UW Physical Therapy

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UW Physical Therapy

• July 22, 2008
• Ellen Robinson, PT, A.T.C.
• Harborview Medical Center

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Objectives

• Acute Care case simulation
• Medical Record Review
• Physical Therapy Examination
• Treatment Progression
• Discharge Planning

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History

• What do you need to know?
• Demographics
• Social history and habits
• Living environment
• PLOF
• Medication

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MD Orders

• What do they want you to do?
• What is the consult for?
• Specific therapy orders or protocols?
• Activity orders?
• Precautions (medical and therapeutic)?

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Procedures

• Diagnostic
• Radiology, CT, MRI, EMG
• Surgical
• Type, location
• How will surgical sites affect function?
• How will surgical sites affect physiology?

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Lab Values

• PO2/PCo2/Ph/HCO3
• Na/CL/BUN/Glucose
• K/HcO2/CR\

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EMR vs Paper Charting
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Finding Information
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Writing Notes
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PT Examination

• Use of The Guide
• Mental Preparation
• Visual Preparation
• Make NO assumptions
• Discharge Planning on the first day!

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PT Examination

• Red Flag technique
• Systems review
• Screen CV/Pulm, M/S, Integ, Neuromusc, cognition,
  affect, language
• communication,
• Focus on the areas that are sending signals
• Call in assist as needed
• MD, RN, OT, SLP, TR, Psych, SW

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Case One

• 50 y/o female involved in MCC. Pt suffered a
  crush injury to her R LE and tib plateau fx LLE.
  R foot was not salvageable and pt underwent R BKA
  and also ORIF to L tib plateau. Pt has a plaster
  cast on her R LE stump and a L HKB.
• PT consult for strengthening and mobility
• Consider the following
• Precautions?
• Evaluation expectations?
• Possible Impairments? Barriers?
• Therapy interventions?
• Discharge planning?

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Case Two

• 18 y/o male s/p 30 ft fall off scaffolding at his
  job as a construction worker. Pt suffered rib fx
  1-9 on R side, R PTX/HTX and R mid-shaft humerus
  fx, and splenic lac. Pt had an exploratory
  laparotomy with a splenectomy and a IMN to his R
  UE. Pt has 2 R sided CTs to suction.
• PT consult for ambulation
• Consider the following
• Precautions?
• Evaluation expectations?
• Possible Impairments? Barriers?
• Therapy interventions?
• Discharge planning?

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Nerve considerations
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HTX/PTX

• PTX air in thorax HTX heme blood
• Air or blood leaks from into the space between
  the lung and the chest wall.
• Dark side of chest is filled with air that is
  outside the lung tissue

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Chest Tubes

• Inserted to drain blood, fluid, or air and allow
  full expansion of the lungs.
• Tube is placed in the pleural space - between the
  ribs (sutured in) and connected to a bottle or
  canister with sterile water.
• Suction is attached to the system to encourage
  drainage.
• The chest tube remains in place until the X-rays
  show that all the blood, fluid, or air has
  drained from the chest and lung re-expanded

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Chest assessment
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Case Three

• 37 y/o male involved in a MVC who suffered a TBI
  with EDH to R FTP lobe. Pt also suffered a R
  acetab fx. Pt s/p R craniectomy with evacuation.
  Pt is in the ICU with an ICPM, a ventric, and DFT
  on his R LE.
• PT consult for ROM and positioning
• Consider the following
• Precautions?
• Evaluation expectations?
• Possible Impairments? Barriers?
• Therapy interventions?

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ICPM/Ventriculostomy
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Skeletal Traction
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Positioning
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Case Three Part II

• Patient is now out of the ICU on the general
  acute care ward. Pt is s/p ORIF of his R acetab
  fx via posterior approach.
• PT consult Mobilize patient TTWB R LE, 60 deg
  HFP R LE
• Consider the following
• Pre mobility assessment?
• Mobilization strategies and progression?
• Discharge Planning?

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Acetabular Fracture
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ORIF
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Mobilization
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Case Four

• 21 y/o female s/p fall from horse and trampled.
  Pt with open book pelvic fx and grade IV liver
  laceration. Pt s/p ex fix of ant pelvis and perc
  pinning of B/L SIJ. Pt s/p exp lap with liver
  packing. Post op, pt suffered acute respiratory
  failure and acute renal failure. Pt in ICU on a
  rotobed with an ETT for MV, a central line, and
  an A-line.
• PT consult for ROM and positioning
• Consider the following
• Precautions?
• Evaluation expectations?
• Possible Impairments? Barriers?
• Therapy interventions?

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Intensive Care Unit
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Organ Injury

• Solid Organ Injuries Grade I-V for severity
• Consider what organ is in where and how it might
  impact treatment?
• Blood values, nutrition, exercise tolerance?

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Pelvic Fracture
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Pelvic Fixation
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Nerve Injury

• Red Flag LE exam
• Distal function
• Sensory assessment

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The Fifth Limb (the trunk)
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Case Four Part II

• Patient is out of ICU on the acute care ward,
  with a tracheotomy and a trach tent in place. Pt
  on 40 O2. Pt is 8 weeks post her initial
  accident.
• PT consult strengthening and mobility
• Consider the following
• Pre mobility assessment?
• Mobilization strategies and progression?
• Discharge Planning?

