I just want to welcome everybody to our second annual inpatient consultation community session. We're very excited to have everybody here and we have a great group of panelists for you today. Just a bit of a background. This community session was started about two years ago. To give those who perform inpatient consultations or those who are interested in starting a consult service an avenue to discuss issues or provide assistance to one another and helping each other be as successful as possible. As consultants, we do more than just provide disposition recommendations. We are active and integral members of the acute care teams. We can provide important and valuable information and medical recommendations to optimize medical care and allow maximization of functional abilities, particularly in certain patient populations like what we'll be discussing today, like brain and spinal cord injuries. We as PM&R physicians specialize in these conditions more than other departments. So we wanted to take this opportunity during our annual assembly to come together and discuss challenging cases with some expert panelists. And our hope is that we can use this time to educate ourselves and learn from one another for the benefit of our individual programs and the patient care and the patients that we care for. So, welcome. First, let's just introduce the session directors and moderators. I'm Jocelyn Gober. I'm the current medical director of pediatric rehab and the Department of PM&R at the University of Miami and Christine E. Lynn Rehabilitation Center, where I also do a lot of pediatric consults. And next we have Dr. Adriana Valbuena. She's the medical director of the consultations in the Department of PM&R at the University of Miami at Christine E. Lynn Rehabilitation Center. And then we do want to make this session interactive. So in order to do so, please join our poll everywhere. We'll be asking a few questions. You can either text JG258 to 37607 to join. Or you can just go on, just go to site, PollEverywhere.com, slash JG258, and then that'll prompt you. And then for our judges today, we're going to be discussing some SBI bowel management, some bladder management. We're going to discuss rehab challenges of patients with stage four pressure injuries in the safer area after a spinal cord injury. We're going to discuss some treatment options to improve weightfulness in patients with brain injuries, discuss some clinical presentations, diagnosis, and management of paroxysmal sympathetic hyperactivity. And then we're going to discuss some pharmacologic and non-pharmacologic management of patients with agitation after brain injuries. And then we have about 90 minutes to get through it all. So our little roadmap today, starting with some introductions, which we are maybe a little bit behind for. We're going to then go into a little brief background information, followed by about 30 minutes of spinal cord injury cases and discussion, and then 30 minutes of brain injury cases and discussion. And then we leave a little bit of time for other questions and answers. So before we get started, we just want to kind of get an idea of who is in the audience. It's not working. It's not working. I don't know I tried it before. All right, we're going to move on. I'll try to fix the poll in a little bit. So while I try to fix the poll, I'm first going to introduce Dr. Gavlona, who is the current director of this inpatient consultation community, and who started it, to give a little bit of background information. Hi, everyone. Thank you very much for taking some time for your visit schedule to participate in this community session. I mainly want to share my experience as a PM&R consult director at Jackson Memorial University of Miami. I started working as an inpatient consultant for about eight years now. I really enjoy the medical and social challenges that every case brings. I believe that the basic components of every consult are, first, the admitted diagnosis course. Also, what the hospital course, what happened on the hospital course. Sometimes, the admitted diagnosis is not the main problem for the functional impairment. It's what happened on the hospital course. Also, what precautions we need to have on that specific patient for therapy, for nursing. What are the functional goals on that diagnosis, that admitted diagnosis to rehab? What do we expect? How long do we expect this patient to get better? I think those are really key points on the initial presentation of a consult. The prior level of function. Was the patient able to be independent prior, and now completely dependent, or a patient was already needing help? How able the patient to tolerate out-of-bed activities, the patient having challenges with the out-of-bed activity. How you, as a consultant, can optimize that medical aspect. It's common to see that other service, they call patients medically stable. For the rehab program, they don't have a clear idea that our program requires and entitles the patient to be three hours of therapy out of bed. They call medically stable on someone that is in bed. So battle signs are stable while in bed. So tolerance of out-of-bed activity is important when we are doing consults. Also very important was the patient's social support and living situation. We know that the same problem, the same medical problem with very complicated hospital course, may be different recommendation in someone that we have a very involved family, versus someone that doesn't have the support and has to go home by himself or herself. And last but not least is the financial resources. It's very important to have a knowledge of what are the resources each patient has, depending on their financial, their insurance. Not just for the post-acute care recommendation, but sometimes we are deciding on treatment management. For example, if we're deciding about baclofen pump trial, is the patient going to be able to be compliant with the outpatient, with the refills, the refills of the medication? So the financial part, it plays a big role on a lot of the decisions that we do as a consultant. Previously, my institution, and Dr. Alvarez is also from the University of Miami Jackson Memorial, the consult service, it was a rotating service between different attendings, including outpatient attending. It was a rotating service every three months. And there was a lot of good things about that, but the challenges were mainly two. There was a lack of communication with the primary team, as you know, the person rotating to the next service was not really having good follow-up on the cases that the previous attending was seeing. And also some inconsistency on recommendation. It will depends of who was rotating in that during that three months. It was a spinal cord, it was a brain injury, it was mainly MSK, outpatient doctors. So depending how comfortable the attending was, the recommendations will change a little bit. So currently, and for the last seven years, the system changed and we now have three attendings, where it's one spinal cord injury, one brain injury, one pediatrics. We have two residents, one a junior resident, and a PY2, which is unusual for a council, but it's also helpful for them to understand the challenges that the inpatient team goes through on the acute side, and a PY4. And also we have a nurse practitioner that also assists us with the council, especially on Friday. So we decided to be able to address the inconsistency on some of the recommendations. We created what we call the Rehabilitation Screening Instrument, which is mainly used by the residents, by the nurse practitioner, and by the liaison screener. So we decided to do it by system. So you'd see in the right side, it's basically what in our institution we are not able to handle, or we are able to handle. And on the left side, it's mainly for the screeners to gather the medical, social information, and financial information. So this is our first step, the first thing that we decided to do to come up with a consensus of how medically, you know, what are the medical things that needs to be optimized? And we take it case by case. This is just a