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Challenges of a CVA

Challenges of a CVA. Demery Dawson, DPT Christiana Hospital Acute Care Therapist. History. Pt is a 47 year old male admitted to the CHER 8/12/09 Pt reportedly stated complaints of a HA prior to becoming unresponsive while exiting his car in a parking lot Pt required intubation by EMS

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Challenges of a CVA

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  1. Challenges of a CVA Demery Dawson, DPT Christiana Hospital Acute Care Therapist

  2. History Pt is a 47 year old male admitted to the CHER 8/12/09 Pt reportedly stated complaints of a HA prior to becoming unresponsive while exiting his car in a parking lot Pt required intubation by EMS Upon arrival pt sedated, intubated, and adm to ICU ETT (endotracheal tube) and NGT (nasogastric tube) placed Central line PMH HTN

  3. What initial information would you want to know from the patients’ chart?

  4. Relevant Tests • Dx tests • CXR • Bilateral upper lobe consolidation • CT c-spine • (-) fx, sublux or dislocation • CT head • extensive SAH extending into cisterns bilaterally, pre-pontine perimedullary cisterns and foramen magnum. Hemorrhage within sylvian fissures left > right, also within hemispheric sulci and anterior interhemispheric fissure. (+) IVH within the anterior horn on the left extending into third ventricle, left posterior horn and into fourth ventricle. (+) acute hydrocephalus. (-) midline shift. no gross mass within the brain. (-) vascular infarct. (-) skull fracture. • Cerebral Angiogram • (+) ruptured aneurysm L MCA

  5. Question #1 Given the extensiveness and the location of the hemorrhage, what motor presentation would you expect to see? A. Left upper extremity and lower extremity flaccidity with mild right sided involvement B. Bilateral upper extremity flaccidity with bilateral lower extremity involvement C. Right upper extremity and lower extremity flaccidity with mild left sided involvement** D. Bilateral lower extremity weakness with bilateral upper extremity involvement

  6. Question #2 Ventriculostomy is a surgical procedure to drain cerebrospinal fluid from the ventricles and also to monitor intracranial pressure? A. True ** B. False

  7. Surgical History Since Admission • Recent surgical interventions • VIR 8/14/09 • Coil embolization of aneurysm • Unsuccessful • L craniotomy 8/18/09 • Clipping of aneurysm 8/18/09 • Ventriculostomy 8/18/09

  8. History • Complications • 8/19/09 CT chest (+) right apical PTX • 3 chest tubes placed • All resolved and removed by 8/28/09 • Bronchoscopy (-) vegetation 8/20/09 • Vent settings changed • Assist control (AC)  High Frequency Oscillatory Vent (HFOV) 8/20/09 • HFOV  AC 8/23/09 • AC  Pressure Support Ventilation (PSV) 8/25/09 • Extubated 8/26/09 • PT consulted 8/27/09

  9. What information would you want to obtain directly from the patient?

  10. What information would you want to obtain directly from the patient? • Alert and oriented • PLOF • Assistance/ family support • Pain/sensation

  11. Question #3 What Rancho level would be most appropriate to classify this patient with information gathered so far? • Rancho II – Generalized • Rancho III – Localized *** • Rancho IV – Confused-Agitated • Rancho V – Confused-Inappropriate, Non-agitated

  12. What additional (secondary) factors would contribute to the patients presentation at Initial Eval? Why?

  13. Initial Evaluation What data do you want to collect at initial examination?

  14. Initial Evaluation • Objective information 8/27/09 • Tests and measures • PROM • WFL • MMT • RLE= 0/5 • LLE= > 3/5 • Sensation • Initially unable to assess due to pt decreased cognition • Decreased R visual tracking, mild inattention • Functional mobility • Dependent for bed mobility and transfers • Poor sitting balance at edge of bed • Rancho level III

  15. Continued Evaluation • Visit 8/31/09 • A & O x 1 • Max A rolling • Rancho level IV • Ventriculostomy d/c’d 9/1/09, no VP shunt warranted • Pt transferred out of ICU to step down unit 9/1/09 • Pt with increased agitation • Pt with minimal PT participation until 9/4/09

  16. Initial Evaluation • Re-eval 9/4/09 • Tests and measures • PROM • WFL except R ankle: DF to neutral • MMT • RLE • Hip: 0/5 • Knee: 0/5 • Ankle: 0/5 • LLE • Hip: 3+/5 • Knee: 4-/5 • Ankle: 4-/5 • Sensation • Numbness RUE and R LE • Occ c/o RUE pain • Coordination • Mild dysmetria LLE

  17. Initial Evaluation • Re-eval continued • Balance • Sitting • Fair (-) • Min A with LUE x 20 seconds • Standing • Poor • Static in parallel bars • Functional Mobility • Transfers • Sit  stand with Mod A x 2 in parallel bars x 5 seconds • Able to stand with LUE support on bar, CGA at trunk and R knee blocked • w/c propulsion • Performed 2 pushes with LUE, LLE, and Mod A • Rancho level VI

  18. Question #4 What behavior would you expect from a Rancho level VI patient? A. Begins to respond to sounds, sights, touch or movement B. Inconsistently responds to simple questions with "yes" or "no" head nods C. Restrained so he doesn't hurt himself D. More aware of physical problems than thinking problems **

  19. PT Diagnosis/Assessment • What is your PT diagnosis? • What findings support your diagnosis? • What are your goals with this patient? • In this setting what impairments do you want to address first?

  20. Plan of Care • What are this patient’s greatest impairments and how might you begin to address them? • Right sided weakness • L sided ataxia/dysmetria • Balance • What PT treatments might be helpful in resolving these impairments and why?

  21. Plan of Care • Treatment/specific tactics • Weight bearing activities with joint approximation and weight shifts • Parallel bars used with assist at RUE, RLE, and trunk • PNF stretching implemented for RLE to improve/maintain ROM • Constraint therapy utilized for RLE in conjunction with joint approximation to propel w/c • Motor coordination and proprioceptive exercises performed to address LLE dysmetria • Re-assessment • Began feeling tingling/numbness RUE 9/8/09 • MMT 9/18/09 • RLE • Hip flexion: 1+/5 • Knee flexion: 2+/5 • Knee extension: 2-/5 • Ankle: 0/5 • Rancho level VII 9/22/09

  22. Patient Complications • Pt updates • Doppler US BLE - (+) Acute DVT BLE 9/27/09 • Doppler US BUE - (+) Acute DVT R IJV 9/27/09 • How does this change your treatment?

  23. Plan of Care • Consultation/referral • Deferred to OT for RUE • Clinical decisions • Alternated focus of treatment to prevent plateaus and patient frustration • Varied cueing and external input • Mirror; marks on floor for foot placement • Quiet gym time vs multiple pts in gym • Seated and standing balance training, proprioceptive training, transfer training, and gait training • Patient progression

  24. What changes would you make to the patients goals to continue his functional progression?

  25. What discharge options are there for this patient and which setting is most appropriate at this time? Home with home health Skilled nursing facility for long term Inpatient Rehab** Home with outpatient therapy Question #5

  26. Outcomes/Results • Pt discharged from Christiana Hospital on 10/6/09 • Pt able to amb 50’ c RW and min A for RUE grip • Able to advance RLE s assistance • Pt transferred to Wilmington Rehab (Inpatient Rehab) • Inpatient from 10/6/09 to 10/20/09

  27. Continuum of Care • Pt discharged home with VNA services • Received home PT from 10/25/09 to 12/8/09 • Pt discharged from home PT to outpatient brain injury program at Wilmington Hospital • Currently being treated

  28. Questions???

  29. Thank you

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