Dr Jasir - Quadriplegia-1., hypokalemic pptx

Hypokalemic paralysis

1. Quadriplegia Neuromuscular VS Metabolic

2. Chief complaints A 60 years old female, housewife from paloor came with complaints of Difficulty in using all 4 limbs for 2 days Vomiting for 5 days Loose stools for 5 days

3. Presenting illness Patient was apparently normal 5 days ago, then she had developed H/o Vomiting – 4 episodes per day, non projectile, non bilious, contains food particles, not associated with hemetemesis, aggravated by taking food H/o Loose stools - 5 episodes per day, watery in consistency, small volume, not associated with abdomen pain and not associated with blood H/o Fever for 1 day associated with chills, low grade and relieved by taking medications

4. Presenting illness then she had developed H/o Weakness in both lower limbs noticed by her while awakening from the bed after a nap in the afternoon, symmetrical, not associated with stiffness in form of difficulty in standing, acute onset and gradually progressive in form of inability to sit followed by she had developed weakness of upper limbs in form of inability to lift the arms from the bed over the period of two days H/o difficulty in rolling over the bed or turn aside H/o difficulty in raising the head from the bed H/o Fatiguability + for 1 week No H/o Loss of consciousness No H/o speech disturbances No H/o Headache, seizures

5. Presenting illness No H/o Difficulty or abnormal perception of smell No H/o Visual loss or Double vision or Blurring of vision or drooping of eyelids or difficulty in eyeball movements No H/o Sensory disturbances No H/o difficulty in chewing the food, clenching the teeth No H/o Angle of deviation of mouth / Drooling of saliva No H/o tinnitus / Hard of hearing / vertigo / ear discharge No H/o Dysphagia / Hoarseness of voice / Nasal regurgitation No H/o deviation of tongue or difficulty in protrusion of tongue

6. Presenting illness No H/o Electric shock like sensation No H/o Band like sensation No H/o Fasciculations or involuntary movements No H/o involuntary bladder or bowel movements No H/o Abdomen pain, Constipation, No H/o Urinary retention, Frequency, Urgency, Hesitancy, Dribbling of urine or Burning micturition No H/o Fall / Trauma No H/o Dog bite / Insect bite / Snake bite No H/o Chest pain, palpitations, Decreased urine output No H/o Breathing difficulty, Cough with expectoration

7. Past History No H/o Similar illness or hospitalization in the past K/c/o T2DM on Tab. Metformin BD for 5 years Not a K/c/o SHTN / TB / Epilepsy / Thyroid disorders No H/o recent vaccination No H/o Drug intake other than for DM

8. Personal & Family History Mixed diet Sleep pattern Normal Bladder n bowel habits were normal before 1 week 1st born to Non consanguineous marriage Her male sibling died at the 8 years of age, reason unknown Married, P3L3 Attained menopause at 52 years of age

9. General Examination Conscious Oriented Afebrile Dehydration + No Pallor / Icterus / Clubbing / Cyanosis No Pedal Edema No Significant lymphadenopathy No Neuro-cutaneous markers No External markers of TB / HIV / Syphilis Skin – Normal, No rashes/Ulcers

10. Vitals Blood Pressure – 110/60 mmHg in Rt Upper limb – Lying position Pulse Rate – 82/min , Regular, Normal volume, No special character, No vessel wall thickening, No RR/RF delay, Felt in all peripheral pulses Respiratory Rate – 24/min, Thoraco -abdominal SPO2 – 96% in room air JVP not elevated

11. Higher Mental Functions Conscious Oriented to time, place and person Memory ( Short, Recent, Remote ) – Normal Intelligence - Normal Speech Comprehension, Fluency, Repetition, Naming, Reading Normal, Writing – Unable to move fingers No emotional liability / Hallucinations / Delusions No abnormal behavior Right Handed individual Systemic Examination

12. Cranial Nerves Cranial Nerve Right Left Perception of Smell Normal Normal Visual Acuity Normal Normal Field of vision Normal Normal Color vision Normal Normal Fundus Normal Normal Extra Ocular Movements Full Full Pupil Size 2mm 2mm Reflexes (Direct light, Consensual, Accommodation ) Present Present Ptosis, Nystagmus Absent Absent Systemic Examination

13. Cranial Nerves Cranial Nerve Right Left Sensation over face & Buccal mucosa Normal Normal Clenching of teeth Normal Normal Wrinkling of Forehead Normal Normal Blowing of Cheeks Normal Normal Deviation of angle of mouth - - Salivation, Lacrimation Normal Normal Rinne’s test AC > BC AC > BC Weber’s test No Lateralization Systemic Examination

14. Cranial Nerves Cranial Nerve Right Left Taste Normal Normal Gag Reflex + + Palatal reflex + + Shrugging of shoulder + + Turning Head against resistance + + Tongue protrusion + + Tongue power Normal Normal Tongue fibrillation - - Systemic Examination

