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Pupillary Paralysis

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1. Pupillary Paralysis

Pupillary Paralysis Pupillary Paralysis Toggle navigation Brain Head & Neck Chest Endocrine Abdomen Musculoskeletal Skin Infectious Disease Hematology & Oncology Cohorts Diagnostics Emergency Findings Procedures Prevention & Management Pharmacy Resuscitation Trauma Emergency Procedures Ultrasound Cardiovascular Emergencies Lung Emergencies Infectious Disease Pediatrics Neurologic Emergencies Skin Exposure Miscellaneous Abuse Cancer Administration 4 Pupillary Paralysis Pupillary Paralysis Aka (...) : Pupillary Paralysis , Ophthalmoplegia Internal From Related Chapters II. Pathophysiology Images III. Signs does not constrict to light or accommodation dilatation IV. Causes Virus or lesion Bilateral third nerve involvement s injury Topical Benztropine (Cogentin) Images: Related links to external sites (from Bing) These images are a random sampling from a Bing search on the term "Pupillary Paralysis." Click on the image (or right click) to open the source website in a new browser window. Related Studies

2018 FP Notebook

2. Pupillary Paralysis

Pupillary Paralysis Pupillary Paralysis Toggle navigation Brain Head & Neck Chest Endocrine Abdomen Musculoskeletal Skin Infectious Disease Hematology & Oncology Cohorts Diagnostics Emergency Findings Procedures Prevention & Management Pharmacy Resuscitation Trauma Emergency Procedures Ultrasound Cardiovascular Emergencies Lung Emergencies Infectious Disease Pediatrics Neurologic Emergencies Skin Exposure Miscellaneous Abuse Cancer Administration 4 Pupillary Paralysis Pupillary Paralysis Aka (...) : Pupillary Paralysis , Ophthalmoplegia Internal From Related Chapters II. Pathophysiology Images III. Signs does not constrict to light or accommodation dilatation IV. Causes Virus or lesion Bilateral third nerve involvement s injury Topical Benztropine (Cogentin) Images: Related links to external sites (from Bing) These images are a random sampling from a Bing search on the term "Pupillary Paralysis." Click on the image (or right click) to open the source website in a new browser window. Related Studies

2015 FP Notebook

3. Pupillary paralysis after tranquilizer. Full Text available with Trip Pro

Pupillary paralysis after tranquilizer. 5569991 1971 11 12 2008 11 20 0007-1447 3 5775 1971 Sep 11 British medical journal Br Med J Pupillary paralysis after tranquilizer. 639 Pearson R R eng Journal Article England Br Med J 0372673 0007-1447 0 Benzimidazoles 0 Parasympatholytics 0 Tranquilizing Agents AIM IM Benzimidazoles therapeutic use Female Humans Paralysis chemically induced Parasympatholytics adverse effects Pupil drug effects Tranquilizing Agents therapeutic use 1971 9 11 1971 9 11 0 1

1971 British medical journal

4. Pupillary paralysis after tranquillizer. Full Text available with Trip Pro

Pupillary paralysis after tranquillizer. 5565530 1971 10 26 2008 11 20 0007-1447 3 5773 1971 Aug 26 British medical journal Br Med J Pupillary paralysis after tranquillizer. 530-1 Crawford R R eng Case Reports Journal Article England Br Med J 0372673 0007-1447 0 Benzimidazoles 0 Tranquilizing Agents AIM IM Accommodation, Ocular drug effects Adult Benzimidazoles adverse effects Female Humans Paralysis chemically induced Pupil drug effects Schizophrenia drug therapy Tranquilizing Agents adverse

1971 British medical journal

5. Management of Poisoning

with poison centre follow-up. A patient suspected of a signi? cant overdose is at risk of serious toxicity and serotonin syndrome (pg 136). Grade D, Level 3 Antipsychotics B Clinical manifestations of atypical antipsychotic toxicity generally include varying degrees of central nervous system depression (drowsiness), agitation, anticholinergic effects, pupillary changes, seizures, hypotension or hypertension, and cardiac conduction abnormalities (prolongation of the QTc and QRS intervals). Clozapine has (...) -ringed octopus envenomation) (pg 198). • Treat anaphylaxis, if present. • Tetradotoxin envenoming or neurotoxicity from jelly ? sh stings will require intubation and ventilation, if respiratory paralysis occurs. • Treat any major haemorrhage. Grade D, Level 4 D Administer analgesics, including local anaesthetics where indicated (pg 198). • Update the tetanus immunisation status. • Relevant radiological investigations, surgical removal of foreign material and surgical debridement may be required