reference. You know, sometimes we bend a lot of these rules because in that specific patient is not that significant or significantly affected patient's progress. The next thing that we did, and next slide, was to create templates for recommendations. And we started with the two main referral diagnoses, and that's the reason that we picked these cases. It's the spinal cord recommendations. So we, you know, depending on the patient level of injury, we adjust these medications, these recommendations, but we try to keep consistency. Whoever is seeing the patient, we have the same template, and our primary referrals, our acute team referrals, they are familiar and they understand now how we approach the recommendations and what needs to be optimized and what is the bladder management needs to be done or what's the bowel management needs to be done in that specific patient. We did the same with brain injury. Next slide. And these two main diagnosis where we also achieved being part of the power plant, which seems to be easy, but it took a lot of calls, a lot of emails, a lot of approval and involving the IT. The other thing that we have been doing is we're educating a lot of the acute doctors, the referrals, transplant, trauma, oncologists, neurology, neurosurgery, educated about our field. We have been doing a lot of in-service, educating about our fields, what are the treatment options that we have, what tools we have to help the patient, not just the post-acute care, but also spasticity management, pain, or patients with disordered consciousness or going through bowel and bladder issues in the spinal cord. And nowadays with having so many challenges with insurance, we also have been spending a significant amount of time with acute team training or educating about peer-to-peers. So a lot of the insurance are now requesting peer-to-peers to be done by the acute team. And the acute team were not comfortable doing this and they were not, they don't know what to say, especially transplant team has been, it's a great advocate from the rehab. And we have seen a significant positive outcome with overturning peer denials and also involving family early on the patient's stay to get the transition faster and smoother. So those are the things that we have done to create this program. As core, there is still a lot of room for improvement, but I can say that I'm happy. What we have been able to achieve, not just for this position, but we know there's been call for baclofen pump trials for disordered consciousness of patients that are not even ready to come to rehab, we're getting involved early in their course. Now, yeah, I think I really gave you a brief synopsis of my experience. I think now we can start with the case discussions. All right. So let's move on to the case discussion. We have an incredible group of panelists today and that will talk us through them. So for our brain injury specialists, we have Dr. Shanti Pinto and Dr. Hema Alvarez. Dr. Shanti Pinto completed her medical school at University of Pennsylvania Medical Center where she then completed her internship after. And then after that, she completed Puyamana Residency at UPMC in Pittsburgh, followed by a Brain Injury Medicine Fellowship back at the University of Pennsylvania Medical Center. And she's now an Assistant Professor of Brain Injury Medicine in the Department of PM&R. Dr. Hema Alvarez completed medical school at Ross University, her intern year at New York Hospital, Queens, followed by a PM&R residency at Kingsford Jewish Medical Center. And then a Brain Injury Medicine Fellowship at Carolinas Medical Center. She is now an Assistant Professor in the Department of Rehabilitation at University of Miami. And she's also the Medical Director of the Brain Injury Medicine Fellowship at the Christine A. Winn Rehabilitation Center. For our Spinal Cord Injury Specialists, we have Dr. Lawrence Vogel, who may or may not be here yet, and Dr. Woody Morgan. Dr. Lawrence Vogel was the Medical Director of Spinal Cord Injury Program at the Chicago Shriners Hospital for Children. He was the Chief of Pediatrics and is an active member of the medical staff at Chicago Shriners Hospital. He received his medical degree from the University of Illinois, completed his residency at Yale New Haven Hospital, and subsequently completed a fellowship in Pediatric Infectious Disease at the University of Chicago. He's a diplomat of the American Board of Pediatrics and is certified in Spinal Cord Injury Medicine. Dr. James or Woody Morgan is an Assistant Professor of PM&R at Vanderbilt University Medical Center, who specializes in the care of patients with spinal cord injuries and spinal cord disorders. He graduated with honors from Tulane University School of Medicine and completed his residency and training at Harvard Medical Center, Harvard Medical School, followed by a fellowship in spinal cord injury at Craig Hospital University of Colorado. All right. So starting with some spinal cord injury cases. So I can't get the, I apologize, my full lever to work. Yeah, I like deactivated after activated. All right, so let's use our chat feature. How comfortable are people with SCI? You can just do A, B, and C from top to bottom. A, very comfortable, B, somewhat comfortable, or B, somewhat comfortable, or C, not comfortable. And some. All right, getting some somewhat comfortable. Oh, chat function is still disabled, only Q&A works. Let's put it into the Q&A. We're having a lot of problems up here. We apologize. Q&A, go directly to us anyway, so it's gonna be better. No one has to feel bad. All right, some somewhat comfortable, some very comfortable. All right, and what about, how comfortable are you with spinal cord injury, bladder management? How comfortable are you with spinal cord injury, So a bit of a mix of very and somewhat comfortable. All right. So here's our first case. We have an 18 year old male with no known past medical history who initially presented to the hospital via air rescue following a helmeted motorcycle crash with a GCF of 15. He complained of bilateral lower extremity numbness and loss of motor function. Imaging demonstrated multiple injuries including right two to three rib fractures which were managed non-operatively. Bilateral trace pneumothoraxes and contusions and a T5 to T7 chance fracture with retropulsion into the spinal cord. The patient was stabilized and underwent T4 to 11 limonexine infusion and a T7 transpedicular IV compression. The hospital course was complicated by urosepsis for which he is currently on IV antibiotics and receiving more than three liters of IV fluid a day. He has a Foley catheter in place. His NC exam demonstrated a T5 Aja. You're being consulted for bowel and bladder management. So first, what would you recommend in bladder management for this patient? And again, let's just do ABCD going down. Would you remove the Foley catheter? Recommend PBRS Q8 and a common cath. Removing the Foley and start PBRS Q4 with a straight catheter for volumes of 250 CCs. Remove the Foley catheter when urine output is stabilized at less than three liters a day and start PBRS Q6. Or remove the catheter when urine output is stabilized at less than two liters a day and then start intermittent calcification every four hours. Okay, so we are getting some mixed answers here. We're getting some Bs, Cs, and Ds. And what would you recommend in the bowel management for this patient? Would you do regular bowel care with Colace three times a day, Senna at night with Magic Bullet suppositories and digital stimulation daily? Colace three times a day, Senna every night and no suppositories until finally indicated? Regular bowel care with bulking agents and manual disinfection daily? Or regular bowel care with bulking agents and with Magic Bullet suppositories? Okay, so here we're getting more A's and B's. I wish you guys could see the difference because part of what we want to show here is how people do manage things a little bit differently. Nope, let's go back. Dr. Margit, how would you manage this case on the bladder aspect to go back to them? Yeah, do you want to go back to the case itself, right? Yeah. So