Medical Emergencies

in Rehabilitation
Medicine
 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.
WHY EMERGENCIES SHOULD BE EXPECTED
1- 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.
 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
 Autonomic Dysreflexia
Syndrome 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.
 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).
 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.
 Granulocytopenia
At 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.
 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).
 Anemia
Allow 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.
 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).
 Thrombo-Embolic Diseases
Prophylaxis:
- 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.
 Thrombo-Embolic Diseases
UH: 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.
 Cardiovascular Complications
Associated 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.
 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.
Guidelines Monitoring of HR & BP
Don’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).
 Aspiration
Spectrum 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…
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).
 Seizures & Epilepsy
Seizures 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.
 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.
Guidelines for Managing Delirium
in Rehabilitation
Identify medications having psychotropic side effects
Complete 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.
 Treatment Interventions
Restore fluids & electrolytes
Stop 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
 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.