2020 Ministry of Health, Singapore

6. Botulism

Botulism Botulism - Symptoms, diagnosis and treatment | BMJ Best Practice You'll need a subscription to access all of BMJ Best Practice Search  Botulism Last reviewed: February 2019 Last updated: March 2018 Summary Botulinum toxin ingestion leads to a clinical syndrome characterised by cranial nerve palsies, oculobulbar weakness, and descending, symmetrical flaccid paralysis in the absence of fever. Affected patients do not complain of sensory deficits. The diagnosis of botulism is a clinical (...) of botulinum toxin into the systemic circulation. History and exam presence of risk factors blurred vision and diplopia impaired accommodation ptosis oculobulbar weakness hypoglossal weakness dysarthria dysphagia symmetrical descending flaccid paralysis hypotonia feeding difficulties in infants weakened cry in infants hypothermia urinary retention constipation dry mouth and throat postural hypotension gastrointestinal illness diminished or absent deep tendon reflexes absence of fever respiratory

2018 BMJ Best Practice

7. Assessment of cranial nerve mononeuropathy

of colour plates. Patients with unilateral optic nerve impairment have great difficulty identifying colours between eyes (dyschromatopsia), and this is more affected than visual acuity. Pupillary testing: a relative afferent pupillary defect (RAPD) is the only objective test of optic nerve dysfunction. Selhorst JB, Chen Y. The optic nerve. Semin Neurol. 2009;29:29-35. http://www.ncbi.nlm.nih.gov/pubmed/19214930?tool=bestpractice.com Visual fields testing: a basic visual fields test can be performed (...) and 4 paired subnuclei can be distinguished. The most dorsal subnucleus contains the visceral Edinger-Westphal nucleus and the levator palpebrae nucleus. The Edinger-Westphal nucleus mediates pupillary constriction. Laterally the dorsal, intermediate, and ventral subnuclei provide innervation to the ipsilateral inferior rectus, inferior oblique, and medial rectus, respectively. The third nerve fascicles leave the nucleus and pass ventrally through the red nucleus before exiting just medial

2018 BMJ Best Practice

9. Skull fractures

fragments. See also the corresponding sagittal CT image From the teaching collection of Demetrios Demetriades; used with permission [Citation ends]. History and exam presence of risk factors open fracture palpable discrepancy in bone contour Battle's sign periorbital ecchymosis bloody otorrhoea CSF rhinorrhoea facial paralysis, nystagmus, or paraesthesia evidence of trauma cranial pain or headache nausea altered mental state/loss of consciousness abnormal pupillary reflexes hearing loss male sex fall

2017 BMJ Best Practice

10. Status epilepticus

for age <1 year), acyclovir and erythromycin are recommended if aetiology is uncertain (ie meningo-encephalitis is a possibility) and acyclovir should be used for focal fits of unknown cause. • Consider mannitol 0.25g/kg and/or 3ml/kg 3% or 2.7% NaCl (aim Na 145 mmol/l) if signs of raised intracranial pressure (bradycardia, hypertension, pupillary signs) this should be discussed with neurosurgery. • Avoid Lumbar puncture in a child with a reduced level of consciousness. • Consider CT scan +/- contrast (...) after benzodiazepines) will require transfer to a PICU. • Ventilate to normocarbia (neuroprotection strategies). • Infusion or bolus drugs for breakthrough seizures available en route (benzodiazepines, thiopentone). • Monitor glucose. • Consider mannitol or 2.7% NaCl if signs of raised ICP (bradycardia, hypertension, pupil changes) and discuss with neurosurgery. • Paralysis to assist ventilation and prevent accidental extubation during transport. • Take copies of CT scans or send them electronically

2018 Children's Acute Transport Service

11. Neurosurgical emergency

Paediatric Intensive Care Commissioning Group through Great Ormond Street NHS Trust. Page 3 of 5 Printed copies of this document may not be up to date, obtain the most recent version from www.cats.nhs.uk • Consider mannitol (0.25 to 0.5 g/kg = 1.25 – 2.5 ml/kg of 20% solution) and/or 2.7% NaCl (3 ml/kg over 20 minutes, aim for serum Na 145) if concerns about raised ICP or rapid changes in clinical signs (e.g. pupillary changes). Discuss with CATS consultant and neurosurgical team. • Frequent attention (...) Physiological targets SpO 2 =94% Mean BP = age appropriate target End tidal CO 2 : 4.7-5.3 kPa Full sedation and paralysis Children’s Acute Transport Service provides paediatric intensive care retrieval for Great Ormond Street, The Royal Brompton and St Mary’s NHS Trusts. Funded and accountable to the North Thames Paediatric Intensive Care Commissioning Group through Great Ormond Street NHS Trust. Page 5 of 5

