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What does it mean for Physical Therapists, especially those in Acute Care Practice to be practicing to the Top of their Licenses?
Approach to the Patient in Case 4 – Cardiac Arrhythmia
Complexity Variations
Cardiac arrhythmias are complex. There are many types of arrhythmias. They range from simple to complex, and life-threatening, just like most acute care & cardiogenic illnesses. The basic arrhythmias have been discussed in the lecture that has been provided to you. You have also learned about the most important life-threatening arrhythmias that are identified by ECG presentation, and all potentially fatal.
There are medical clinical practice guidelines for each individual arrhythmia or arrhythmia classes. However, the impact of arrhythmia on function has commonalities, and that is where we as PTs are concerned.
The primary reason for PT consultation is usually the fall associated with the arrhythmia, or if patient is afraid to ambulate due to falls that are related to Syncope. . However, sometimes, the only complaint can be dizziness. Indeed, the most obvious clinical manifestations of non-life-threatening arrhythmias are palpitations, feeling of unwellness, and syncope. This is why, the clinician should approach the evaluation of the patient from the angle of differential diagnosis of dizziness.
Medical diagnosis of the cause of dizziness can be difficult because symptoms are often nonspecific and the differential diagnosis is broad. The burden of the differential diagnosis is not isolated to the physical therapist – it is not our role to figure out precisely what is causing the dizziness if it is beyond our training or ultimate role. For example, if it is cardiogenic arrhythmia- induced dizziness, we can wait for a cardiologist to verify it. However, it behooves our practice to isolate OUT those causes that we are skilled in evaluating, such as orthostatic hypotension, from any underlying issue.
Generally speaking, there are 4 main types of dizziness:
| Vertigo | Disequilibrium | Presyncope | Lightheadedness |
The definitions, and differential diagnostic considerations for each of these causes have been discussed at the link (same as above). It is important for you to review this at length.
If there has been no fall, despite primary diagnosis of arrhythmia, then most usually, the consultation is either an automatic order set, or, due to additional variable comorbidities that are unpredictable. It could be that patient complains of localized pain, or other mobility impairments, regardless of time duration. In any case, such scenarios are evaluated on a per case basis.
Word about life-threatening Arrhythmias
These are medically fragile situations. A patient in life-threatening arrhythmias are not appropriate for physical therapy intervention until patient is medically stabilized. Remember, a majority of life-threatening rhythms will lead to death.
Due to loss of rhythm, all arrhythmias would have some form of negative inotropic effect with a component of heart failure. See the heart failure management as well in this regards.
Pre-condition to Plan of Care
It appears extremely attractive to jump to the plan of care of a patient. However, the plan should be LAST thing to do, unless it is an emergency. There is a checklist of thoughts that need to be organized before we get to the intervention on a patient
It is not just customary, but to organize your thoughts on the condition of the patient. This organization is represented by your writing the examination & assessment of the patient. You should have a good understanding of how medical documentation (including physical therapy in acutely ill patients should flow, because this has to universally appreciated across your stakeholders, including your physician colleagues, as well as insurance providers, and other medical & non-medical personnel. I am listing a few resources to allow you to review organized documentation structures in medical documentation.
- University of California, San Diego – Writing Guidelines
- UNC School of Medicine – Examples of History & Physicals
Top
Assessment: The Summary Statement (including Problem List) – How to Write
The Summary Statement in an interpretative & executive summary – Defined as providing a concise summary statement that uses semantic vocabulary to highlight the most important elements from the history, exam, and testing and to interpret and represent the patient’s main problem.
- minimal to none
- some to many elements
- most or all elements
Following example will highlight Summary Statements & Problem Lists that could be written by physical therapists for variations of patients presenting with symptoms of arrhythmia. Where possible, I have included actual case reports that show more details than is included in the summary statement
Examples of Summary
Let’s assume that your differential exam is to rule out orthostatic hypotension, and BPPV as your primary exclusions. Your write-up would look something like this:
“…xx-year old male, who is admitted to hospital after a witnessed fall, and is being evaluated by multiple specialties for underlying cause. Neuro, Cards, & PT have been consulted for differential and management needs. On examination, patient has no orthostatic response when serial tested in supine, sitting, then standing. With a negative Dix-Hallpike maneuver, it is unlikely that this is a vestibular problem either. Await neurology, and cardiology to workup the patient – their consults are pending….“
Discussion: Note the succinct but complete nature of the summary statement that rapidly summarizes with enough details to give a quick lead into the diagnostics of the case, and its problem list (relevant to your role in the case) without repeating any of the examination minutiae that exists only to inform your critical thinking & decision-making. Also note the semantic vocabulary. Vocabulary is important to show your maturity of thinking and expression.
PT Interventions in Case IV – Patient with Arrhythmias
PT Interventions will be relative to stability of the underlying rhythm disorder.