I guess the first thing you always want to figure out and you kind of, if you come into the room and you have a patient with spinal cord injury is, you know, one, you're trying to find out the level, which they have here is T5, and then you're trying to figure out is it upper versus lower motor neuron. And really that kind of cut off there, at least classically, has been level anything below T12 and below usually have like lower motor neuron, bowel and bladder, which tends to be more your areflexic, bowel, areflexic bladder. There are some studies that looked at some components, even up to T10, there's some gray area of like T10 to T12. Is there a little bit of gray area? It can have some component of lower motor neuron versus upper motor neuron. So it's not always completely one versus the other, but in general, anything above T10, you'd have more upper motor neuron or reflexic bowel and bladder. So for this patient being above that, being above T10, you'd think they would eventually have some reflexic bowel and bladder management. They could still possibly be in spinal shock this early on where you would still have absence of spinal reflexes. So typically with either, we'll address the bladder first. You know, typically with any patient with complete spinal cord injury, they're not going to be having sensation of their bladder's full. They're not going to be able to voluntarily void bladder. So you're going to have to empty the bladder one way or another, whether it be indwelling Foley catheter or intermittent catheterization. And so this patient you would expect is going to eventually, you know, should have hand function to cat themselves, but it looks like there's a lot of other factors going on. They could have, you know, they haven't gotten up out of bed. They really haven't been trained to mobility and moving around. They could have bracing on that limits their ability to cat themselves. You know, it's got rib fractures, which cause pain. They're also getting IV antibiotics. So they're infusing fluids, both from the antibiotics, but also the high volume of IV fluids that they're getting per day. So you worry about a little bit about how much output and urine the patient's going to be making. Because if you're giving them IV fluid, they're drinking a ton plus they have three liters of IV fluids going in, then they're going to be just making more urine. So for this patient, I would opt for leaving the Foley in place for now. If we can go back to the answers. So out of these options, you guys did an excellent job of putting in some very good distractors, but kind of going from A to B. So removing the Foley catheter and performing PVRs every eight hours with a condom catheter. You could possibly remove the Foley catheter, but if you're doing that in someone with a complete injury with very low likelihood of returning to like spontaneous voiding, probably wouldn't want to do just a condom catheter and checking PVRs. You'd probably remove the Foley and just go straight to intermittent catheterization, probably more frequently on the tune of every four hours when you're starting out. And then really just watching the volumes. You don't have to scan pre or post void. You just go schedule intermittent caths, Q4 hours, watch the volumes with a goal volume of less than 500. So you don't over-distend the bladder. So already A is out. B, right, removing Foley. PVRs, Q4 hours. Again, I think you could scratch out the PVRs if you're doing this. If you're removing the Foley, you would just go straight to intermittent caths or straight caths. And again, you're watching the volumes. Basically you change your frequency based on how much volume you're getting out per cath. And again, you're shooting for cath volumes less than 500. So that one's out just from the PVR standpoint. The bottom two, right, think about more removing catheter when urine output is stabilized, which is beginning to be on the right course, right? So we were talking about there's IV fluids, there's IV antibiotics, dumping a lot of fluid out, or more fluid in, more fluid out. So you don't want to over-distend the bladder because otherwise they'll probably need to be cathing every hour, which you could do. It's just a little, not super feasible, the acute care. So this says remove Foley, urine output less than three liters per minute, and start PVRs. Again, I think your tip off here that that's not ideal is that you're checking PVRs again without just automatically cathing on a schedule. And then the other one is removing the Foley catheter when urine output is stabilized less than two liters per day, and then going straight to your catheter, which what, every four hours, which is what guidelines usually recommend to begin with. So I guess the learning point here is that if people are on getting tons of extra fluids, both from recovering from resuscitation initially from coming in, but also if they're maintained on IV antibiotics or the acute care folks are managing the orthostasis or infection with supplemental IV fluids, it's just better to probably leave the catheter in until their urine output has stabilized, and then consider going straight to intermittent catheterization. Depending on level of injury, now the caveat here, this case, this person has T5 level of injury, and you'd expect intact hand function and ability to cath themselves. But the tricky part is when you run into cervical level injuries, either complete tetraplegia or even central cord syndrome, just limited hand function where the patient's gonna not be able to cath themselves initially. It's, you know, and the team, let's say they're off more cervical injury, they're off all their IV fluids, urine output stabilized, the trick is what do you do at that point? Because then you get into the debate of, you know, the acute care wants to limit catheter associated UTIs, but you don't want to overdose in the bladder and the patient's not gonna be doing it themselves. I would argue, and what I've been taught and what is actually in joint commission is that for some patients, it's recommended to leave an indwelling Foley catheter in place. And some of those diagnoses include spinal cord injury, MS, spina bifida. So oftentimes if folks aren't able to cath themselves, it's just easier to leave the Foley in until getting to rehab until you see a specialist. I think that's the key point there because this patient, it was in the acute side. So there was a lot of issues of the volume that they were getting with every stray cat already. So the reason the level of injury and the reason autonomic dysreflexia and nurses are not really following that. So I discussed it at that time with Dr. Gator and he said, just leave the Foley, keep the Foley, and this is a real case. Getting several calls about, we're doing your program, but it's not working. The volumes are very high, but then realizing he was getting fluids on top of, because of the orthostatic hypotension every time they get him out of bed, plus the infection. But I think that's the difficult conversation you have to have with acute care teams and nursing. Everybody wants to get the Foley out as soon as possible. And it's just hard. I feel like, and that's one of the things with spinal cord injury, and it was joint commission in 2017 that actually said it's okay to leave it a prolonged Foley catheter in, but everyone's very worried about CAUTIs but for folks that are either not going to be on the regimen or still getting tons of fluid, it's better just to leave it in even throughout the inpatient stay until you get to rehab. I mean, often we get folks that have been cathing or being cathed by nursing and they come to rehab and then I'm like, there's no way this person's going to be cathing themselves. And we put the Foley in day one. And so we can get bowels under control, get them in the system, figure out their orthostatics, get their pain under control, just get them in the program for at least a week or two. And then we start addressing the bladder a little bit better. And what about bowel management for this patient? Good question. So traditionally it's been, A has been, I'll