Medical Emergencies in Rehabilitation Medicine

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Medical Emergencies in Rehabilitation Medicine

Transcript of Medical Emergencies in Rehabilitation Medicine

Page 1: Medical Emergencies in Rehabilitation Medicine

Medical Emergencies in Rehabilitation

Medicine

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DEFINITION

Medical emergencies include life-threatening episodes, events that interfere with potential therapeutic functional effects of rehabilitation treatments, and the potentially deleterious effects of rehabilitation treatments.

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WHY EMERGENCIES SHOULD BE EXPECTED1- Older age: associated with more medical

comorbidity and higher levels of functional disability

2- Medically complex patients: cord and traumatic brain injuries, multiple organ system trauma, cerebrovascular and neurodegenerative diseases, organ transplantations, cancer, and end-stage manifestations of chronic diseases, such as severe heart failure, renal failure, and obstructive/restrictive pulmonary diseases.

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COMMON MEDICAL COMPLICATIONS SEEN IN REHABILITATION

1- INFECTION UT infection, pneumonia

2- CARDIOVASCULAR

Heart failure, arrhythmia

3- THROMBOEMBOLIC

DVT, pulmonary embolism

4- ORTHOPEDIC Wound infection, hip prosthesis dislocation

5- GASTROINTESTINAL

Pseudomembranous enterocolitis, gastroesophagitis

6- NEUROLOGIC Delirium, new focal findings

7- RHEUMATOLOGIC Acute gouty arthritis, septic arthritis

8- RENAL/METABOLIC

Dehydration, worsening of renal function with oliguria, electrolyte imbalance

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Autonomic DysreflexiaSyndrome of massive imbalanced reflex

sympathetic among patients with spinal cord injury at or above the midthoracic level.

Sudden significant rise in both systolic and diastolic blood pressures (20-40), bradycardia, profuse sweating, flushing, blurred vision.

Symptoms and signs can indicate an array of underlying disorders, such as urinary tract infection, venous thrombosis, and pneumonia.

Consequences are life threatening and include hypertensive crisis, stroke, and/or seizures.

Treatment is often commonsensical and simple.

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Managing Hypertension in Automatic Dysreflexia

Head of bed up, sit patient up.Check for abdominal distension (bladder,

fecal impaction), screen for UT infections.Investigate other possibilities (abdominal,

pelvic, genitourinary, skin, joint & musculo-skeletal, vascular), treat or remove noxious stimuli.

Treat hypertension (ICU, temporary or chronic medications).

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Pancytopenia in the Immuno-Compromised Patient

Caused by bone marrow failure as result of metastases, fibrosis in hemoproliferative disorders, radiation and chemotherapies.

Occurs within 10 days, recovers by 3-4 weeks.

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GranulocytopeniaAt risk of bacterial & if prolonged fungal

infections.Endogenous bacteria, mainly gram - ve.Thorough clinical examination (catheter,

oral, rectal areas, skin, sinuses).Investigations: blood, urine, sputum,

stool, chest x-ray.Treatment: 3rd generation cephalosporin. CI exercises: fever, shortness of breath,

tachypnea, absolute neutrophil count <1000/µL.

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Thrombocytopenia

Little risk of spontaneous bleeding >20.000/mm.

Platelets <20.000/mm: exercises CI.Platelets 20.000-50.000/mm: aerobic

exercises permitted, avoid strengthening, resistance & high impact activities.

Treatment: platelet transfusion (HLA matched).

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AnemiaAllow gentle ROM, brief standing

exercises, breathing exercises.CI exercises: 1- Hb < 7g/dL in asymptomatic patients. 2- Hb < 9g/dL in symptomatic (dizziness, shortness of breath) & coronary artery disease patients.Treatment: packed RBCs transfusion, SC

erythropoietin injections.

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Thrombo-Embolic Diseases

DVT, pulmonary embolism due to inactivity, paralysis or paresis.

Total hip arthroplasty, stroke (50% affected limb compared to 10% in normal).

Diagnosis: LL venous compression US (legs), spinal CT or MRI (pelvic & calf vessels).

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Thrombo-Embolic DiseasesProphylaxis: - Unfractionated heparin, low molecular

weight heparin, coumadin, aspirin. - Intermittent pneumatic compression. - Inferior vena cava filter.Treatment: - Pulmonary embolism: ICU. - Venous thrombosis: LMWH,

UH(unfrationated), coumadin.

