Awesome. Thank you, Hassan, for this great introduction. Hello, everybody, and welcome to my talk. I really appreciate the attendees that were able to make it. Again, I would say the shift of the paradigm, but I think all the acute level one trauma care centers appreciate the role of physiatry more as we evolve in our profession and become the cheerleader. With that said, I will share with you my screen and we'll start talking. Again, remember that this talk, I might kind of throw questions. Hassan kindly will take care of monitoring the chat panel, and whoever answers the most will send them a $100 gift card. So, I mean, you can't ask for more, right? Alrighty. So, basically, we're going to go through a case-based presentation. The objectives would be to recognize the role of early physiatry involvement in acute trauma care on acute spinal cord injury, and that's the first part of it. The second part would be a brain injury rehab role in the intensive care unit. These are case-based approaches. Both of them are real cases, and the third one also would be real. Hopefully, the time will allow us to go through the three cases, spinal cord, brain injury, and then to the palliative care delivery. I will start first with the first case. It kind of gives you a hint, as well as urinary incontinence. Before that, she was pretty independent with her activities of daily living, and can you folks hear me or not? Yes, so far, it just froze for a minute, but so far it's okay. I apologize. Is everyone still there? I think we're having some slight technical issues. I apologize. Sandra, can you hear us? Can you hear me? At the moment, yeah. I think it froze for another moment. OK, no worries. I mean, once you don't hear me, just give me a buzz and I'll check my emails. OK, perfect. So OK, so it kind of gives you a hint of weakness in the arms more than in the legs. Urinary incontinence. She was pretty independent beforehand. So we'll go from there. Now, this is her MRI findings. And physical exam showed decreased fine motor control of her hands with a positive Huffman sign, which indicates an upper motor neuron lesion. Her MRI showed central cord syndrome. Now, I'm going to throw it to the chat panel. What does the image on your left side indicate? There is a certain word for that. Neuroradiologists like to ask physiatry when they do their neuroradiology rotation. The image on the left, is it called the owl eye sign or the snake eye sign or something I am not sure about? You can throw your answer in the chat panel. Don't be shy, anyone. Yeah. You can either type that out or say it. Amelia says snake eyes. OK, that's the snake eye sign. Perfect, you nailed it. So the patient underwent surgical intervention of her cervical spine. And then physiatry was called. So we went, OK, you have a spinal cord injury patient, can you see the patient for rehab requisitions and making sure that we get her sooner to the rehab unit? I'm like, yeah, sure. So of course, what do you want to know more? You need to know more history about what do they mean by hand weakness, urinary incontinence, what's the post-void residuals, where are the bowel movements, are we doing turns around to prevent pressure-related injuries or pressure ulcers, what's her mental status, sleep-wake cycle, the whole meal deal that we physiatry do. We also do the expedited Asia exam most of the time in the ICU level because it's kind of hard to do the full meal deal when they are immediately post-op. Again, it really depends on your institution and what you end up doing. But the expedited Asia exam is something I used to do in the trauma bay when I call immediately, as well as immediately post-op. Basically, what's the expedited Asia exam or the INSCE exam? It's used to determine the neurological level of injury. It gets you the Asia exam or the Asia impairment scale within the minimal number of steps compared to the full Asia exam. So when you do a full Asia exam, I was trained to do it all in 10 to 15 minutes, including the motor, the sensory, the deep anal pressure, the voluntary anal contraction, and the whole meal deal. With the expedited Asia exam, it takes you probably three minutes to do it. And we'll get to the details why it's way shorter and it's more convenient. It also helps in early prediction for a full Asia exam post-surgical intervention. Don't forget that when you do the deep anal pressure and the voluntary anal contracture, that's where your money is. And then that would tell you how you would proceed with. How to do the expedited Asia or the INSCE? The sensory part, you've got to go where the money is. So one side of the body, start from the head, test one sensory modality, which is the pinprick in a descending fashion, through the dermatomes until an abnormal sensation is recorded. If the injury level is already known or suspected, it could be possible to start the rostral end of the sensory exam. Two or three dermatomes rostral to the suspected neurological level of injury. So you're basically cutting to the chase where you tell the patient what's the last level where you feel the sensation is. And they would tell you probably around the umbilicus or T10. So you've got to do three dermatomes above, three dermatomes below. But if you start from scratch, I wouldn't mind going quickly through the whole spell of the dermatomes. But again, this is the expedited, so it makes your life easy. Once an abnormal level is found, you check the same sensation on the contralateral side of the body and the others as yet untested sensory modality. So you do also the light touch on both sides of the body sufficiently enough to identify the most caudal intact dermatomes. The motor part, once the sensory level is determined, test the key muscles at the level corresponding to the sensory level. So for example, if they tell you, oh, I feel around the umbilicus and that's it, you know their arms are OK. So you've got to start through your lower extremity and do the full spilloflexion, knee extension, dorsi planta, and extensor house as long as. Again, in our case today, because she's presented with central cord syndrome around the neck, you know that you are obligated to do both upper and lower extremity. So kind of put your examination almost similar to the ASIA, depending on the level of injury. That's what the next point explains. Testing of the upper limb muscles may likely be omitted when the sensory