ASSESSMENT
Practical Approach to a child with suspected Guillain-Barre Syndrome
- Onset is usually gradual over a few days, or less frequently sudden (over 12-24 hours) and paralysis is sometimes extreme, requiring assisted ventilation (20%).[8]
- Deterioration may be acute and can occur primarily in the first three phases.There is a 5- 8% mortality rate and successful management depends upon continuous reassessment of the patient and early intervention.
Clinical Phases
- First 24 hours from presentation
- Phase 2 - Disease progression
- Phase 3 - Plateau phase
- Phase 4 - Initial recovery
- Phase 5 - Rehabilitation
Clinical Presentation:
- Ascending flaccid paraparesis.
- Respiratory distress / depression.
- Bulbar dysfunction.
- Back or lower limb pain +/- paraesthesia.
- Acute Ataxia.
- Irritable hip.
- Non specific viral illness.
- Myelopathy - paraparesis, pain, sphincter disturbance (urinary retention).
- Miller-Fisher variant.
Assessment:
- Primary assessment (initial assessment of the patient).
- Resuscitation.
- Secondary assessment.
- Definitive care.
Primary Assessment
- A AIRWAY: Respiratory distress, depression, arrest
- B BREATHING: Work & effectiveness of breathing, respiratory rate; effects of inadequate respiration (heart rate; mental state; exhaustion)
- C CIRCULATION: Heart rate (arrhythmias), blood pressure (labile/hypertensive), capillary refill time, skin colour & temperature.
- D DISABILITY: Conscious level (usually preserved; children may be frightened)
- E EXPOSURE: Other causes of acute presentation e.g. tick bite, rash, trauma, immunisation, NAI?
Resuscitation
Life threatening problems should be treated as and when they are identified during the primary assessment
Breathing and airway management (oxygen, suction, bag & mask ventilation,intubation).
Circulation (iv access, fluid therapy, treatment of arrhythmias and bloods).
Secondary Assessment
Preform a detailed physical examination in an anatomical manner.
- HEAD : Conscious level using the Glasgow Coma Score or AVPU (A ALERT, V responds to VOICE, P responds to PAIN, U UNRESPONSIVE).Motor function - reflexes, tone , power.
- FACE : Cranial nerve involvement, bulbar palsy.
- NECK : Cervical spine rigidity, tenderness, bruising.
- CHEST: Breath sounds and added sounds (pneumonia), heart sounds (arrythmias).
- ABDOMEN: Palpable bladder, constipation, sensory level, abdominal reflexes
- SPINE: Bruising, deformity, swelling, tenderness. Motor & sensory function
- EXTREMETIES: Bruising, swelling, deformity, tenderness, peripheral sensation, motor function (power, MRC grading, and tendon reflexes)
Emergency Treatment
- Treatment that is necessary during the first hour or so of management.
- Once the secondary survey has been completed a treatment plan should be made.
Continued Monitoring
- Pulse, Blood Pressure, Respiratory Rate,Vital capacity, Pupil size, Glasgow Coma Score. Exhaustion and ability to swallow safely should be monitored frequently.
- Any deterioration should lead to immediate reassessment and appropriate management.
Definitive Care
- A detailed history and accurate documentation of the clinical findings are important.
- A differential diagnosis should be established, appropriate investigations requested and referrals made.
- The parents and the child should be fully informed of any management plan and specific treatments.
History:
- Pain, paraesthesia.
- Ataxia, unsteadiness
- Lethargy
- Preceeding illness: diarrhoea (Campylobacter jejuni)[9], fever[10], URTI
- Exposure to insect bites, immunisation[11] or antibiotics/analgesic use.
- Progressive motor weakness
- Dysphagia, dysarthria, drooling
Risk Factors.
- Respiratory infections[9,12]
- Gastroenteritis preceeding GBS by 1 month[13]
- A documented pyrexia[10]
- Greater exposure to antibiotic & analgesic use[10].
Adverse Prognostic Indicators
- Rapidly progressive flaccid tetraparesis with cranial nerve and/ or respiratory involvement
- Other serious medical illness
- Marked reduction in compound motor action potentials when first measured
- Campylobacter jejuni infection[14]
Admission to PICU:
Children should be admitted to PICU if they have one or more of the following:
- Flaccid tetraparesis
- Severe rapidly progressive course.
- Reduced vital capacity at or below 20mL/kg
- Bulbar palsy with symptoms.
- Autonomic cardiovascular instability; i.e. persistent hypertension or labile blood pressure, or arrhythmias.