Physical Therapy Intervention for a Child Admitted with Influenza A

1. Physical Therapy Interventionfor a Child Admitted with Influenza A Dana Mieczkowski, PT, DPT A.I. duPont Hospital for Children

2. Chart Review • 10 year old boy with no significant PMHx in previously good health • 3 days prior to admission developed cough, fever, myalgias and lethargy • 1 day prior to admission developed difficulty breathing • Brought to Brywn Mawr ED after recommendation by pediatrician • Respiratory distress and intubated • Tested + for influenza A (H1N1)

3. Chart Review (cont’d) • Transported to AIDHC PICU for further evaluation • During transport saturations between 50% and 70% with hypotension • Upon arrival pt with poor cardiac function and evaluated for ECMO (extracorporeal membrane oxygenation) after initial measures were unsuccessful to stabilize patient and transferred to CICU • Also found to have disseminated intravascular coagulation (DIC) with primary manifestation of clotting • In danger of losing parts of extremities or suffering brain damage from hypoperfusion and clotting

4. Course of patient presentation • Day 1: ECMO • Day 2: CRRT/CVVHD • Continuous Renal Replacement Therapy • Continuous Venovenous Hemdiafiltration • Day 3: concerns of ischemic changes/injury to limbs • Day 5: PT Evaluation for Wound Care • What do we have….. • 10 year old boy with no significant PMHx admitted with Influenza A, acute respiratory distress syndrome, cardiogenic shock, hypoxemia, pleural effusions, renal failure, septic shock, multiorgan dysfunction, DIC, ischemic changes to bilateral feet and left hand

5. What do you need to know before going in to see patient?? • What will you do in initial evaluation??

6. Initial Evaluation • Precautions: B subclavian vein catheters, arterial line, several peripheral IV’s, pleural catheter, foley, mediastinal chest tube, transthoracic ECMO catheters, intubated • 3rd and 4th digit black eschar at DIP on left hand • +swelling of B hands • B hands dusky color

7. Initial Evaluation • LE dusky and blue with diffuse color changes, poor perfusion • + swelling B feet and LE • No open lesions, skin intact • Demarcation line approx 4 finger breaths above malleoli • Faint doppler pulses for right dorsalis pedis and bilateral posterior tibialis, no pulse at left dorsalis pedis • no palpable pulses • No ROM or change of position allowed

8. Question #1 • Based on initial evaluation, what is the main PT concern for this patient? • This patient is too critical, there is nothing I can do for him • ROM • Skin integrity • Neurological status • What will your recommendations be after initial evaluation?? • Consult plastics and orthopedics • Monitor every day for changes • Elevate to decrease pressure • Place on specialty bed

9. What is this patient’s prognosis? • What would you expect the treatment plan to include at this time? • What do you think the frequency of treatment would be?

10. Follow-up Therapy Sessions • Orthopedics and Plastics Plan • Eventual surgical management of limbs if medical condition allows • Day 8 • + blister formation, applying vaseline and adaptic to areas • Elevating limbs • Attempts to decrease ECMO support – failed with presentation of hypoxemia • Awaiting lung improvement • Day 12 • Ankles with fluid filled blisters • No capillary refill or palpable pulses • Localized wound care • Specialty bed with low air loss/alternating pressure to protect skin integrity

11. Follow up Therapy Session • Day 28 • Several failed attempts of weaning from ECMO – met with severe bradycardia, hypotension and hypoexemia • Persistent pulmonary hemorrhage and necrotic lung tissue • Ortho wants to splint UE and LE and provided ROM to prevent contractures and take pressure off soft tissue • No early surgical management unless develop infection, but amputation in future • Orders received for ROM– met with CICU staff • States patient not medically stable to receive PT at this time

12. Question # 2 • CICU staff will not allow you to perform ROM on patient. What should you do??? • What is your role as an acute care PT in this situation? • Do nothing, this patient is too unstable for intervention • Educate nurses on importance of positioning and elevation of limbs • Monitor wounds and only provide wound care as needed • Provide resting splints for UE and LE for improved positioning Already monitoring wounds, so educate staff on elevation of limbs to provide gentle knee extension stretching during day

