
The House-Brackmann scale (HBS) is
the most commonly used grading system and has six grades, where I = normal function and VI = complete paralysis
Grading
Outcomes
Prognostic factors include:
- Age (With increasing age, successful recovery begins to decline)
- severity (HBS)
- time to start of recovery
- time to start treatment
- presence pain on day 11-17 after onset of palsy negatif prognostic factor
MATUR SUKSMA
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