level is between T4 and L1. But testing should not be skipped if there is a complaint of upper extremity motor neuropathology. Again, sacral sparing, that's where the money is. Testing S4, S5 bilaterally for light touch at pinprick. Deep anal pressure, where again, you tell them, I'm going to insert my finger around your bum area in a very nice way and tell me whether I'm pointing upward and downward. There is a certain communication skills that comes with it. And basically, throughout your training, you kind of learn with your population how to convey that message. Of course, with voluntary anal contraction, you always tell them, I'm going to ask you to squeeze, and I'm going to ask you to squeeze, so squeeze it as you're holding a poop, not pooping. Because they're going to poop on you. Determination of the ASIA exam. Again, the steps and classification have not been any different than the normal ASIA exam. It's basically making sure that your test is short, shorter than the full ASIA exam. However, meeting the main recommendations in assessing the level of injury. So you determine the sensory level, and then you determine the motor level, which is the most caudal normal, both in sensory and motor. And then you determine the neurological level of injury, which is the most caudal segment with intact sensory in three or more of the motor exam. And then you determine the level of, or the completeness of the injury through the deep anal pressure, voluntary anal contraction, and the sacral sparing. And then you say if it's ASIA A versus ASIA B, C, or D. Again, this is not an ASIA exam session per se, but it's kind of give you an idea that the path or the thinking path is similar to the full ASIA exam. The expedited though is something that makes your exam shorter, more convenient, and up to the point at the trauma bay. So this is the patient's ASIA exam results. As you can see, the sensory level was C3, the most normal one. The motor level was C3, C4. The neurological level of injury was C3. She did have voluntary anal contraction and deep anal pressure. That's why it's incomplete, ASIA D. And with that said, it's a very, as you know, it's a pretty much good prognosis, but because it's cervical, you might want to have longer time with the patient counseling about mobility, about neurogenic bowel and bladder, about her ADLs and so forth. So patient underwent C36 laminectomy infusion. That's your typical spell with neurosurgeons. And post-surgery, her pain is poorly controlled. She also has visual and auditory hallucinations as per the nurse. She sees people walking on the wall. She's yelling and screaming. Family is overwhelmed. They're unhappy. They're like, she was okay before the surgery and now she doesn't make sense to us. So they consulted physiatry for proper evaluation and management. I deal with hallucinations, delirium, whether it's hyperactive or hypoactive and agitation all the time. So this is not something new to me. And I get consulted, although I get consulted once for the first time when the patient comes in, and I follow up and the continuity of care, even at the acute side that matters and optimize the patient care and ship them quicker out of the acute side to the inpatient rehab. So pain management, you gotta dissect their pain, whether it's post-op versus neuropathic versus musculoskeletal pain. Don't forget post-op pain is there. There is an element in our patient given her cardiovascular risk factors of potential polyneuropathy. There is also the musculoskeletal pain, staying in bed all the time. You don't know what else got hurt in her MBC. Was there other rotator cuff injury, trigger point, or myofascial pain. In terms of hallucination, now we're gonna take off your physiatry hat and wear your internal medicine hat and think about what could be the reason. Is there a new stroke? Is there a heart failure? Is it a new AFib? Is there a new aspiration pneumonia given the risk of dysphagia post-ACDF? There is a urinary tract infection. Is there constipation? You gotta wear your internal medicine hat and think about the differential diagnosis and go from there. Meeting the family is essential. You sit with the family. What have you been told by the trauma surgeon? What have you been told by the neurosurgeon? And you start from there, start where they end, and you're like, okay, this is a lot on your plate. I know it's a big change to you as loved one, as well as the patient, but we gotta make sure that the recovery is a smooth ride. And this is what's gonna happen after the surgery. Pain is not uncommon. We gotta make sure that the pain management is there. It's not uncommon after an injury to the spine that the ball and bladder nerves are acting crazy. So we wanna make sure that we empty the ball and bladder. We wanna make sure that there is no evidence of infection and go from there. We wanna make sure that medical-wise, the patient is stable before sending her to the rehab. Again, it's not a one family meeting. I usually meet with them once or twice per week and then discuss with them and counsel them. This is what we do here at the acute side. This is what the expectation would be at the rehab side. And this is what you do anticipate in the recovery ride as the patient goes home. It doesn't stop from there. It also comes with the continuity of care at the outpatient clinic. So I do see them in my outpatient clinic and manage what has been left from the inpatient care. So how to prepare the patient for inpatient rehab? Of course, you gotta follow the CMS criteria for inpatient rehab because otherwise they're not gonna be accepted. Proper education to the patient and caregivers. I do tell the patients most of the time if their cognitive status is intact is you gotta be your own cheerleader. You have to advocate for this. I do tell the caregiver, you gotta ask your insurance company for this. You gotta ask your case management for this. Medical stability, that's number one. You don't wanna make your inpatient medical director up all night managing the unstable patient you send. And as I said, follow the CMS criteria for rehabilitation admission. That's essential, otherwise they will not be accepted. And as you all physiatrists know in our business that basically sometimes you have to go through peer-to-peer you have to justify. Again, you have to know the lingo. You have to know how to advocate for your patients. You