15. Motor System Right Left Bulk Normal, No Atrophy /Wasting Normal, No Atrophy / Wasting Tone Upper Limb Lower Limb Hypotonia Hypotonia Power Upper Limb Lower Limb 1/5 0/5 1/5 0/5 Superficial Reflex Corneal, Conjunctival Abdominal Plantar + + - Flexor + + - Flexor DTR Jaw jerk Biceps, Triceps Supinator Knee, Ankle Not Exaggerated - - - - - - Systemic Examination

16. Sensory System and Others Systemic Examination Right Left Pain, Temperature, touch Normal Normal Vibration sense, Position Sense, Pressure, Deep pain Normal Normal Cortical Sensation Normal Normal Coordination System Couldn’t be elicited Couldn’t be elicited Neck Muscle weakness + + Neck rigidity - - Gait couldn’t be assessed No Involuntary movements No Fasciculations No Spinal tenderness

17. Other Systems CVS – S1S2 +, No murmurs RS – B/L Air entry present and equal Normal Vesicular Breath Sounds + P/A – Soft, Not tender, No organomegaly, No free fluid, Bowel sounds +

18. Summary A 60 years old female, known diabetic presented with Acute onset ascending Flaccid Quadriplegia With Intact Higher Mental Functions and Sensory system with no autonomic and Extrapyramidal system involvement

19. Date 20/05 23/05 25/05 Hb 13.3 13.1 12.8 TC 11300 10900 15,600 DC 83/10/7 85/10/5 92/5/3 PCV 38 39 38 Platelets 3.16L 3.00L 2.65L Date 20/05 23/05 T.B / D.B/ I.B 0.6 / 0.2/ 0.4 0.6 / 0.2/ 0.4 OT / PT / ALP 100 / 59 / 84 96 / 53 / 106 T.PRO / ALB 6.3 / 3.1 5.6 / 3.0 RBS 89 127 Urea 24 16 Creatinine 1.1 0.7 Date 20/05 21/05 22/05 24/05 25/05 Na+ 138 127 130 135 138 K+ 1.8 1.43 2.8 3.9 5.1 Mg2+ 1.54 2.5 Date 20/05 Urine Albumin + Urine Sugar Nil Urine Spot PCR 0.3 Routine Investigations

20. ECHO – AV Sclerosis, Mild MR, Normal LVEF – 56% USG Abdomen – Gr-I fatty liver, B/L mild altered renal echoes, No ascites

21. Differential Diagnosis ?

22. Patient was found to have Low serum Potassium ( K+ - 1.8 ) No Pseudo Hypokalemia ( Metabolically active cells can uptake K+ in blood which lasts several hours before processing in lab ) Not on insulin, No previous similar history, no Drug intake Thyroid Status FT4 12.24 TSH 4.1

23. Urine Potassium (K+) done to rule out whether it a renal loss or not Renal loss TTKG = Urine K+ x Serum Osmolarity Serum K+ x Urine Osmolarity TTKG calculation only be done if Urine K+ > 20 but < 40, 31.52 Urine Na+ > 10 mEq/L 65 Urine Osm ≥ Serum Osm 321 > 285

24. 31.52 x 285.2 TTKG = 1.54 x 321 = 18.2 ( > 4 ) Distal K+ Secretion Blood Pressure – 110/60mmhg Euvolemic

25. Urine Chloride = 106 ( >20 ) Urine Calcium / Creatinine ratio = 7.30 / 20.84 = 0.35

26. Since Patient had no history of taking Loop diuretics, Provisionally diagnosed as Adult Onset – BARTTER’S SYNDROME ( Probable ) To confirm the diagnosis Plasma Renin Activity Serum Aldosterone Serum PGE2 24Hours Urinary Calcium Genetic testing

27. Day 1 Conscious, Power Upper Limb – 1/5 , 1/5 Lower Limb – 0/5, 0/5 KCL infusion, MgSO4 infusion and Oral KCL supplementation Serum K+ Day 2 Power Upper Limb – 1/5 , 3/5 Lower Limb – 1/5, 1/5 KCL and MgSO4 infusion on flow 1.8 Day 3 Power Upper Limb – 4-/5 , 4-/5 Lower Limb – 2/5, 2/5 KCL infusion on flow MgSO4 infusion stopped 1.43 Day 3 Respiratory failure – Elective intubation done KCL infusion on flow 2.8 Day 4 Diagnosed ?VAP BP – 80/50mmhg, IV Inotropes started KCL and Inj.Noradrenaline infusion 3.9 Day 5 Patient went for Hyperkalemia, correction given Inotropes continued, KCL infusion stopped 5.1 Day 5 Patient went for cardiopulmonary arrest

28. Thank you..!!!