Interventions
There is nothing in Physical Therapy Intervention that can prevent a fall associated with a rhythm disorder.
The mainstay of our role is to PREVENT another FALL. This has to do with identifying the cause of the fall as related to the cardiac arrhythmia / dysrhythmia.
While PT can be of help during this period, the focus is not so much physical rehabilitation, as much as it is supportive care and ultimate goal of sufficient ability to return home, and reduce the incidence of falls.Â
Only guaranteed way to avoid falls is to prevent getting up from bed. The practicality of this has to be weighed carefully against patient scenario, and effectiveness of medical intervention. The risk of falls persist with unresolved cardiac dysrhythmias. Gait may lead to syncopal events and falls. A wheelchair and close supervision are highly recommended workarounds.
Any exercise interventions are generic, and does not serve direct purpose of impacting or reversing any particular problem presented by the patient.
If additional medical interventions such as noted below are undertaken, patient is relatively safe to resume baseline activities, after healing is complete (for pacemaker or AICD placements for example).
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Additional Care Based on Medical Interventions
Pacemaker; Automatic Internal Cardiac Defibrillators; Life-Vest(R)
Educate Precautions
- no lifting of arms above shoulders for 3 weeks post-implantation
- no heavy exercise on side of the implantation
- Expectations of “kick-in-the-chest” if device fires
- Life-Vest(R) – specifically in this case, should the gel-pack release the gel, it will be visible due to spread of blue dye on clothing – caregivers should stand clear for delivery of shock
- ambulate ad lib after procedure, monitoring for BP response, and using RPE scale to monitor exertion level.
http://box5122.temp.domains/~sujoybos/home/courses/pt-783-cardiopulmonary-rehabilitation/rehabilitation-approach-to-the-patients-in-cases-presented-in-pt-783-class/monitoring-parameters-during-exercise/
Disposition
Options: Home vs. Inpatient Rehabilitation – Which one is appropriate? Patients with non-life-threatening arrhythmias typically do not need acute care rehabilitation even though you will be routinely consulted when they are admitted.
Disposition will be home, once the patient has been medically treated, unless severe life-threatening arrhythmias lead to complexities of prolonged hospitalization and other issues. In case patient has prolonged hospitalization, revert to hemodynamic monitoring, and early mobility rehabilitation.
Durable Medical Equipment
The choice of DME is large and the decision may appear confusing. Among other things, do make sure to consider patient’s ability to pay for DME. These are not cheap, except for small items like canes ($10-15 at Walmart, or Drug Stores). Unlike healthcare that cannot be denied, DME certainly can be denied if no payment source. Do not promise DME without verifying payment source available.
- Walkers
- Wheelchairs
- Bedside Commodes
- Shower chairs & benches
- Oxygen – arranged by Respiratory Therapists on written prescriptions of Physicians
Decision-making with DME
Walkers Decision: Always best to have rolling walkers. A rolling walker decreases the workload by not having to pick-up and advance the device. Rollators make for the best option in patients with heart failure – it has 4 wheels, and a seat, often with a basket, that is helpful for various purposes.
Wheelchairs: Some patients will no longer be able to tolerate gait. One must think of wheelchair-level mobility for these patients.
These are covered by insurance. Exercise some analytical thought. A standard vs. a large wheelchair? (Often patients with advanced heart failure are also overweight or obese). Can the patient push the wheelchair themselves? If they cannot, do they have someone to always help? Can the patient be more functional AND be productive if they are independent in pushing the wheelchair by themselves? In such scenarios, a power wheelchair may be an option. However, analytical considerations in deciding a power wheelchair must ponder over life-expectancy. If patient is younger or has a chance at longer life-expectancy, then a power wheelchair expense makes sense. Be careful in promising equipment for which you cannot determine patient’s longevity, or, ability to pay for.
Bedside Commodes: There are many types. These are covered by insurance. Consider the types available (see the link – these will evolve over time as new kinds are engineered – so stay abreast of new equipment). A bedside commode (BSC) is best if they have removable buckets which then transforms into a raised toilet seat (RSC) that can be placed above a regular commode in the bathroom. There are BSCs with removable arm-rests if one would serve the cause better.
Shower Chairs: Shower chairs are NOT COVERED by insurance. Apparently, they are not considered “essential” items for life. These are not cheap either. One work-around is that a bath/transfer bench is ordered that is actually covered by insurance. With a transfer bench, a patient sits down on the bench outside of a bathtub, then swings legs over into the bathtub. Check the link for examples of Shower Chairs vs. Transfer Benches. Some patients will opt to buy shower-chairs out-of-pocket.
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DME Decision-Making
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The choice of DME is large and the decision may appear confusing. Among other things, do make sure to consider...
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Case 4 – PT 783
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Approach to the Patient with Cardiac Arrhythmia Quick Reference to the Case Sections Discussion on complexity variationsAssessment Write-upPlan of CareEducationDispositionDurable...