start right off the bat though, regular bowel care, kind of starting with that three, two, one regimen of Coley three times a day, SENA maybe two tabs at night and then one suppository daily, augmenting that with digital stimulation to be performed kind of at the same time every day. Typically it's after a meal. We typically do it in the morning times, but it can be done in the evening and you try to take advantage of some of those reflexes. So there's kind of that gastrocolic reflex that's happens after you eat, where you have food in the stomach, stomach distends and stimulates the bowels to move a little bit, try to take advantage of some of those spinal reflexes there. There's debate on if Coley is effective or not. There's actually some articles in the Journal of Hospital Medicine about things we do for no reason. And it talks about Coley's for constipation. So probably Coley's alone for constipation doesn't do much, but a lot of times, a lot of providers I've worked with and talked to, they use Coley's more for a stool consistency aspect, not necessarily as a pro motility agent by any means, but you have to basically a fat surfactant and it surrounds the fat, emulsifies that, allows water to get drawn into the bowels to hopefully soften the stool consistency so it passes easier. So you actually do have to have a little bit of a fattier meal anyway. A lot of times, and I've switched over to using more Miralax once a day instead of the Coley's three times a day. So you can do Miralax at lunch. Senna is your pro motility agent, which helps. And ideally we're timing that with neurogenic bowel. So you do maybe 12 hours before your bowel program, you give Senna. So Senna at nighttime, bowel program in the morning time, and then suppository morning or during your bowel program it's followed by DigStim to kind of evacuate those stools. Thank you. I don't know if there's any other questions or chats. Let's see questions. I can go through the wrong answers there if it's helpful or the less ideal options, I should say. Exactly. Okay. So next case. I think it's time. Oh, there's a question. No, no, no. There you go. Oh no, next case. All right. So here you have a 59 year old male with no significant past medical history who was working out in the gym when he experienced a severe back pain associated with severe weakness of both lower extremities as well as bowel and bladder incontinence. MRI of the spine demonstrated L4 massive permeated disc prevertebral edema and compression of the conic aquina. Neurosurgery treated him surgically. Now you're being consulted for bowel management. It's so slow. What would you do in this case for bowel management? I believe the options are the exact same. So again, let's stick, maybe let's stick to the Q&A so that people don't have to feel nervous about it. Thank you. Oh, sorry. Back to the options Thank you for listening. All right, Dr. Moran, what are you saying? Yeah, it sounds like you guys are on the right track. Definitely, you gotta do some regular form of bowel program. And typically, with this level of injury, right, this looks like L4. I don't know if he's complete or incomplete here, but it sounds like he's having some issues, this patient's having some issues with their bowel management and you would think more with the herniated disc and the lumbar region that you're hitting, you know, the cataeclina there, so you're getting more of that lower motor neuron, areflexic bowel. And you can do some things to test on exam outside of just your, you know, the INSKEY exam of deep anal pressure and voluntary anal contraction, but checking for some of those sacral reflexes. Sometimes we check for anal wink, which is the anal rectal reflex, which you can actually do while you're testing for pinprick sensation. And then also bubble cavernosis reflex as well, that can just let you know if some of those sacral reflexes are present or not. If they're absent, you're thinking more that this is a areflexic bowel or lower motor neuron bowel. And for that, yeah, it changes drastically what you do and you kind of tend towards trying to go more on the constipating side of things, which you use your bulking agents, like fiber agents, dietary changes, and then more of the manual disinfection performed daily, if not multiple times a day to try to get that stool out. Because the suppositories, the suppositories are usually less effective is that they're about irritant. And so that's taking, it takes advantage of some of those reflexes. So if you are areflexic bowel, you're not gonna have any of those bowel reflexes. In theory, the suppository shouldn't work. I've actually tried to see if they work. Sometimes they do, some patients say they work okay. I've actually leaned more towards the mini enemas, like enemies or enemies plus. Those are kind of our mini enemas that we have available. Again, those are more, it's a liquid packet and it is able to be inserted into the rectum and you kind of squeeze the packet. And some of that I think helps with actual more like mechanical flushing of the stool out rather than activating the bowel reflexes. So that's another option that could possibly try to help some of that out there. But yeah, the answer here would be bulking agents and manual disinfection, at least daily. And there's a question about lidocaine jelly. I'm not sure if that was for, you can use it for both intermittent catheterization and bowel program for ditched stem or disinfection. Typically you can use lidocaine jelly. If it's, you know, people have for cathing, you can use it and just kind of use that instead of, or in addition to lubrication. If people are having some autonomic dysreflexia from the catheter passing in, or if it's just uncomfortable for people, they still have some sensation. You can try to use it for bowel program for ditched stem. If there's autonomic dysreflexia to try to decrease the amount of noxious stimuli. There's some debate, you know, some people say maybe bowel program takes longer if you're using the lidocaine jelly, but certainly worth a shot, I think. There's a question that says lidocaine jelly is often advocated to minimize autonomic dysreflexia and complete injury. Is that true? Yes, yes. That's kind of what I was alluding to. Yeah, lidocaine. Yeah. But so it depends on if, you know, if the patient is experiencing autonomic dysreflexia during cathing or during bowel program, not everybody does, but certainly if they're symptomatic during that and they're having flushing and diaphoresis and all the classic symptoms of AD, then you could certainly try that. Hi, I'm sorry. I'm a little late joining, apologize. I would, the interesting about lidocaine, one thing also is that you got to give some time to it. You know, it's kind of like, you know, you should wait five or 10 minutes. Obviously, if somebody has severe AD, then of course it's hard to wait, but if somebody is not having AD, then, and you're worried about initiating AD either with a bowel program or with cathing, then you probably need to give five or 10 minutes. I was going to say for lower motor neuron things, only other thing I would think about, and again, this may be more chronic than acute would be things like a pyristine, you know, so irrigation, but acutely that would probably, acutely probably would, you know, I think this disinfection would be the key, maybe some like a, you know, a water enema, some kind of a regular enema, which I'm not really favorable for, but I would just think that at least for lower motor neuron lesions, you would think about using a pyristine as time went on, but a little more neuron lesions would typically not be, hopefully not be much risk of having AD just in general, especially not somebody like in this case, there's a, you know, a quadracline or a conus injury, that would be very unlikely they would have dysreflexia, so lidocaine would not be something I would be using. Yeah, I think transanal, that's a good point. I mean, transanal irrigation can be super helpful, especially if you're getting to the point where, you know, they're doing bowel, for someone with low motor neuron is doing bowel program