2018 Children's Acute Transport Service

12. Vein of Galen malformation

Street NHS Trust. Page 2 of 3 Printed copies of this document may not be up to date, obtain the most recent version from www.cats.nhs.uk • Neuroprotective strategies - sedate and paralyse with morphine and vecuronium infusions, regular pupillary observations, 30 degrees head up tilt. • If signs of raised ICP, consider osmotherapy (3ml/kg of 2.7% saline aiming for Na 145- 150mmol/L or 0.25g/kg mannitol). • Aim for normothermia – to minimise further peripheral vasodilation and tachycardia. • If any (...) bicarbonate 8.4% 1mmol/kg, o Inhaled nitric oxide at 20ppm Refractory cardiac failure • Insert IO or central venous access. • Start adrenaline if not already started (0.1-1mcg/kg/min). • Consider milrinone for diastolic dysfunction. Monitor diastolic BP, if low may require low dose noradrenaline. • Aim for normothermia, monitor with oesophageal temperature probe. • Ensure adequacy of sedation and paralysis. • Discuss with CATS Consultant – consider prostaglandin E2 infusion (using the duct as a pressure

2018 Children's Acute Transport Service

13. How well do you know your anticholinergic (antimuscarinic) drugs?

as a bat, mad as a hatter , red as a beet, hot as a hare, dry as a bone, the bowel and bladder lose their tone, and the heart runs alone.” This refers to pupillary dila- tion and impaired lens accommodation, delusions, hallucinations or delirium, flushing, hyperthermia, dry mucosae and skin, gastrointestinal and bladder paralysis, and tachycardia. 1 Shorter mnemonics fail to capture the broad range of anticholinergic toxicity shown in Table 3. © Table 1: Anticholinergics in the Top 100 (BC Data, 2016

2018 Therapeutics Letter

14. CRACKCast E147 – General Approach to the Poisoned Patient

collateral information as possible! Aspects of the physical exam not to overlook (clues toward a specific toxin or toxidrome): Airway! Breathing! Circulation… Full vitals, rectal core temperature, glucose LOC, pupillary size, Seizure activity, clonus, reflexes, muscle tone Skin moisture Odour Finally, just because we’re talking Tox, don’t forget about a comprehensive approach to altered mental status! DIMES Lifeinthefastlane has a great mnemonic: R – R – S – I – D – E – A – D – Note: Most tox icologic (...) is performed in the following way: Intubation Heavy sedation +/- paralysis Place patient in L lateral decubitus Place a 30 Fr or larger orogastric tube Use specialized fenestrated tubes with rounded ends for this purpose Confirm w/ xray Apply suction: If it is a liquid ingestion simply applying suction through an NG is sufficient Otherwise, you should give ~100 -200 cc alloquotes of water down the OG and then aspirate it back until you are no longer getting gastric contents/pill fragments. [10] List 5 D

2018 CandiEM

15. CRACKCast E103 – Headache Disorders

risk factors Venous stasis Neurosurgical procedures Hypercoagulable state Genetic Antithrombin III, protein C and S deficiencies Factor V leiden mutation Acquired pregnancy Malignancy Exogenous estrogen Vasculitis IBD Connective tissue disease Endothelial injury Head trauma Surgery Parameningeal infections Presentation: Increased ICP due to impaired venous drainage Diffuse, increasing h/a over days-weeks. Seizures Papiledema **Key symptoms: Ocular findings of pain and proptosis and paralysis (...) ) Attributed to ISCHEMIA and SYSTEMIC INFLAMMATION Headache – 70% OF PTS. usually chronic for 2-3 months. Can be anywhwere on the head 40% of pts develop symptoms of PMR Risk for: TIA’s of the eye, peripheral neuropathies, strokes. On exam: Temporal artery: Findings include tenderness, reduced or absent pulsations, erythema, and nodularity or swelling. Visual acuity, visual field testing, and thorough funduscopic examination should be performed. The presence of a relative afferent pupillary defect (Marcus

2017 CandiEM

16. CRACKCast E105 – Brain and Cranial Nerve Disorders

function and pathologic features when injured Cranial Nerve Function of Nerve Presentation CN I: Olfactory N. Gustatory sense Unilateral anosmia CN II: Optic N. Sight Unilateral vision loss CN III: Oculomotor N. Motor function of levator palpebrae, superior rectus, medial rectus, inferior rectus, and inferior oblique muscles; pupillary constriction Ptosis, eye deviated laterally and downward, diplopia, dilated and non-reactive pupil, loss of accommodation CN IV: Trochlear N. Motor function of superior (...) = Carbamazapine 100mg PO BID. Other options: Phenytoin Baclofen Valproate sodium Lamotrigine Gabapentin Levetiracetam Disposition: Neurology with +/- Neurosurgery or ENT consult if surgical decompression is required [4] Facial nerve paralysis: List 6 differential diagnoses for facial (CN VII) paralysis Bell’s palsy Ramsey Hunt syndrome (herpes zoster oticus) Lyme disease (neuroborreliosis) Bacterial infections of the middle ear, mastoid, or external auditory canal Guillain-Barré syndrome HIV infection Tumor