have to find every single opportunity to benefit the patient for the inpatient rehab because regardless whether it's inpatient, SNF or LTAT, inpatients take the core importance and the value in optimizing patient care. So that's what you're advocating for. With that said, sometimes you don't have a choice especially with patients who cannot participate for three hours and then you have to weigh your battles. What would work best for the patient? Alrighty, well, moving on to the next case. Before I move on, Hasan I don't have the screen in front of me. Any questions in the panel or anything I should be aware of? So far so good, keep it up. Okay, perfect. So this is a real case of course, brain injury rehab in the ICU. We have a 24 years old gentleman presented as level one trauma, sustained a motorcycle accident when he reportedly crashed into the car. Patient sustained the following injuries. You can see it's polytrauma. So right interparenchymal hemorrhage, seven millimeter midline shift. I'm telling you, when I see more than five millimeter midline shift, my heart sinks to my boots. Anyways, left squamous temporal fracture. So you do expect a basal skull fracture on top of that. Left pneumothorax, left clavicular fracture, multiple rib fractures and grade five splenic laceration. So you can see brain injury patients come with a full meal deal. They don't just come with a brain injury. And that's the reason I got brain injury fellowship because I deal with everything and I still keep my skill set of musculoskeletal, spinal cord, amputation, you name it all. So patient underwent multiple surgical intervention. I'm just listing them decompressive craniectomy, ICP placements, splenectomy, X lab. And his ICP bolt was removed later on as it was not clinically indicated. Beside you was called, of course, what are the reasons you're calling me trauma? Patient is agitated all over the place, throwing temper tantrum on everybody. Family's not happy, overwhelmed with his agitation. They're like patient was never crazy this way before. He used to be a sweet puppy and now he's losing it. There's also abnormal vitals with all blood work with normal labs. There's no infection. What are we treating, Dr. Lawari? I'm like, okay, I'm coming. Let's start with agitation because again, the goal of the trauma team and the trauma surgeons is to calm the patient down, to be able to send them to the floor and get the next trauma patient comes to the ICU. So dealing with agitation is gonna be number one priority in the acute trauma care. With further information, you would like to know from the history as a physiatrist. Now and see if somebody wants to throw what sort of information you would like to know from the history, from a brain injury perspective, what are the things you would be looking for in the history that I haven't mentioned? And don't be shy. You can say it, you don't have to just type it out. Yeah. Anybody? Riley, Ramza, Amelia. Yeah, for history of substance abuse, previous head trauma, psych history. Perfect. That's good. That's good. You're ready for the boards, girl. Can't complain. Okay. So basically you wanna know the whole spiel of the brain injury kind of history, the details of the incident. How did the MVC happens? And I'm telling you, sometimes you don't get the whole details that you're wishing to get. And that's okay. That's part of the deal. You gotta work with what you have to work with. The severity of TBI, the Glasgow Coma Scale at the trauma bay or in the scene. Sometimes your EHS reports that. How long did he lose consciousness? Is it 30 minutes? It's 30 hours. It makes a difference. Post-traumatic amnesia and the range of those amigos. I'm telling you in the trauma world, sorry, in the rehab world, these are the things that I would be like, if you don't report that, there is something wrong with you. But in the trauma care, you would be lucky to find these two sets of informations. Because they don't like when I, like the range of those amigos is basically something that's more of a brain injury rehab thing, as well as the post-traumatic amnesia. And again, it really depends on the speech language pathologist you have and how much they understand about it. Neuroimaging. What did neuroimaging show? And talk to your neurosurgeons. What are you planning to do? With a subdural of seven millimeter shift, what are the ICU interventions? How are we proceeding? When would you remove the ICP or the intracranial pressure monitor? So the patient's Glasgow Coma Scale was three at the scene. We don't know how long the duration of lose of consciousness and again, with the GOAT or the post-traumatic amnesia evaluation methods, we're not done. We have no idea if he is within post-traumatic amnesia period or he's over that. He's currently confused and agitated. He exhibits bizarre, non-purposeful, incoherent or inappropriate behaviors. No short-term recall, no attention span, non-selectives, swears at everybody. Not being physically violent though, but you don't expect that to come on the way. He is incontinent, using pads, sometimes eat food, which is placed in the front, sometimes throws on the floor, whatever his mood is, usually in bed all day. Some restraints as they're short on staff and I'll come to talk about restraints in the acute trauma world because it's such an art. And it's hard to redirect for any recommendations. He's just not listening to you. He's just throwing tamper tantrums. Of course, the acute team gave him one milligram of Ativan every two hours. And then the on-call resident gave him a five milligram Halodol intramuscular twice to knock him out. So where would you classify his brain injury severity? And he's kind of, given that we do not have the post-traumatic amnesia and the duration of lose of consciousness, we have the Glasgow comma that says three. We have the structural imaging that's bizarre. We can classify him as severe traumatic brain injury. It wouldn't be surprising. It would be ideal to have all the information, but again, it is what it is. So what's agitation post-traumatic brain injury? It's a subtype of delirium occurring in the state of post-traumatic amnesia, characterized by excessive behavior, combination of aggression, akathisia, disinhibition, or emotional lability. So you kind of have all sorts of being aggressive. Akathisia means they are kind of unable to stay still and kind of all over the