in the morning, they're still having accidents in therapy or during the day or having to do it, you know, two, three times a day, where it's just, you know, very difficult to even leave the house, something you'd want to refer to or discuss with them to do transanal irrigation, which can irrigate more of the colon than just a mini enema or manual disinfection can kind of get some meds to well, so. And there's been some really good results with that. Nice, thank you. So let's move on to the next case. I think it's the last one that, for spinal cord injury, then you guys are off the hook. So here you have a 23 year old male with no significant past medical history who presented as an unrestrained driver in a motor vehicle collision. DTC spine demonstrated C6 to 7 tear duct fracture with severe bony retrofusion and bilateral jumps facets. He underwent C5 to 7 ACDF and he was found to be a C5 AJA. He is now presenting with neurogenic orthostatic hypotension, neurogenic bowel and neurogenic bladder. He also has a stage four pressure injury in the sacral area currently being managed with a wound vac. You're being consulted for wound care recommendations and IRF candidacy. What would you recommend for this patient? A wound care consult, nutrition optimization, turn patient over two hours and keep area clean and dry. And they're not a candidate for IRF due to the current sitting precautions. B, wound care consult, nutrition optimization, turning patient over two hours, keep the area clean and cushioned mapping while out of bed. But he is a candidate for IRF. C, insert a Foley and a rectal tube to keep the area clean. Or D, surgical consult for evaluation of a sacral. Thank you. This is a topic, a controversial topic. Yes, I was going to say this is a tough question. I don't think there is a specific right answer here, but how will you manage this case, Dr. Morgan and Dr. Bogle? And just before they answer, so we're getting a mixed answer. We're getting B's and A's right now. So you said B's and A's? B as in boy and A as in man. So yeah, the first two, we were having some technical difficulties. So we went to A, B, C, D, and E for these. Sorry. Okay, well, I'll tell you, I would elect the first one, because again, unless you go to a shriners hospital or some place that doesn't care about insurance, it's a problem because, trying to get intensive inpatient rehab with a great stage four pressure injury is next to impossible. So, I mean, that would be, obviously A would be correct. Ideally, the patient needs a medical bed to take care of the pressure injury to try to get that sound. I guess as an alternative, if time or finances become an issue, the other issue would be to bring somebody in and try to pressure map them and put them up for an hour here and there progressively and see how the pressure injury goes. If it gets better, good. If it stays the same, good luck. If it gets worse, you know very well what to do. You just can't continue making the ulcer worse. So that's, I mean, I know A is the right answer, unfortunately, unless you're in a situation where you can bring them someplace and put them on a quote, unquote, a medical bed, take care of the pressure injury, but yet provide the expertise that the inpatient rehab people provide, therapists, nurses, everybody else, social workers, psychologists, on and on. Yeah, I would tend to agree that if you have a stage four pressure injury, you gotta communicate with the, usually the surgery team or the plastic surgery team who's managing that, but usually they're gonna have some sort of their sitting restrictions and it's just not typically compatible with a full course of inpatient rehab. They're not able to participate in the full program. I think we all have some soft spots for our patients and you wanna give them the rehab and the care they need. And I feel like we should probably care for their spinal cord comorbidities better at rehab than some LTACs that some people go to or skilled nursing facilities. So I always hate that alternative unless there's a specialty center that provides good care, but that's not always the case. They don't totally understand a spinal cord injury and brain injury like we are trained. So sometimes I wanted, in this case too, it's a C5 injury. Their patient's probably gonna need some help after they leave. So yeah, the flip side is, do you get them in? Do you get them out of bed? Do you get them the right equipment? Do you get them to bowel and bladder program, teach them and the family kind of how to manage that and then either get them home or to the subacute rehab from there? Yeah, it's a hard one to answer. And I guess you just discuss pros and cons with the patient and family and probably the liaisons at the hospital to figure out would they be even, would you even be able to do some sort of augmented therapy schedule? Because you could probably also, there's the three and what is it? The one and a half hours over seven days is the augmented therapy schedule. So maybe you're getting seven days of therapy, but just fewer hours during those days during your patient rehab. 15 hours and seven days. Yeah, and this is what I meant in the beginning how it can change the same diagnosis, different family dynamic and financial could be different recommendations. That it's as having the ability to admit patients from home, from LTAC, from skilled nursing. Sometimes you want that wound to heal first in whatever this other alternative. And when the wound is healed, bring the patient to the rehab so the patient can really be able to take advantage of their rehab days. But in other circumstances, the family wants to take it home. They don't want it in another facility, then you, in that situation, family wants to train a bowel bladder, wants to train a wound care equipment, send the patient home, that wound heals, bring the patient back from home to acute rehab. So depending on what are your social, your dyspho and your vulnerabilities and limitations with therapy, then you're gonna change your recommendation or what's the most appropriate post-acute care at that time. Awesome. Thank you. I think that's it for spinal cord injury. Thank you so much, Dr. Morgan, Dr. Vogel. Sorry I was late. Thank you. Very good. We're happy to have you. Moving on to some brain injury cases. So first again, let's use the Q and A so no one has to be nervous. Anybody can see. How comfortable are you in the management of PSH? A, very comfortable. B, somewhat comfortable. D, somewhat comfortable. C, not comfortable. A's and B's. Awesome. And what about, how about management of agitation and TBI? And TBI's, yes. A's and B's. Awesome. And what about, how about management of agitation? Yes. Awesome. And what about disorders of consciousness? C's. A lot of C's. A's and F's. Periodic B. All right. Awesome. Thank you for answering. All right. All right. Let's start with our first case. So here we have a 26 year old female with an unknown past medical history who was involved in a motor vehicle collision where she required extraction out of a car after a prolonged attempt. Her initial GCS was three. She was intubated immediately on arrival. Hand scan was negative for traumatic findings except for bilateral frontal traumatic subarachnoid, bifrontal contusions, and a highly comminuted nasal bone fracture that was seen on the CT. As she was admitted to the neurosurgical ICU for hemodynamic and neurologic monitoring, no acute surgical intervention was performed. And the hospital course was complicated by persistent fever, tachycardia, restlessness, and irritability for which workup was negative for infectious etiology, DVT, and PD. Just to start, how would you recommend management of the fever in this patient? A, start empiric antibiotics. B, repeat the infectious workup and start Tylenol around the clock. C, consider PSHS etiology and trial it with Bromo. Or D, start Lovenox and therapeutic dose due to high risk of a PD. Therapeutic dose due to high risk of a PD. All right, we're getting mostly C's and B's. That's one B. One B. Go back. Go back. We'll start with this session and that case in the meanwhile. Yeah. Dr. Pinto