2017 CandiEM

17. CRACKCast E109 – CNS Infections

] List 6 immediate and 6 delayed complications of bacterial meningitis BOX 99.2 Complications of Bacterial Meningitis IMMEDIATE Coma Loss of airway reflexes Seizures Cerebral edema Vasomotor collapse Disseminated intravascular coagulation (DIC) Respiratory arrest Dehydration Pericardial effusion Death Others DELAYED Seizure disorder Focal paralysis Subdural effusion Hydrocephalus Intellectual deficits Sensorineural hearing loss Ataxia Blindness Bilateral adrenal hemorrhage Death Cerebral venous (...) suggested that a normal CT scan does not always mean that performance of an LP is safe and that certain clinical signs of impending herniation (ie, deteriorating level of consciousness, particularly a Glasgow coma scale <11; brainstem signs including pupillary changes, posturing, or irregular respirations; or a very recent seizure) may be predictive of patients in whom an LP should be delayed.” [12] What are indications for LP in CNS infection? What are contraindications to LP? Indications: Whenever

2017 CandiEM

18. CrackCAST E129 – Bacteria

paralysis. The mortality rate for patients with left bundle branch block and atrioventricular block is 60% to 90%. [2] What are the 3 phases of illness in pertussis? Respiratory illness transmitted by aerosolized droplets. It can occur at any age but is predominantly a pediatric and adolescent illness. Pertussis means “violent cough.” It is also called whooping cough because the severe episodes of coughing are followed by forceful inspiration, which creates a characteristic whooping sound. Pertussis has (...) support. Even with limited resources, mortality can be reduced to less than 50% with basic medication and experienced medical personnel. [7] List 5 differential diagnoses for Bell’s Palsy Common entities: CVA Trigeminal neuralgia Herpes zoster oticus (Ramsay Hunt syndrome) CNS tumour – acoustic neuroma; cerebellopontine angle lesions (meningioma); facial nerve schwanoma, parotid gland tumour, sarcoma Parotitis Malignant otitis externa Uncommon entities Cephalic tetanus Tick paralysis Botulism CN

2017 CandiEM

19. Orbits, Vision and Visual Loss

of an anterior-draining CCF or diplopia and pain in the posterior-draining CCFs [20]. Enophthalmos, or posterior displacement of the globe, may be caused by a development condition resulting in an absent globe (anophthalmia) or small globe (microphthalmia) by traumatic injury to the bony orbit, silent sinus syndrome, processes that result in atrophy of the extraocular muscles, or by a desmoplastic neoplastic/inflammatory process [9,21-24]. If the asymmetry is associated with a white pupillary reflex (...) to detect pathology in patients presenting with vision loss. Variant 8: Ophthalmoplegia or diplopia. Initial imaging. Ophthalmoplegia is paralysis of one or more extraocular muscles. This may be caused by impaired motility of the muscles, disrupted nerve conduction along the neuromuscular junction, or from denervation of the affected cranial nerve or brainstem nucleus. Ophthalmoplegia may also be related to granulomatous, inflammatory, neoplastic, and traumatic abnormalities that primarily affect

2017 American College of Radiology

20. CRACKCast E022 – Red and Painful Eye

of the eye exam: Eight Key Components: VVEEPP + Slit Lamp + Fundoscopy VVEEPP Visual acuity (Vital Sign) Visual field testing External examination Extraocular movements Pupillary evaluation Pressure Determination Slit Lamp Fundoscopy VVEEPP Explained V: Visual acuity (vital sign of the eye): Snellen eye chart at 20 feet or Rosenbaum chart at 14 inches Allen chart for young children and infants If they cannot use the chart: Are they able to read the paper/phone? Counting fingers Perceive hand motion Able (...) the eyes through ALL the cardinal movements of gaze Inquire about diplopia (especially at the extremes of gaze) This may suggest ocular muscle entrapment, or functional edema P: Pupillary evaluation Assess size, shape, reactivity Assess for RAPD using the swinging flashlight test P: Pressure determination Intraocular pressures normally 10-20 mmHg IO HTN Differential Diagnosis: Glaucoma Suprachoroidal hemorrhage Retrobulbar pathology Pressures in the 20-30 range should get ophthalmology follow-up

2017 CandiEM

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