post cardiac arrest

[anoodyPT]

i have patient admitted to ER with cardiac arrest and CPR is done for her but she had ischamic encephalopathy and it's effect on her movement, speech and understanding and short term memory.

i want more informations about post cardiac arrest PT intervention especially it's contraindicated for cardiac rehab

now i am working with her like neuro pt but i wanna improve her cardiopulmonary status .



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[sami.crpt]

Salamalaikum anoody,
first u should know that-the brain depends on a second by second supply of oxygen and glucose by the blood. A drop in cerebral perfusion, hypoxia, hypoglycemia, and severe anemia can cause a critical shortage of energy (energy crisis). The most common cause of energy crisis is a drop of cerebral perfusion (global ischemia), usually resulting from cardiac arrest .This damage to cells in the central nervous system (the brain and spinal cord) from inadequate oxygen is called ischemic encephalopathy.
so i understand that here the ischemic encephalopathy resulted from cardiac arrest!
i really appretiate your desicion to treat the cause !! because its right that if u make the patients cardio response better the pt is sure to improve..clear.
as u wanna know the contraindications for cardiac rehabilitaion lemme write that first:
Who Should Not Participate In Cardiac Rehabilitation ?

Patients With Unstable Angina - i.e. - Refractory To Pharmacological Management
Patients Who Are In Acute Congestive Heart Failure
Patients Who Have Uncontrolled Dysrhythmias
Patients Who Have Resting BP's >200/100 mm Hg
Patients Who Have Moderate To Severe Aortic Stenosis
Patients Who Are In Third Degree AV Block
Patients With Acute Pericarditis
Patients Who Are Being Acutely Treated For Recent Embolic Events
Patients With A Resting ST Segment Depression Greater Than 3-4 mm
Patients With Uncontrolled Diabetes Mellitus
Patients With Moderate To Severe Cardiomyopathies
Patients With Orthopedic Problems Which Preclude Them From Exercise
so these are the patients who should not go for cardio rehab (or those on whom its contraindicated)ok.
a cardio pulmonary status of a post heart attack patient should be improved slowly so u need to go in order of phases as she is hospital now. its the first phase management thats applicable.
in phase 1 management ,what all u should be planned is explained below step wise...
A. Medical Chart Review
Here are some questions you should be asking as you do the chart review.

1. What is the patient's diagnosis - MI, aortic stenosis, CABG, (here its post cardiac arrest)etc.
2. Was the patient defibrillated ? The patient may complain of chest pain or have burns on the chest from being cardioverted. Once a patient has been defibrillated, about 60% of these patients will go into ventricular fibrillation resulting in a second or a third defribillation experience.
3. Has the patient undergone a CABG ? Many patients think their "cardiac problems" have been cured and they will be angry as they have another MI after a CABG. It will be important for you to anticipate that anger and realize that it is not directed at you.
4. Know what the EKG report says about the patient.
5. Did the patient receive Tissue Plasminogen Activator (TPA) or Streptokinase to try to break up clots in the early diagnostic stages of the heart attack.
6. Did the physician document the rise of serum cardiac enzymes in the early stages of the heart attack ? This would be found in the blood lab workup and would refer to creatine kinase (CK), aspartate aminotransferase (AST) and lactate dehydrogenase (LDH). These enzymes have the following pattern :

Enzyme Name
Initial Rise
Time To Peak
Return To Baseline
Creatine Kinase (CK)
4-6 Hrs
24-36 Hrs
3-4 Days
Aspartate Aminotransferase (AST)
12-18 Hrs
36 Hrs
4-5 Days
Lactate Dehydrogenase (LDH)
6-10 Hrs
2-4 Days
10-14 Days

1. Look at the lipid panels also found in the blood lab reports.
2. Look for the echocardiogram report. This report will tell you whether the septum or the ventricular wall is hypokinetic or akinetic. Also wall thickness will have been assessed. Ejection fraction will have been measured - an EF of >60% is normal; <40% EF is ominous and an EF of <18% is probably going to exclude the patient from meaningful exercise.
3. Was the patient taken to the catheterization lab for coronary angiography ? The cath report will tell you which vessels are blocked and by what % are they blocked.
4. Read the pulmonary function test to see if the patient has a history of obstructive or restrictive lung disease.
5. What medications is the patient taking ?
6. Read the nurses notes.