place. Disinhibition, there is lose of frontal inhibition to tell them whatever they're doing is inappropriate, or emotional lability, which is ups and downs. And what is Rancho's scale? It's a scale to help interpret the cognitive behavioral recovery after brain injury. Ranges from one to eight, and now it's up to 10. Again, in the rehab world, we come to the 10, and lower scores indicates more severe impairment of consciousness. You will not transfer any Rancho's amigos below three to an inpatient rehab unit, unless you know they have a brain injury specialist, they have monitors, they have well-equipped nurses and resources to make sure that the patient is safe and they are safe. This is a quick snapshot of the Rancho's Los Amigos scale. Again, it also shows that depends on the level of their response, how much, sorry, how much assistance they need in terms of their ADLs and IADLs. This is one to eight. This is what I use to prepare for my boards, but then you have the nine and 10. This is more, the nine and 10 is more at the discharge level and how much care they need upon discharge. So you can justify that to the insurance companies. Is it all because of the brain injury? Of course not. I mean, everybody blames the brain injury, but as a brain injury specialist, you know it's more than that. You wear your brain injury hat as well as your internal medicine hat. So kind of classified into multiple subtypes. I like classifying it into three. Are there medical causes? Are there traumatic brain injury causes? And are there environmental or behavioral causes? So in terms of medical causes, you have, could be aspiration pneumonia, myocardial infarction, you have DVT-PE, how many times they have PE and that would explain their delirium, dislocation or fractures, brachial plexus injury or sepsis. There are many other medical causes. Sometimes you don't figure anything out and don't hesitate to get your internal medicine folks on board. Environmental causes. Most of the time in the ICU, the answer is yes, because who sleeps in the ICU? It's always buzzy. There's always somebody comes in, whether for vitals or whether for lab work or whether to check on you, how are you doing? Uncomfortable position. Don't forget, family dynamics are weird. So although the family comes and check on the patient, you have sometimes your weird uncle or aunt or a stressful visitor who comes in fuels the fire and take off. So make sure that you address that if that's an issue. And your nurses and your therapists are your eyes and ears on that. So if they tell you, okay, I've seen this visitor, he's kind of, he's the reason where once he leaves, the patient goes kind of all over the place. So make sure that you also detect that and have a clear communication with your nurses and your therapist. Could be related to brain injury. Is it an absence seizure? Is it a rebleed? Do you need to rescan their brain? Is it a cranial vasospasm that happens most of the time with subarachnoid hemorrhage? Is it hydrocephalus? Usually you don't see that much in the ICU. Hydrocephalus is a late complication, but don't be surprised if you rescan the brain and you find it. Also brain herniation, especially with a seven millimeter midline shift. So how do we manage this patient? Again, you gotta tackle, you gotta find the reason. You gotta find the cause because if you don't find it, you will never know how to manage that. You will just chemically knock him out, put him on restraint. If it's a rebleed or brain herniation, good luck with that. So what environmental modifications should be considered? Basically, don't put them in the crowd. I know ICU is not the perfect environment to manage that, but sometimes you're left with no choice. You have to keep them in the ICU because they are critically sick. However, at the same time, you have to make sure that they have one-on-one nurse. You have to make sure that minimize the noise, establish the sleep-wake cycle, make sure that the environment is more calming down rather than provoking stress. So first, reduce stimuli, light, noise and distractions. Should have a limited number of visitors at a time and everyone should speak in a low volume one at a time. Like, ICU is a stressful environment and everybody, whether they have the intention, like they intentionally be a bit tough or not, it comes on the patient and they don't perceive it well. So you gotta make sure to speak in a very low volume, acknowledge, move on. Reduce the patient confusion, consistent schedule and staffing. Don't move the patient to another room and reorient the person frequently. Hi, this is Dr. Ullawadi. I'm a brain injury specialist. You're here at UMC in El Paso. Today is October 14th. It's the time of 1.30 p.m. right now. How are you doing, sir? This is how we would proceed. Behavioral strategies, tolerate the restlessness as much as possible. So if they wanna pace, if they're ambulatory, go for it. However, you gotta make sure that your crew is safe and the patient is safe. So if there is a 1% chance that they might be physically violent, you need to call the security to keep them on a standby. Some patients may need a closed unit or sensor unit for their safety. Remove the lines and tubes as soon as possible. Consider craig bed or veil bed. Now, craig bed or veil bed is a bit controversial on the acute side. It's considered as a restraint and not all the institutions would accept it as something to calm the patient down. So it really depends on your institution and the policies they have implemented. Just make sure that if it's an option, use it. Sometimes, yeah, avoid restraints if at all possible. You might use padded hand mittens if necessary. I use that most of the time, the mittens, if there is an IV line and they pull their IV line. A soft lap belt in the wheelchair and a stable, heavy wheelchair so they wouldn't tip over because it happened. They tip over, they crack their head again and we are back to point zero. What medications not to give. There are certain things that you're like, oh, I really don't wanna do that. Haloperidol. Now, here's the thing. If you look now, if you Google, you will find that there has been, again, what I was trained on, haloperidol is a no-no because it does prolong the post-traumatic amnesia in humans and prolong the neurological recovery. But if you look at the literature right now recently, it's not as that much strict of a no-no. It