13. Day 36 • Medical team states “This is a critically ill child who has failed to show improvement after 1 month of ECMO support in hopes that lungs (pulmonary hemorrhages) will heal enough to remove ECMO. At this time survival unlikely but in presence of functioning CNS will continue support.” • Day 38 • Trialed decreased ECMO support with acceptable oxygenation but +respiratory acidosis • Day 39 • PT Orders received and approved for ROM and evaluation

14. Now what will you measure, what data will you collect?

15. Initial Evaluation (12/10/09) • Precautions: ETT, open sternum, NG tube, a-line, B subclavian lines, CVVHD, intubated and ventilated, transthoracic ECMO catheters d/c’d yesterday • Pain 0-4/10 FLACC • Behavior: awake/drowsy during session. +eye opening and nodding head to questions although inconsistent • UE: mom states pt had grasped her hand prior to isoflurane treatment, not in past 2 days, full PROM in hands, wrist and elbow. Severely decreased shoulder ROM. NO AROM • LE: hip flexion 75 degrees, popliteal angle 60 degrees left, 45 degrees right, able to fully extend knee with hip in slight flexion, no PROM of feet, no AROM • Mobility/Transfers: unable to perform or assess secondary to open sternum and medical status

16. What is PT diagnosis? • 11 year old boy with significantly decreased ROM, strength and functional mobility secondary to prolonged and complex hospital stay • What is PT plan?

17. Question # 3 • How would you evaluate neurological status in an intubated and non-sedated patient? • Consult Neurology • Ask patient yes/no questions each session and evaluate for consistency • Ask patient to follow 1-step commands, such as squeeze hand, blink eyes or nod head • A and B • A and C • All the above A and C, not B since he would be mouthing words over ETT

18. What goals will you set for this patient?

19. Goals • Pt will be able to follow 1 step verbal commands • Pt will maintain eyes open/awake state x15 minutes • Pt will tolerate lotion massage to BLE and BUE with minimal discomfort • Pt will achieve full ROM into knee extension to accommodate prosthetics for likely BKA • Tolerate repositioning as medically appropriate • How can you make these hospital short term goals into functional goals?

20. Treatment • Splints: why would you or wouldn't use them? • How will you encourage optimal positioning?

21. Findings-Follow up Therapy Sessions • 12/15 • Pain 0-3/10 FLACC • Plan for closure of sternum after session • Eye opening and nodding head to answer yes/no questions • Tolerates PROM to LE and UE • Able to bring arms from surface of bed together on chest • 12/17 • 90 degrees hip flexion • 45 degree popliteal angle right, 30 degree popliteal angle left • Full knee extension with some hip flexion • SLR 30 degrees • 45 degrees IR/ER of hip • Continues with medical procedures for lung repairs

22. Findings-Follow up Therapy Sessions • 12/24 • Pt with increased fevers and elevated white and platelet count despite antibiotics • Ortho believes feet consistent for wet gangrene • Taken to OR for emergent amputation • 12/28 • POD #4 BKA • Awake throughout session • AAROM/PROM • Attempt to communicate over ETT • More consistent command following • Positioning, PROM, AAROM

24. 12/31 • Tracheostomy • Ortho wants to hold therapy until stitches removed from amputation • OT continues for UE and speech initiated for oral motor and augmentative communication • 1/12/10 • PT able to resume per orthopedics • Pt has had peritoneal dialysis catheter placed instead of subclavian line

25. PT Evaluation 1/12/10 • Pt is POD #7 from tracheostomy and POD #19 BKA, • Precautions: CVL, necrotic 3rd and 4th DIP left hand, 3 chest tubes, NG tube, replogle drain • What would you measure now?

26. Objective Findings • Behavior: Pt awake throughout session • Able to tolerate elevation of HOB to 50 degrees x20 minutes • Able to hold head in midline briefly • Limited hip extension, good/fair ROM of LE’s • Less than 3/5 strength with AAROM • SLR, supine hip abd/add, quad set, knee flex/ext, hip flexion • Rolling with mod to max assistance • Maintain sidelying with min to mod assist

27. Plan of Care • Assessment: Pt able to demonstrate good PROM of LE with exception of hip extension, improving strength, difficulty with mobility skill such as rolling and sitting tolerance • What are this patient’s greatest impairments and how might you begin to address them? • What PT treatments might be helpful in resolving these impairments and why? • Is there evidence to support these interventions?