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Thrombo-Embolic DiseasesUH: 8.000-10.000 units SC/8-12 hrs, PTT 30-

40, not common as prophylaxis.LMWH: 40-60 mg SC daily or 30 mg/12 hrs,

prophylaxis in orthopedics.Coumadin: maintain international numerical

ratio (INR) 1.5-2.0, must be continued 6 weeks as prophylaxis.

Aspirin: 325 mg twice daily, commonest in uncomplicated history.

IVC filter: high risk of bleeding, protect against pulmonary embolism.

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Cardiovascular ComplicationsAssociated with disability that augment

functional compromise.Amputation : - Higher level of amputation of LLs,

higher myocardial energy consumption during ambulation per unit distance.

- However, not associated with CVS complications, decreased walking speed.

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Cardiovascular Complications

Stroke: - Cause & associated event after stroke. - Most common comorbidity, 30% at onset, negative influence on functional outcome. - Most common cause of death after stroke. - Among survivors, 67% hypertension, 53% hypertensive heart disease, 32% coronary a.

disease, 18% heart failure.

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Guidelines Monitoring of HR & BPDon’t treat if resting HR > 120 0r BP >

160/100.Don’t treat if resting HR < 50 or systolic < 80.During exercises or functional activities,

maintain HR to 20 above resting. During exercises or functional activities,

maintain systolic BP to 50 mm Hg, diastolic 5 mm Hg above resting.

Stop if systolic BP decreases during activity (ischemia).

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AspirationSpectrum of situations ranging from

laryngeal penetration & micro-aspiration of ingested or refluxed substances to frank pneumonia (40% mortality).

Associated with swallowing dysfunction or dysphagia & upper GIT disorders causing reflux.

Three major mechanisms: - Neuromuscular: stroke, head injury, brain

tumor… - Mechanical: anatomic , inflammatory,

tumor… - Iatrogenic: enteral feeding, endo-tracheal

tube, GA…

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Guidelines for Prevention & Management of Dysphagia

Know disorders commonly associated with dysphagia.Screening questions for dysphagia (coughing,

choking after drink or eat, nasal regurge).When dysphagia suspected, hold oral intake until

further assessment.Monitor if daily caloric requirement are met.Integrate compensatory feeding & positioning

strategies & supervision requirements.Order appropriate radiographic studies (modified Ba

swallow)Refer to other medical specialists (ENT, GIT, surgery).

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Seizures & EpilepsySeizures are paroxysmal events caused by

abnormal excessive discharge from CNS neurons.

Epilepsy is disorder characterized by occurrence of at least 2 unprovoked seizures.

Classified upon clinical symptoms & EEG findings (partial focal or localized, generalized).

Causes: TBI, brain tumor, idiopathic, cerebro-vascular disease, degenerative diseases, alcohol withdrawal…

Management: monitor vital signs, provide respiratory & cardiovascular support.

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Delirium & Psychiatric Emergencies

Delirium is change in mental status (cognition, perception, thought content, mood/affect, personality).

Risk factors: stroke, brain tumor, neuro-vascular degenerative diseases, sleep deprivation, pain, pre-existing dementia.

Drawback: - Lengthen period needed for treatment. - Increase burden of care required by

caregivers.

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Guidelines for Managing Delirium in Rehabilitation

Identify medications having psychotropic side effectsComplete physical examination , include cognitive

screening , for infectious sources & new neurologic focality.

Monitor cognition & behavior serially.Monitor sleep/wake cycles, factors interfere with

sleep.Laboratory tests: CBC, s electrolytes, glucose, urea,

creatinine, liver , thyroid profile, Ca, Mg, B12, folate.Order ECG, pulse oximetry, urine, sputum culture,

chest , abdominal x-ray, brain CT or MRI.Consult geriatrician or neurologist if no explanation

is elucidated.

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Treatment InterventionsRestore fluids & electrolytesStop unnecessary medications, minimizing

doses & simplifying dosing regimens.Reduce wake-ups during nighttime,

benzodiazepine derivative at bedtime.Control pain by non narcotic analgesics.Control agitation : benzodiazepines,

neuroleptics.Supplemental oxygen, bronchodilators.Antibiotics if suspected infections

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When Delirium Becomes Psychiatric Emergency?

Displayed behaviors are harmful to the patient & others in immediate environment.

Delirium worsened without clear explanation.

Patient behaviors are interfering with a diagnostic investigation, or interrupting appropriate treatment.

Psychiatric consultation is needed to define patient competence & if involuntary psychiatric admission is necessary.