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Oxygenation

• RA 21
• 1 Liter O2 4
• 5L O2 20 21 41
• 40 Face mask 5L

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Tracheostomy tubes

• Selection of sizes varies among MDs
• Guidelines include patients weight general
  anatomy.
• Can be cuffless or cuffed
• Myth People cannot talk with trachs.
• Myth People cannot eat with trachs.
• Myth Trachs are permanent.

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Cuffed vs Cuffless
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Mobilization Options
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Moveo (Trees)
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Moveo (Trees)
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Endurance Training

• Consider use of upper body and lower body
  ergometers for more aerobic activities
• Light resistance to begin, increase time and
  resistance as tol.

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Other Issues Impacting Recovery

• Prolonged intubation, long term ventilation may
  lead to Critical Illness (aka ALI, ARDS, SIRS)
• CIM/CIP critical illness syndromes
• Swallowing impairments
• Communication impairments
• Cognitive Impairments
• Emotional Impairments

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Red Flags/Indicators for Swallowing Evaluations

• Hoarse voiceIndicates laryngeal involvement s/p
  extubation.
• Weak or wet, gurgley voice.
• Coughing or vocal wetness after swallowing
  food/liquid.
• Poor ability to manage own secretionsdrooling,
  coughing on saliva, wet voice baseline, requiring
  suctioning.

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Intubation Trauma

• Patients s/p extubation that are aphonic or
  present with hoarse whisper quality may have
  laryngeal involvement.
• If aphonia or hoarse vocal quality (dysphonia)
  does not improve in 7-10 days following
  extubation consider an Otolaryngology consult
• If true vocal fold paresis/paralysis present,
  temporary vs. more long-term interventions may be
  indicated to decrease risk of aspiration
  complications, improve cough strength and/or
  improve quality.

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Cognitive function after ARDS

• 100 of ARDS survivors at discharge and 78 at 1
  year show some degree of cognitive abnormality
  (Hopkins)
• For most, this is in executive function skills
• Attention/concentration
• Speed of processing
• Memory
• Executive function

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Etiology of Cognitive Impairments

• Pathogenesis of the cognitive problems is not
  well understood, but is likely multi-factorial
  and the subject of ongoing discussion/research.
• Possible etiologies include
• Prolonged hypoxemia
• Toxic or metabolic effects from sepsis
• Combination of hypoxemia sepsis may result in
  more severe impairments than either alone
• Gas emboli to the CNS which results in decreased
  tissue oxygenation
• Result of psychological state associated with
  stress of prolonged critical illness

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Emotional Impairments

• Anxiety - (consider situation)
• Depression - Feelings of hopelessness, Crying,
  Indecisiveness, Restlessness, Decreased
  initiation
• PTSD (consider situation)
• Withdrawal from medication?

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Case Five

• 45 y/o male s/p logging accident in which a tree
  fell on him at work. Pt suffered C6/7
  fracture/dislocation and complete SCI. Pt
  underwent cervical fusion C4-T1 and is in a CTO
  (Minerva) brace for stabilization.
• PT consult for SCI
• Consider the following
• Precautions?
• Evaluation expectations?
• Possible Impairments? Barriers?
• Therapy interventions?
• Discharge planning?

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Spine injuries

• Anterior
• Middle
• Posterior
• Treatment will depend on which columns are
  unstable

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Fixation
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Spine Injury
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Rehabilitation

• Consider level of injury as how it relates to
  function
• Predict Outcomes based on level of injury
• Develop treatment plan based on predicted outcomes

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Other Systems Consideration

• Neurological     - autonomic dysfunction,
  spasticity
• Pulmonary     - Assisted coughing, positioning,
  suctioning
• Cardiovascular Monitoring vital signs   
• Bradycardia may occur due to parasympathetic
  response
• Pt may have low SBP from loss of sympathetics and
  muscle pump
• Integumentary
• Turn Q2
• Basic positioning principles for bony prominences
• Brace monitoring for decubiti
• GI/GU    - Bowel and Bladder program Undetected
  GI/GU dysfunction in vertebral fractures

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Early Mobilization
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Enhancing patient success

• Utilize extra hands as needed (RN, therapy aides,
  family member) to begin mobility training as soon
  as possible
• Be flexible when setting rehab goals and
  scheduling therapy sessions to allow for the
  patients changing needs, stamina, and medical
  status
• Continuity of care from ICU to Acute

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Physical Therapists

• In the course of a single day, a PT working in
  acute care may act not only as a care provider,
  but also as a consultant, a researcher, an
  educator and an advocate
• Feburary 2006 PT Magazine

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Questions?
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Resources

• http//www.gentili.net/fracturemain1.asp
• http//www.wheelessonline.com
• https//depts.washington.edu/hmctraum/
• http//sci.washington.edu/
• lnrobin_at_u.washington.edu