and Dr. Alvarez, how would you approach this case? Yes. So the one big thing to look at, we could go back actually to the slide with the case on it. So the good thing is, is that they have actually done an infectious workup and a VTE workup. Because as you can imagine, a lot of these symptoms kind of mimic those underlying conditions. And it's interesting that at least in some of the places that I've worked, you see a lot of times that patient has a fever, had a brain injury. And then maybe some of the teams immediately go to, oh, this is storming, is what it's colloquially called, a paroxysmal sympathetic hyperactivity. And so a lot of times I spend time trying to, you know, encourage people to work up the symptoms. But since they've done that entire workup, it's really important to kind of think that this is potentially the diagnosis and start appropriate treatment. Bromocryptin is one great medication. I personally like to go with a multifaceted approach to it. And so bromocryptin can help with arousal. So as long as they're not on sedation is one that I will go there. To help with the tachycardia and the hypertension, I typically will add some propranolol, which I personally schedule at Q6. So every six hours, just so you don't have that weird overnight hold when most hospitals like to try to do the three or four times a day medications, not after nine or 10 and then not again until 8 a.m. And then you see the fever curve and everything get a little worse around like six. And then if, you know, if they have any spasticity, dantrolane is a great option. And some gabapentin is also a really good option to help with some of the alidinia. So that's my typical approach is try to treat it with a multifaceted approach for PSH. Dr. Alvarez, how are you? Hi, how are you? So, you know, my take to echo Dr. Pinto, I think that this, when we're treating paroxysmal sympathetic hyperactivity, or we typically call it storming, you know, like there's not like a one thing fix all. I think we have to try different things, not only with the pharmacology, but another thing that I always like to address is what are the environmental elements with the patient, which sometimes is very difficult to be able to control in the acute setting. But, you know, like thinking about, you know, how is that cervical collar? Does the patient have an NG tube? Are we addressing pain? I agree with Dr. Pinto, you know, gabapentin is a great alternative for that. Obviously, in this case, we're discussing about fever. Embromol, it's a great medication for both aerosolability and also to deliver persistent fevers, but it's important to also know, you know, what is the LFDS of the patient? What are the labs of the patients when started? Because it's a medication that we have to be sometimes cautious, but a great way to kind of do it. I use as well also propranolol. I like the idea of the Q6. One of the things that I find is like I always try to put what are my parameters with this medications because sometimes they tend to hold it. So I typically put 100 over 60 with a heart rate less than 60 so they still give the medication, and it will help also with the fact that the patient has irritability and restlessness. So I think that's for that reason. I think the propranolol will be a great medication in this case. Another thing that going back again on the environmental aspect, you know, when patients are going through the process of storming, it's a very hypercatabolic event. So if the patient has any access regarding an NG tube or a PEG tube, this is a good opportunity to discuss with nursing how much water are they providing to the patient. Sometimes these patients are just dehydrated and the whole nutritional aspect is not well managed. So I think it's important to kind of address those things. And another great approach is pain. You know, when they do this fast, and they're so complicated, this patient came in as a Glasgow of three, you know, like they trying to make sure that everything is okay, the neurological aspect, does the patient has on a cold fracture. It's important to kind of know on exam if there's something else that needed to be addressed that may be a trigger, right, for this condition. Yeah, and to echo, it's a great point about the environmental factors and some of the bracing, too. So when we get them into rehab or they're a little bit further out, sometimes, you know, they have a lot of spasticity or contractures and you want to start doing things like serial casting. And those are patients that I always tell the therapist is like they need to make them bivalves, we need to be able to take them off for that reason. And I've also found some people that have that have come, you know, and they just say, oh, they're storming, they're having PSH, the workup's been negative. All of a sudden, you start when you do a really good skin assessment, you find some like really interesting skin breakdown underneath some of the medical devices like trachs and stuff. And once you get that addressed, then the symptoms actually go down. So it's again, the biggest thing I always educate the primary teams on is that this is a diagnosis of exclusion. So everything needs to be ruled out. And another one that we see a lot of is alcohol withdrawal really mimics this. Other than the fever, you see all of these symptoms with alcohol withdrawal, and that has to be treated very differently because that's life threatening. Question. If you decide to use bromopretein, do you usually put it three times a day? What if you're going to start it daily? I mean, you're going to start it as a neurostimulant. I see commonly seen neurointensive is putting really high doses of bromo three times a day to treat PSH for fever. I personally go in the morning and at noon and I start with just point five. Yeah. And I do it because part of it, too, is that my concern is that we do it three times a day. You disrupt their sleep wake cycles and that sometimes kind of makes it worse. And that's where, you know, sometimes I'll actually give them a decent dose of gabapentin at bedtime because I don't care about sedating them at night. It'll also calm this. You can always think about just giving them some scheduled, you know, scheduled benzos, which we usually don't like or scheduled like oxycodone or something, especially if you think pain is going to help kind of dampen down some of those those symptoms, but not disrupt their sleep wake cycle. What I have to say is, like, I think every brain injury doctor and I know that Dr. Pinto will agree with me on this. It is like the rule of go low, slow, but go, you know, like I wouldn't put a high dose of bromo in a patient. So typically, I mean, I can be a I'm a little bit conservative. So sometimes I start two point five BID and then if it's up, then I go to five and then go to 10, depending on on on the case. So I think that's something to to be very considerate. Dr. Pinto mentions about gabapentin. I love gabapentin. It's one of those medications that it really helps me a lot with the patients and also help with the sleep. You know, this is a question of a case that you have, like the duality of the storming, but you have a patient that is also agitated. Right. So making sure that that patient is sleeping is key for it to improve those symptoms as well. We do have one question. I don't know if it's kind of answerable, but it says, I'm curious how many people use bromo protein. I really don't use it often. I, you know, I think in this case, it's just because we're talking about fever, you know, and I think that's why why probably it's used. I mean, it is a can be also a dirty drug. So you just have to be used with caution. Yeah, I agree. I only, for the most part, use bromo cryptane for people that are storming and once they're kind of past that, then I switch them over to amantadine. I usually don't use bromo cryptane and amantadine at the same time because they're very similar and both kind of dirty and I get a lot more side effects with it. But bromo cryptane, I don't try to use it long term unless it's storming. It's very expensive as an outpatient for unknown reasons