can be helpful and it can't. So it really depends on, and again, the beauty in brain injury medicine, it's a black box. So it's something that there is no right or wrong answer. It's you as a physician and how much you're comfortable with certain medications, knowing their side effects and what to monitor. So I would say if you, from a exam preparation perspective, you gotta know that haloperidol is a no-no, but in the recent literature, there is some sort of leniency around, okay, can we use it or not? I don't use it personally. I don't advocate for it because most of the time when you consider it, it can paradoxically make them more anxious. Avoid benzodiazepine. Sometimes you have to use it as a part of the CEWA protocol if they come with high alcohol level, but as much as soon as their CEWA or scores are getting into like control or within certain numbers, take it out. Yeah, the reason behind avoiding benzodiazepine is basically it can cause paradoxical agitation in the elderly and it can cause amnesia and confusion. Other side effects, respiratory depression, disinhibition and impaired coordination. What medications to give. If there is one medication you're gonna get out of this presentation is propranolol or beta blockers because Cochrane does not say yes to something easily. And the fact that they support post-traumatic agitation with the usage of propranolol or propranolol role in post-traumatic agitation is a big deal. So if you just remember the beta blocker, you made my day. No adverse effects on motor recovery, but may cause depression and lethargy at higher doses. Make sure that when you deal with a patient with diabetes, you monitor their blood sugars very well. Sometimes beta blockers works hitting two birds with one stone, especially with autonomic instability when they have tachycardia. At the same time, they help the agitation. So it can be used up to 520 milligram per day in one study. You can start with 20 milligram TID. I kind of weigh my battles, depends on their heart rate, 20 versus 10 versus five. And again, it really depends on what your institution, what your mentor says, or you as a brain injury specialist, what's your comfort zone. Metoprolol can also be helpful in your geriatrics population who sustain a fall in a brain injury. You might wanna bump their metoprolol if they already using it for other cardiovascular risk factors. Monitor for hypertension and bradycardia. And as I said, it used to treat post-TBI dysautonomia. You might wanna consider atypical antipsychotics. However, you got to monitor the extraperitoneal side effects like tardive dyskinesia, Parkinsonism, dystonia, and akathisia. This is kind of a nice sweet picture that I always look back to when I prescribe atypical antipsychotics. Keep in mind that typical antipsychotics can induce extraperitoneal side effects more than atypicals. So even when you prescribe it, you mentioned the side effects to kind of protect your back, but it's less likely to happen. And how to monitor the response? Again, it's always by using agitated behavioral scale or overt agitation severity scale, nursing shift, and nursing documentation. In the acute side, they don't use the agitated behavioral scale or overt severity scale. They use the RAS or the Richmond. Sometimes they don't use any at all. Again, it really depends on the trauma center that you're working and what options they have to propose to you. With that said, your nurses are pretty well-versed on how agitated they are. So when you ask them, how did the patient do? They're like, okay, they did this and this and that. This is what happened. This is how we managed. And you kind of keep a track of it. So you kind of make your own little kind of diary to monitor what's happening. And based on that, you make your plan. Sometimes what happens is you keep your agitated behavioral scale at the back of your mind and you kind of go through that checklist. This is what I was talking about. This is what I do most of the time. So the agitated behavioral scale is subdivided into three, like I would say behavioral categories, disinhibition, aggression, and lability. So you would see which one of these behaviors is predominating the patient's agitation. Is it disinhibition? Is it aggression? Or is it lability? Because any of these subtypes determines which medication you can use, the dose, and how to monitor that. Again, you can see the disinhibition questions, you can see the aggression questions, and you can see the lability questions. What I can tell the family, you're gonna use the same approach as breaking bad news, using the spikes, setting up and starting. So you start first, okay, tell me what did the neurosurgeon said or what did the trauma surgeon told you? What's your perception about the patient's injury? What do you understand? And then you initiate the conversation based on what they know. Again, you're dealing with different populations with different level of education, with different level of understanding of brain injury. It's a learning path, not just for patients that are caregivers, it's also a learning path with your trauma surgeons and neurosurgeons. They just know the acute side. They just know the math. You're the one who's dealing with the aftermath. You're the one who's gonna tell them what would happen and how would happen and how would you manage that? So it's you, I would say being educative and advocative at multiple levels. At the hospital administration, when it comes to the level one trauma center, to the trauma surgeons and the neurosurgeons and to your patients. So you have to know your audience before you start talking about, okay, this is the brain injury. Oh, he's severe, he's never gonna recover. That's gonna be wrong, I'm sorry. So you initiate the conversation, give the information in small chunks and pieces. It's a brain injury. It's a big change in your loved one's life. However, we'll make sure that we take care of every single medical issue and address that in a timely fashion. There are some gray areas in any counseling kind of session. So there are things that you would be definitely saying, I am not sure how this would go. And you have to be honest about that, because yes, it's even a severe brain injury. As physiatrists, we see miracles, we see changes. And we never know what's gonna happen. So saying that, okay, it's severe, he's not gonna recover, is not gonna be