28. Goals • Pt will tolerate HOB elevated to 75 degrees with head in midline x1 hour multiple times per day • Pt will tolerate PT x60 minutes daily to improve strength and functional mobility • Pt will increase LE strength to greater than 3+/5 • Pt will improve ROM to within normal limits • Pt will tolerate maintaining LE on surface of bed for the majority of the day without need to prop on pillows • Pt will be able to roll from supine to sidelying independently • Pt and mom will be independent in stump wrapping for daily dressing changes • Pt will be measured for specialty wheelchair • Pt will be measured for temporary prosthesis

29. Question # 4 • Now that this patient is s/p B BKA, what is the most important goal / plan of care for this situation? • Increase mobility and ability to transfer • Stump care • Assessment of neurological status • Increasing strength Stump care – without proper formation of residual limb, will not be able to fit prosthetic

30. Plan of Care • Treatment • Repositioning and mobility • AAROM • PROM • Desensitization • Skin integrity – breakdown on back of head • Residual limb care • Reassessment • Hamstrings tighter • Popliteal angle was 45 left and 30 right, now 60 left and 75 right • Having difficulty with nursing with positioning • Consultation/referral • Rehab and Psych

31. Treatment • 1/22 • Out of bed for first time x15 minutes • 1/27 • Beginning phantom limb pain – avoiding desensitization actvites • Performing supine to sidelying to sit • Sitting EOB with max assist • OOB in wheelchair • Becoming frustrated and angry • Nursing difficulties • 1/25 and 2/1 Rehab consult • Not medically ready secondary to ongoing medical issues • 2/8 able to go to rehab gym for therapy • Prosthetics fitting • Sliding board transfer • Sat EOM with supervision – poor posture • Tilt table x 5 minutes

32. Question # 5 What muscles are primary focus for strengthening for standing and walking with prosthesis? • Hip adductors • Hip extensors • Knee flexors • Knee extensors • A and B • B and D • B and D, plus hip abductors

33. Outcomes/Results • 2/15 Move to rehab floor and begin inpatient rehabilitation • Pt now able to: • Don shorts in bed independently in supine • Mom independent in donning prosthesis • Sidelying to sit EOB transfer with min assist x1 • Sliding board transfer min assist x2 • sitting 10 minutes at edge of mat • Tilt table x15 minutes at 45-60 degrees • What comes next in rehab? • What would your treatment plan include?

34. Rehab Evaluation • Behavior – tearful, disinterested, withdrawn, did not initiate conversations, followed commands but when did not it was because he stated he didn’t want to perform activity • Max assist transfer x2 bed <> wheelchair • Moderate assist to roll from supine to sidelying, refused prone • PROM BLE • Hip flexion: (B) 120 • Hip extension (sidelying): (R) 12, (L) 10 • Popliteal angle: (R) 30, (L) 40 • Hip Abduction: (R) 30, (L) 45 • Hip Adduction: (B) 10 • Knee Flexion: (R) 135, (L) 140 • Knee Extension: (R) -3, (L) 0 • Maintains legs postured in hip and knee flexion

35. Rehab Goals • Pt will be able to maintain upright static sitting balance for 10 minutes with close supervision x 3 consecutive sessions • Pt will be able to maintain dynamic sitting x5 minutes while using arms for activities with contact guard assistance, 2/3x • Pt will be able to perform sit-pivot transfer from wheelchair to mat with bilateral prosthetics donned with mod assist, 3/5x • Pt will require min assist for rolling supine to prone, 3/3x

36. Rehab Goals • Pt will require min assist for supine to sidelying to sitting EOB, 3/3x • Pt will be able to tolerate tilt table, with bilateral prosthesis donned for 20 minutes at an incline of 60 degrees x2 sessions • Pt will be able to independently don and doff bilateral prosthesis

37. THANK YOU!