(u review the chart or discuss with attending physician to get the answers & write in order in your physio assessment chart)
B. Patient And Family Interview
Ask the patient why they are in the hospital. They may not understand all that is happening to them. Ask the patient what kinds of symptoms they had in the past before their admission to the hospital - i.e. - did they have chest pain, chest pressure, pressure or pain that radiated into the left arm. Were any anginal equivalents ever noticed like jaw pain, navel pain, low back pain, pain that radiated into the right arm, numbness and tingling in the fingers. Anginal equivalents are any sign or symptom that can alert the patient they are having problems with their heart - alternative signs other than chest pain and pressure.
Find out if the patient had any predisposing risk factors like diabetes mellitus, peripheral vascular disease, hypertension, hyperlipidemia, significant family history, etc. Was the patient a smoker and if they were how long did they smoke ? Ask the patient if they have stopped smoking and have them give you a specific date when they stopped. Sometimes they will say they have stopped but they stopped as the ambulance rolled them into the Emergency Department at the hospital.
The patient will often not remember what has been said in the early days of his/her admission. For this reason, it is crucial to include family members in all of the education sessions with the patient. It is important to assess the family to see how willing the extended family, outside of the home, are willing to help once the patient returns home. Does the family love the patient and have a sense of duty to help once he/she returns home. Is the spouse supportive or critical ? A person with good family support will likely recover and rehabilitate sooner.
If the MI is not too severe, the patient may well be able to return to his/her vocation. Try to assess the patient's willingness to return to work. The patient may have been employed as a manual laborer. Does the patient acknowledge that manual labor may not be appropriate anymore ? How willing is he/she to undergo job retraining in order to continue being the financial support to the family ?
Does the patient have hobbies and interests that may sustain them in leisure times ? What is the psychological profile of your patient ? Do they need a psychiatric consult to help them over times of depression and denial ?
C. Patient's Physical Exam

1. Does the patient have normal ROM ? (take rom)
2. Is there any detectable atrophy in any of the limbs ? (muscle girth measurement & compare)
3. What is the gross over all muscle strength for the arms and for the legs ? (MMT)
4. Is the skin color normal ? (Look for cyanosis,varicose ,yellow colorg etc)
5. Are all of the pulses normal and bilaterally equal ? Check the pedal, radial, carotid, popliteal, and brachial pulses.
6. Are there any surgical incisions on the thorax or the extremities ?
7. Are there any palpable areas on the chest wall that are painful ? Is there normal anterior/posterior excursion of the chest on inhalation ? Do the lower ribs flare out to the sides on deep inspiration ?
8. Take the patient's blood pressure on both arms. Are they equal side-to-side ?

D. Evaluation Of The Patient's Tolerance Of Exercise (very important)
Next, the Physical Therapist needs to do the self care evaluation on the patient. Essentially this involves determining if the patient can do a variety of self care activities in the supine position, sitting up at the edge of the bed and in standing. This involves such activities as brushing your teeth, combing your hair, washing your face, shaving, putting on your clothes, socks and shoes. If the patient can do all of the standard self care activities in supine, sitting and standing without having any complaints of dizziness, unusual fatigue, syncope, chest pain, or the appearance of an exaggerated heart rate, blood pressure or an EKG dysrhythmia, then the patient has passed the self-care evaluation.
(at this stage u can mix ur neuro rehab plan with cardio)-do spirometry,assistive helmich to diaphragm,trapezius,ask to blow a lighted candle without blowing it off completly etc.)
Now, the patient can begin a walking program that is heavily monitored and progresses slowly. It looks something like this :

1. The patient is hooked up to a telemetry unit so that their heart rate and rhythm can be constantly monitored.
2. The patient's blood pressure is measured every 3-4 minutes while they are out of bed.
3. The patient is slowly walked by the therapist x 25 - 50 feet after which there is a short rest period on a chair.
4. If no unusual HR, BP or EKG readings were seen, then the walk is repeated and overtime lengthened according to the patient's subjective feelings as well as the HR, BP and EKG responses.
5. Activity is progressed as long as the patient tolerates the exercise.

At the end of Phase I, the patient will be walking several times a day with increasing distances in a patient with an uncomplicated MI. If the patient displays unusual symptomatology during the walking times - EKG dysrhythmias, shortness of breath, the development of crackles in the lungs where none existed prior to exercise, sharp increases in HR and BP with light activity, onset of syncope, vertigo, and other stress symptoms - they must be referred to their primary care physician before additional exercise times are undertaken.
If all has gone well for the patient, they will be discharged to home after the completion of a low level graded exercise stress test. The test looks something like this :

Stage
Speed (mph)
% grade
Duration (min)
Met Level
I
1.7 mph
0%
3 minutes
2.3 METs
II
1.7 mph
5%
3 minutes
3.5 METs
III
1.7 mph
10%
3 minutes
4.6 METs
IV
2.5 mph
12%
3 minutes
6.8 METs

Most patients with an uncomplicated moderate sized MI will be able to complete stage IV. Often, the physician will give the patients about two weeks at home for additional recovery and then have the patient submit to a Bruce treadmill protocol. The Bruce protocol is significantly more aggressive than the low level graded exercise stress test. The patient has now completed Phase I cardiac rehab and will progress now on to Phase II cardiac rehab.
i would like to kno in which area or province of saudi arabia u r working.i hav a gud amt of frens there.
hope these informations will help u.....