fair to you or to the patient. It's fair to say at the acute side, it's really hard to say at this time, with every stage of his recovery path, we will readdress this and go from there. Always address emotions. Not uncommon that the caregivers would be in tears all the time. That's what I deal with all the time. It's your compassion and it's your communication skills that plays a role in making sure that you comfort them, being realistic, and at the same time, delivering this news. Always, always, at the end of any communication, provide summary. If you have brochures or pamphlets, which I usually have handy, I do provide them. I do tell them that I would be back. It's not a one session or one meeting communication. And I would definitely readdress any issues or questions as they come right. It's not always a flowery as you can hear me, like I'm kind of making it more of a like easy, smooth ride. No, I'll be a liar if I would say that. But to be honest, it really depends on your audience and who you're speaking with. Sometimes you have caregivers that are very rigid in their mindset that this happened, this is what you need to do as a doctor. And again, at the same time, while you're explaining that to them, do not hesitate to bring the evidence base. One time I had a brain injury in which his loved one was a nurse. And while counseling, sometimes I use Amantadine to promote neuro recovery. And I told her, this is what we use, Amantadine. These are the side effects. This is the level of evidence. Do you want me to provide you with a medical evidence? And she's like, yeah. Printed out the article and give it to her. And then we started Amantadine and he recovered pretty well. But do not hesitate to bring your equipments and your tools to justify or rationalize your interventions. At the end of the day, again, brain medicine is a black box. There is no right or wrong answer. That's why we have all the research around it. But you have to back up yourself with evidence if sometimes it's indicated. Always provide handouts again, as I said. And I usually provide them with a family guide to the Rancho's level of cognitive functioning. Depends on the Rancho's Los Amigos. Don't give Rancho's level four the pamphlet of level one. You're not gonna do well. This is basically Rancho's four pamphlet, which our patient exhibited in his examination. Always offer to touch base again in the future and offer contact for any other questions. So I'm gonna switch gears to abnormal vitals. So what the trauma team told me, the patient has abnormal vitals and we did all the blood work with normal labs. So his heart rate is 115. Of course, he's tacky. His blood pressure is 145 over 90, which is high. The respiratory rate is 35 and he's sweating. So what would be your thought? What do you think is going on? I'm gonna pause for a second and see if somebody is interested in listening. Oh, sorry, in answering, my bad. You can say the answer, you can type the answer. Ramza said sympathetic storm. All righty, so perfect, you nailed it. It says sympathetic storm or sometimes I call it dysautonomia or paroxysmal autonomic instability with dystonia. If there is dystonia in it, you literally nailed it. Autonomic storming is your safest word. So paroxysmal sympathetic hyperactivity, it's also called central dysregulation, sympathetic storming, autonomic dysfunction syndrome. It's common in patients with acute neurological disease. I see this all the time. I'm telling you, when I was in my residency and rehab, we barely saw it. But in the acute side, oh, my God, you see it all the time. It happens in one third of traumatic brain injury occurs within days. There is dysregulation and autonomic responses to either external or internal stimuli. So there's no clear answer for that. The pathophysiology is very complicated. I'm not going to go through the nitty gritty of it. Basically, you might want to know it for your board prep, but not for this session. There is basically, you would say not completely defined. There is unregulated sympathetic activation due to disruption of higher order autonomic regulatory system. There are multiple spots that are responsible for this show. The brainstem, the hypothalamus, the midbrain, some cortical centers, and there's some excitatory pathways. So there's no clear answer which of these kind of pathways pulled the trigger. It's like all over the place. And that's okay. They present within days, duration less clear. Again, it could be up to weeks to several months. And again, the more you're involved in the acute care, the more you would see it. Anything sympathetic, like think about fight or flight response, would be manifested, whether it's tachycardia. Sometimes you have arrhythmias, and that's where we intervene with digoxin or with beta blockers. Hypertension, tachypnea, diaphoresis, hyperthermia. You get spasticity or muscle rigidity as well as dystonic posturing. When there is dystonic posturing, make sure that you label it as PAID or paroxysmal autonomic instability with dystonia. Make sure, though, you discuss with your neurology colleagues that this is dystonia and this is not seizures, because one of the things you want to rule out is seizure-like activity, especially when you are over the Keppra or the anti-epileptic drug use within one week to prevent early seizures. So you have to have that very detailed history, whether it's dystonia, abnormal movement, tongue-biting, urinary, the whole spill of seizures history, you know the deal. The diagnosis, again, the mystery is in the history. You always know that the history will give you the details of the information and get it from the nursing, get it from the care providers, get it from your trauma surgeons, get it from the patient's caregivers. There is a certain clinical feature scale where you monitor these vitals, you score them, and based on that, you determine if there is likely, probable, or possible paroxysmal sympathetic hyperactivity. So I'm putting this, not that I'm using it most of the time, but when I see the patient, I do have this sort of a kind of picture in my mindset that kind of gives me a rough number of whether it's 8 versus 16 or more. Treatment, again, propranolol hits too many birds with one stone that you can use it. You can use gabapentin. It kind of also helps with their central pain syndrome if they have it. So you can use both if you think it's clinically