why it's still an expensive medication. And you can get a lot of like long term concerns with like cardiac valve issues or, you know, and I've also seen people get, especially if they have low ejection fractions, I can see people get really orthostatic with it. So it's not my, it's not my favorite for a long term medication. Great. And our next question for the audience members to start, how do you monitor your response and treatment for PSH? You ask the nurse, A, ask the nurse about patient's clinical status. B, use the clinical features scale and diagnosis likelihood tool. C, you ask family members if the patient's better, or do you use the coma recovery scale or bias? I like the A, N, B, and C. Yeah, we can talk about it. What do you guys use at your institution? A, E, and D. A mix of all. I mean, I mean, I don't, I don't, I don't know that we use the, this is also a multivoter, you need to ask the nurse, you have to review. I'm so sorry, I'm like, if you don't move here, the lights go off. All right, there you go. You know, like, for the clinical feature scale, it's basically talking about, you know, measuring how high is the blood pressure, how high is the pulse, and it's, it has a good utility. You know, the way I kind of match is looking at the chart, looking at how the vitals are, what is documented, and looking at the patient record itself. Not that we're using those scales, but I think that they have a great utility. No doubt about that. Yeah, I agree. I, for the most part, don't use any of the scales, but what I'll do, especially if your electronic medical record is able to do this, is I like to graph out the vitals, and I'll graph out the systolic blood pressure, the fever, and the heart rate. And that's kind of how I look at it. I'll look back at, like, one medication's resorted and adjusted, and just kind of see the trend. And that's also how I've, you know, been able to pick up on, like, oh, maybe we just need to retime medications, because they're every day, like, having this spike around this point in time, where you're seeing all three of them go up. And then it's just like, oh, they're getting their next medication, you know, in an hour or two, and that's when it's like, well, maybe we just need to retime it. So that's how I typically go. The interesting thing I will say with the coma recovery scale, and that'll be another slide kind of going into the disorders of consciousness, but these patients, I honestly will tell you that every time I've seen these patients where they're storming pretty bad, and then we get their storming under control, they honestly start waking up a little bit more. So that actually, to me, is also something that you can do. It's not going to tell you about the PSH, but it's going to tell you about the underlying pathophysiology of the brain is improving to the point that now they're starting to be, you know, more awake and overall recovering better too. Awesome. Thank you. Thank you. And then what would you recommend regards to agitation management of this patient? A, order restraint and start Haldol PRN? B, consider pain as a trigger of agitation and start Tylenol around the clock? C, trial with propranolol to address PSH and agitation? Or D, decrease overstimulation, treat pain, and PSH? I didn't put the gavopanti option. D, gavopanti. Or E, right? We're getting C's and D's. What do you guys say? What would you add? You already elaborated on this part at the beginning. Anything else you will add on the management? I think the only thing that I will add is the concept of the importance of actually scheduled medication. You know, there has been study that, you know, pain in the brain injury population is very underreported, right? They're unable truly to tell you that they're hurting. So it's very important to consider scheduling a medication because the patient won't ask. The family member is unable to identify what are the triggers. So typically, once they're with me, you know, I tend to schedule medication before therapy, so that way we get a better performance of the patient. But, you know, in the consult component, it's important to consider that, that those medications that we're going to use for pain management are scheduled rather than being in a PRN status. Yeah, I agree. The one thing too is that I always, I always tell the residents, like if anybody calls you and tells you the patient is agitated, the very first thing you should ask is what are they doing? Because it seems like in the description of this case, the patient was more restless than truly like agitated. There was no signs of actual aggression. A lot of times what I'll ask the staff is like what's going on around the times that they have it, you know, sometimes, depending on how your hospital is set up, our hospital, which is great, is that you can stand outside the room and you can like change the So you can stand outside the room and look in and see what's going on in the room before you go in. And that actually sometimes to me, it's like, you look at the patient, they're completely calm or, you know, and then people come into the room and that's what really triggers them. So it's just kind of trying to get more information about that. Propranolol is the one that's got the best evidence for agitation, but, you know, gabapentin can help, especially I find for some of my alcohol, alcoholics tends to help with the GABA and NERGIC. And then if it is true agitation that it needs to be addressed, you know, as long as their LFTs are okay, Depakote's a really good option too. Yeah, especially if they're still on Keppra. Keppra tends to make people agitated too. So it's one that if they're still on their Keppra and it's past seven days and they haven't seized, it's a good one to get off. But if they need a AED long term, getting moving them to Depakote, if the LFTs are abnormal, I really like Triloptil too. So, you know, to try to kind of get that going. Yeah, I agree with that with the agitation. The only thing on Depakote that I say, because it's actually one of my faves, it's like if the patient has a hemicraniectomy, I'm a little bit more hesitant to start, even if it is temporary, yes, but some of my surgeons are a little bit tricky when they want to put the cranioplasty because they can have a little bit of platelet dysfunction with Depakote. Very hardly seen, but it's one of those things that if it happens once, they're like scarred forever. So I try to think about whenever I have a hemicraniectomy patient regarding the Depakote, but definitely there's many ways, you know, like one of the difficult things about brain injury is like a lot of our stuff is anecdotal. We have some of the things it's limited regarding what is the best approach, but definitely Moose Stabilizer is another alternative to work with agitation, not only from the, you know, anti-epileptics, but also considering SSRIs as well. All right. Let's move on to our second brain injury case. So here we have an 18 year old female who was involved in a motor vehicle collision. She was found ejected from the car with a GCS of 6. She was airlifted to the hospital and upon arrival found to have a GCS of 3 requiring immediate intubation. The trauma protocol CT revealed a traumatic subarachnoid, a left frontal subdural multifocal contusions, pumping hemorrhages concerning for DAI as well as significant IVH with hydrocephalus requiring emergent EDT placement and a trauma ED. She also sustained her right superior pubic brain was fractured. Once she was stabilized, she was extubated and sedation was deemed. You're being consulted for evaluation of disordered consciousness. Based on your evaluation, patient is in a minimal conscious state minus. What would you recommend in regards to nerve stimulant and DOC? A, start trial with imantadine, 100 BID. B, start with melatonin, QHS. C, roll out seizures and hydrocephalus and if stable, consider imantadine at AM and noon. And then D, consider trial of Ambien. C's, C's, B's. How will you approach this case, Dr. Alvarez? You know, I have to say that if it's on regards of the question, you know, like we have to say that if we definitely