Day 5 - Medical Complications Flashcards
Write down rehab plan for newly admitted ABI patient.
**Physiotherapy**
- Postural control
- Static & Dynamic Balance
- Gait re-education (+/- harness)
- Motor coordination of the lower extremities
- Cycle ergometry
- Casts, splints and passive stretching (planterflexion contracture is common)
**Modalities**
- Functional electrical stimulation
**Occupational therapy**
- Sit-to-stand
- Functional reaching (transfer)
- Functional fine motor control retraining
Define Benign paroxysmal positional vertigo (BPPV), PEx and Tx.
Definition
Brief episodes of vertigo provoked by movement of the head.
Examination
Dix-Hellpike maneuver
Treatment
Promote static and dynamic postural stability by Epley maneuver
List 4 DDx for vertigo
- BPPV
- Labyrinthine Concussion
- Perilymph fistula
- Temporal bone fracture
- Ototoxicity
Ref: Canadian Coarse Review
Definition of Heterotopic Ossification & List 4 Risk factors🔑
Heterotopic ossification (HO) is the formation of mature lamellar bone in extra skeletal soft tissue.
Risk Factors
- Prolonged coma (>2 weeks)
- Immobility, Hemiplegic
- Limb spasticity/↑ tone (in the involved extremity
- Traumatized / fractures
- Pressure ulcers
- Edema
Clinical Presentation of Heterotopic Ossification (HO)🔑
Earliest sign often being decreased range of motion in the involved joint.
- Pain and ↓ ROM
- Local swelling
- Erythema
- Warmth in joint
- Muscle guarding
- Low-grade fever
Complications of Heterotopic Ossification (HO)🔑
- Bony ankylosis
- Peripheral nervecompression
- Vascular compression
- Lymphedema
List 4 Differential Diagnosis for Heterotopic Ossification (HO)🔑
- Deep vein thrombosis (DVT)
- Tumor
- Septic joint
- Hematoma
- Cellulitis
- Fracture
Which joints are most often involved in HO post ABI?
Hips, shoulders, and elbows. Rarely are the knees affected.
ERABI Model 9
Managment of Heterotopic Ossification (HO)
Non-Pharmacological
- Physiotherapy and Range of Motion Exercises
- Shockwave and Radiotherapy
Pharmacological
- Bisphosphonate (Etidronate)
Surgical
- Surgical excision (after 12 to 18 months to allow maturation of HO)
List 2 Prophylactic interventions for heterotopic ossification
- Passive range of motion exercises
- Etidronate disodium (EHDP)
How do you grade Heterotopic Ossification (HO)?
List 3 Diagnostic tests for Heterotopic Ossification (HO)
- Serum alkaline phosphatase (SAP) elevation
- Xray Require 3 weeks to 2 months postinjury to reveal HO.
- Bone Scan Sensitive method for early detection of HO
What is currently the gold-standard assessment to confirm a diagnosis of DVT? PE?
- Magnetic resonance venography or ultrasound.
- Computed tomography pulmonary angiogram.
List 3 DVT prophylaxis in TBI
- low-molecular-weight heparin (LMWH)
- Intermittent pneumatic compression
- Inferior vena cava (IVC) filter
DVT treatment in ABI and duration
First initiated with intravenous (IV) heparin or dose-adjusted SQLMWH
Followed by oral anticoagulation (warfarin or NOAC).
Anticoagulation continues for 3 to 6 months.
Does warfarin needs bridging?
- Warfarin takes about 5 days to achieve full anticoagulation (INR above 2).
- During the first few days of warfarin therapy, patients are prothrombotic due to a decrease in protein C and S (natural anticoagulants) before thrombin levels diminish significantly.
Mention 4 risk factors for DVT in ABI patient.
- Age > 40
- Presence of clotting disorder
- Severe Injury
- Bone Fracture
- Prolonged immobilization > Cast
List 2 Types of touch and their spinal tract.
- Light touch: ventral spinothalamic
- Pain: lateral spinothalamic
- Position: dorsal colum
- Vibration: dorsal colum
Define silent aspiration.
Penetration of food below the level of the true vocal cords, without cough or any outward sign of difficulty.
Such cases may be missed in the absence of a videofluoroscopic swallow study (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) assessment
What are the risk factors for dysphagia post-ABI?
- Severity of brain injury
- Duration of coma
- Lower Glasgow Coma Score on admission (GCS 3-5)
- Severity on CT Scan findings
- Duration of mechanical ventilation
- Tracheostomy
- Translaryngeal (endotracheal) intubation
- Severe cognitive and cognition disorders
- Physical damage to oral, pharyngeal, laryngeal, and esophageal structures
- Oral and pharyngeal sensory difficulties
ERABI Model 3
What are the risk factors for aspiration following an ABI?
- Lower Glasgow Coma Score (3-5)
- Presence of a tracheostomy
- Poor cognitive functioning
- Hypoactive gag reflex
- Prolonged period of mechanical ventilation
- Reduced pharyngeal sensation
- Brainstem involvement
- Difficulty swallowing oral secretions
- Coughing/throat clearing or wet, gurgly voice quality after swallowing water
- Choking more than once while drinking 50 ml of water
- Recurrent lower respiratory infections
- Dependence on feeding assistance
ERABI Model 2
List 4 examples of compensatory strategies
(a) oral care and hygiene
(b) food consistency and viscosity alterations
(c) low risk feeding strategies
(d) postural adjustments while eating
Describe some low-risk feeding strategies
From Heart and Stroke Foundation, 2016
- Calm eating environment, with minimal distractions.
- Patient is in an upright position with the neck slightly flexed facing midline.
- Self-feeding.
- Proper oral care.
- Feed at eye level.
- Feed slowly.
- Feed using metal teaspoons (no tablespoons or plastic).
- Drink from wide mouth cup or a straw to reduce the neck extending back.
- Ensure bolus has been swallowed before offering more.
- Properly position the patient and monitor for 30 minutes after each meal.
What are some common diet modifications that can aid swallowing?
- For solid textures, food may be diced, minced, or pureed.
- For fluids, they may be thickened to nectar, honey, or pudding consistencies.
- Limit mixed consistency foods
List at four postures adjustments to improve swallowing function.
- Chin Down Posture
- Chin Up Posture
- Head Turn (left or right)
- Head Tilt (left or right)
- Lying Down
List at least two swallowing maneuvers that may be used in dysphagia management.
- Supraglottic swallow.
- Super-supraglottic swallow.
- Effortful swallow.
- Mendelsohn maneuver.
When is the best time to initiate oral care with a patient who has dysphagia?
Mouth care should be thorough and performed before eating or drinking
Research suggests that the introduction of oral bacteria to the lungs via aspiration is more problematic than the food or liquid that is aspirated
List 4 indications for enteral feeding.
- significant dysphagia
- high rates of aspiration
- comatose
- medically ventilated.
Dysphagia Flow Sheet