indicated. Again, it's your patient's clinical presentation that determines the need for medication usage. Bromocriptine, I might lean more into using it in the geriatrics population. Clonidine, again, they use it sometimes to help them wean the patient off in the ICU. So it really depends on, it's like, I would say, a collaborative agreement between you and the trauma team to determine what needs to be implemented. Okay, so that was the second case. Are we good to move on to the third one, or are we good to stop? It's 3.50 right now. So if you want to continue, it's up to you. Depends on everyone's energy level. Yeah, what do you think, Gang? I would like to hear everybody's thoughts. You can type in the chat to continue or stop. Amelia said let's continue. Alrighty, let's roll with it. Anybody else want to chime in? Okay, perfect. Let's move on. So this is the geriatrics rehab because, again, I deal with a lot, and this is like across the nation. We deal a lot with the old population that falls, crack their head or crack their hip, and then while you go and take the history, guess what? There is dementia, and now there is delirium, and now there is a fracture on top of that. And they have all the cardiovascular risk factors you can think of. So how you would proceed. With that, I would start with the case. So you have a 95-year-old male who was attempting to get out of his Lazy Boy chair when he fell on his left side. His past medical history includes diabetes, hypertension, dyslipidemia. He's already diagnosed with dementia, but again, what's the severity of dementia? I have no idea. He had CABG four years ago, hypothyroid, osteoporotic, bilateral cataract, AFib on beta blocker, and I would say Xarelto, depression, and anxiety. So he has a lot on his plate, right? What were the interventions done in the ER? He was found to have a left femoral neck intertrochanteric fracture. Patient underwent cephalomedullary or intramedullary implant procedure with orthopedics. So they have seen the patient in the ER. They said, we can do the surgery. Let's move on with it. And that's what happened. Post-op, physiatry was called. Why? Patient is delirious. There is a new urinary tract infection. And we're not sure how we would discharge the patient in this shape. So to be honest, it was tricky from the get-go. I know it's like more tricky. Delirium, how we would approach delirium. It's an acute confusional state marked by altered consciousness, fluctuating symptoms, and inattention. It's common. More than half of the population who's been admitted to the hospital gets delirious. Again, dealing with a geriatric population tells you that, yes, it's going to be something that is not uncommon that you encounter. And it's more common in the elderly. So about 20% of hospitalized patients over age 65 develop delirium. I'm kind of questioning the 20%. Because in my experience, I see more. Up to 60% of nursing home admissions and post-acute care admissions develop delirium. I can justify that. So it's a serious condition. Because it's a burden on the patient, the caregiver, the hospital, and the society. It does increase the risk of mortality. They have increased, sorry, 22% to 76% mortality rate in hospitalized patients happens with delirium. Almost one-third one-year mortality rate. And it does indicate a serious underlying illness. So it's really a big deal. It does affect the hospital in terms of hospital stay, cost of admission, and complications. It affects physicians. It affects patients sometimes. Or most of them head to the nursing home even from just being at home before the admission. How would you diagnose delirium? It's a clinical evaluation. It's your clinical skill set. And that's why we are unique in physiatry. Because we know how to dive into the details and get delirium diagnosed. There is no specific test for diagnosis. It's very underdiagnosed. Because there is lack of clinician education and recognition. The fluctuation of the symptoms. Sometimes they wax and wane. Especially with vascular dementia superimposed with delirium. And symptoms vary between patients. So you have the hyperactive and hypoactive delirium. That makes you more confused. Obtaining a thorough history is the key. Check the vital signs. Do a full neurological exam. And when I say neurological exam, not just your sensory, your motor, your reflexes. A cognitive examination is mandatory. Do a mental exam to make sure you have a baseline to start with. And lab evaluation, of course. Workup. It really depends on your clinical evaluation. You might want to do the hospital of CBC metabolic panel, blood gas, thyroid function, CT brain, EKG, lumbar puncture. We can go on and on. But based on your clinical presentation, it really depends how you would proceed. Management. Again, supportive care. You've got to maintain airway, fluid, proper nutrition. Make sure that they're not aspirating. Provide DVT prophylaxis. And if they need GI prophylaxis, go with it. Always, you have to determine always the causing factor. What caused delirium? And provide additional supervision and family support. I'm telling you, one-third of the time you will find the cause. Two-thirds you will be like delirium is multifactorial here. Especially in our patient. So number one, he has all the cardiovascular risk factors that promotes or make him more prone to vascular dementia. He's already diagnosed with dementia. He's very frail. He has a UTI. And now he has a fracture. Is there uncontrolled AFib? Is there a PE going on? Are we missing anything else? So sometimes you would find one cause and direct the treatment towards it. Most of the time you want or most of the time it's multifactorial. Medications should only be used when the non-pharma management has failed and the patient is in danger to self. Again, some American Geriatric Society promote Halodol. It really depends on your comfort zone. Personally, I don't. I'm staying away from Halopilidol or Ativan. But if you have to and you don't have a choice, go from 0.5 to 1 milligram. There are other options. Respiridone, Olanzapine, Kutaiapine, and Lorazepam, as well as Trazodone. If you ask me personally, if I have to choose one, I would use Olanzapine minimal dose. If I would have to. Like an IM and that's it. I would only use it if this frail 95-year-old gentleman is unsafe to himself or others. Most of the time that's not the case. So if they're just