for sure know that the patient is still in a disorder of consciousness, we know that the drug that has been studied the most is imantadine, so that always will be like my choice to try to wake up the patient. In addition to that, if the patient is stable enough, I still would want an MRI, just because although, you know, it says that the imaging here is the CT and it has all this information, but, you know, imaging may matter to identify if there's diffuse laminar necrosis on this patient that potentially can give us more of that comatose, you know, picture and, you know, really diagnose the diffuse axonal injury on the patient. My drug of choice will always be imantadine. Nonetheless, I will always kind of look when the consulting components, if there's any signs of a cold seizures or a cold something that is, you know, impeding for this patient to kind of wake up. I'm looking at the question. I mean, it's, I think it's valuable again, when we see this patient that we have to do that multimodal approach, you know, like you have to attack this patient from every single angle is this patient sleeping, not sleeping? It's the, what are those elements? Because sometimes we do the evaluation and you go and talk to the family, talk to everybody kind of around it to see if there has been any signs. And it's important to do a very proper exam to avoid misdiagnosis on this patients. Dr. Pinto. Yeah, and I agree. The thing that I, so the MRI, the one thing I will say is that none of the imaging, at least that we have available clinically has been really shown to be predictive of outcomes. But the nice thing about an MRI is at least we can look at it and see where the DAI is, the diffuse axonal injury. And part of the problem with doing the exam, especially like a coma recovery scale is if they have clear motor deficits in some area, like some motor tracks or any of that's out, you're gonna, it's gonna impair your examination. So it's gonna make it a little bit harder. But from kind of the treatment options, definitely imantadine has been the one that's studied the most. It's the only one in a randomized clinical trial that's been shown benefit. The other big thing that's not on here is that I do a pretty good review of medications because I have had so many patients that we're told is a disorders of consciousness patient. And then you look and you find a lot of sedating medications on them. And then you try to figure out like, you know, why, you know, especially if you find antipsychotics on some of these patients, like what exactly are they doing? So then that makes me think they're actually doing more that, you know, it's there. So it's really good to also try to take off all the sedating medications if possible. One of the things that I tell the residents is I live in the MAR. I live in that medication component because, you know, they do get some medications that can be contributing to the fact that the patients are not waking up. And, you know, avoiding all of those things is important. And again, I think I can not, in this case, this case particularly is minimal conscious state, but in somebody who is in apparently a majority state and you are working with the component, if they're transitional or emergent, then I think it's important to do a proper examination and review the medications to optimize as much as possible. I have to say that I commonly see Kebra significantly affecting a patient's ability to engage with environment and that affecting also their participation with therapy. And that automatically recommendation is by therapist it's still nursing facility because the patient is like drunk, like they are sitting at the edge of the bed without being able to walk. And it's very common seeing patients with Kebra. So that's a very, very valid point, reviewing medications and seeing, you know, we may be causing the whole thing. Yeah, and it's also, even when you see them before the seven days out, I always on the Kebra, I look for making sure they have an end date on it. They're really good about it in our hospital that I'm currently at, because I think it's part of their just order set for TBI. But my last hospital, they never put an order, like the end date. And so you always had to like let them know, like, please make sure this is the date for it. The one thing that wasn't discussed was the Ambien and I will just kind of, yeah, I'll just put a big thing with the Ambien is that I have done Ambien trials on patients that are a bit further out and they're stable and not making any progress. And the big reason why I don't usually go to it too early is because the studies of Ambien did not show any difference than placebo. But, you know, if I would admit them to inpatient rehab, I'm able to better monitor and see the environment. And what I usually would do is do a sleep log before starting Ambien and then a sleep log after, or while they're on an Ambien and kind of look that way and do it at night, just because I figure if I make them sedated, I'm not impairing my therapy during the day. But when they're in acute care, what I've done is I've, you know, we've done our own, gone, done our coma recovery scale. And I usually time it around eight o'clock because I don't want to do it at nursing shift change, but I'll time it at eight o'clock and then we'll go every hour for four hours and do our own coma recovery scale. And it's a good one for some of the patients that aren't making progress. Again, no difference than placebo, but 5% of people did have some improvement, which was the same as placebo. So you might consider that as a next option. What dose do you use for the Ambien trial? I'll go with five. And if I don't see any difference, then I'll do the 10 milligrams. If they are sedated with the five, then I know that they are not, they're going to have the typical response, but if they don't make any response, which is a little weird, then I'll go with the 10 milligram. I've been doing it here with the neurologist and with 10 milligrams, one dose. The neurologist are very aggressive. But yes, that's how they do it. And it's usually they try it after they, we have tried everything and nothing works. So we give it a one shot at noon when they're not supposed to be taking a nap. So we'll see, and we do that the same, the recovery scale prior and then afterwards, at least one hour after the medication administration. You made it. We made it. Any other questions from the audience or anything else from the panelists? Thank you very much for the positive feedback we're getting on the message and chat. Thank you very much to all the panelists and thank you for all the attendees for joining us. Thank you. Thank you. Dr. Pinto, we need to change numbers. Oh, yes. Yes, I think Dr. Valbuena has my cell phone number so she can give it to me. Yes, all cell phone numbers. Thank you so much. The main purpose was to make it interactive. I want to take advantage of this opportunity to invite you guys that was going attending to the AAPMNR. We're going to be having an open discussion of the common issues that we have as a consultant, including peer to peer challenges, who is a candidate, who is not a candidate, and sharing if you want to bring guidelines from your institution. And I'm very curious to know how sick, how many, it's getting to the point that we're pushed to get so sick patients because insurance are pretty much denying everyone. So I curious to know how you've been dealing with that issues, how your institution is adapting to this new era of the rehab. And it's, as I said, it's an open discussion. So it's on the 20th at 8 in the morning. 8 a.m. A little early, it's a little early, but I hope to see you guys there as a weekend meeting person. Absolutely. Thank you for the opportunity. Yep, thank you. Okay, if we don't have more questions, I think we'll finish the meeting here. Have a good weekend. Thank you. Thank you. Bye.

inpatient consultation

spinal cord injury

bladder management

bowel management

Foley catheters

lidocaine jelly

transanal irrigation

paroxysmal sympathetic hyperactivity

minimal conscious state

amantadine

multimodal approach