moving and kind of twist and turn in their bed, I'd be like, okay, that's okay. As long as they're not at risk of hurting themselves and falling with no bed rails. But they're easily redirectable. This is a small kind of summary of approach to delirium. And here we go. Patient is back to the ER. The doctor is not happy. He's very confused. He had a stroke, subacute, which I'm not sure when that happened. And now he has been bed bound for the last year using wheelchair for indoors and outdoors and requires assistance 24-7. This is where the critical conversation happens. This is you as a physiatrist. If you're trained to address palliative care, have that communication skill set, go for it. But if not, you might want to involve palliative services. So discuss the frailty status. The frailty status, there is mild, moderate, severe, very severe. And you have to talk with the daughter about how frail her dad is and how much his care needs to be delicate and tailored to his situation. Palliative care, this is a whole different spiel. I'll be very quick because I know we have only two minutes. It's an approach that improves the quality of life. You're not just signing the patient for, okay, this is your last days. No, it's not the case. You're improving the quality of life within the circumstances and the situation that the patient is in. With early identification of this situation, of his physical, psychological status, and providing the maximum amount of care that works well with the patient. There's a difference between palliative care and hospice care. So palliative care is physical and psychological relief, focusing on the quality of care with a multidisciplinary team approach. There is no limitation for it. Versus in hospice care, you know that the time that the patient has is very limited. So you have to maximize within that timeframe. In palliative, you have concurrent with curative treatment. Versus in hospice care, you do exclude curative treatment. Again, palliative care improves quality of life because you provide the right resources to the right patient at the right time. So you make these patients do whatever they want to do and what they love to do, providing the resources they deserve. There are many domains of it. Again, I'm limiting. I kind of, I'm very limited in my time. But there is structure. There is physical, psychological, social, spiritual, cultural aspect, as well as ethical and legal aspects of care. And there are many challenges and opportunities. Again, in the rehab world, we deal with that all the time. And I think we are directly or indirectly trained to be palliative care specialists, especially with the Asian population we're dealing with. We have to bear in mind the psychosocial, the biopsychosocial model of care and the cultural aspect with the patient population you're dealing with. And how to advocate for palliative care as providing the resources rather than we're just doing this because, oh, he's frail. He has limited time. No, that's not the case. And proper education is the key to either your patient, caregivers, and the other team members. With that said, I am concluding my presentation. This is adopted from the last year AAPMNR picture. I loved it because it summarizes what we do for a living. And I am open to have any questions. Thank you so much, Zainab. That was an excellent talk. Very informative. I appreciate it. It was very engaging. Any questions from the audience? Any thoughts? Zainab, how long do you follow up with your patients on an outpatient basis? As an outpatient? Once they get discharged from the inpatient rehab, it depends on the patient's severity. I usually say four to six weeks. But again, it really depends on the patient, on the insurance, and how much they are, like, the resources available to come to see me in the clinic. But that's usually, I put four to six weeks. Because the earlier I see them, the earlier there are issues to be addressed. And then based on that, I'm like, okay, I might see you in another six weeks' time or six months' time. So it's very individualized, to be honest. How do your patients do the ones that are a little bit longer, like after a year or two years after being in rehab? What would you say the recovery is? So to be honest, that's a very good question. So I basically give them a sort of a year to 18 months. And then I say, okay, we're in a point where we're fluctuating. There might be some improvements. Like, I do kind of divide them into third, third, third. One third is, like, they're going to get worse. Or we might need to tweak things around. One third is going to stay the same, and one third could get better. And based on that, I'm kind of putting them into, okay, the options are all open. But to be honest, as a clinician, as a brain injury specialist, I think after a year, you kind of see some sort of a plateau. And you don't see much improvement. It all depends on the behavioral and the therapy support that they get to have it. So, you know, I would say that, you know, diagnostically, the younger, the less drugs they use, the milder the brain injury would make the stats on this side. But the severe would be, like, yeah, I would be questioning if any improvement. Thank you so much. One person said if we're able to have your contact for any questions, they have to be in contact with you. Sure, sure. I usually respond quicker on the Gmail, so feel free to contact me. Yes, yes. And I would love to establish that sort of a collab across the nation in the acute trauma care. I think it's evolving. I think the awareness is there. We need to be the champ and say, hey, we physiatry are here. We can do more. Great. And Amelia won the award because she answered two questions. So we're going to have to definitely get her contact information. Thank you so much. And Amelia, if you get a chance to send us your information through the chat, and we will contact you when you get the $100 gift card. Yay. Any other questions? I think that's pretty much. And yeah, I look forward to seeing you all in Baltimore. Thank you. This recording will be available along with your ability to claim your CME through the academy's online learning portal. So you guys can access the recording there. Thank you, Natalia. I appreciate your help.

acute trauma care

spinal cord injury

ASIA exam

brain injury rehab

medications

RANCHO scale

geriatric patient

delirium

palliative care