Ischemia and Med-Surg Management 2024 PDF

Sit in a new part of the room next to someone you normally don’t sit with.  ISCHEMIC CONDITIONS AND MED/SURG MANAGEMENT Lora Packel PT, PhD 2024  MEDICAL MANAGEMENT Patients with CAD and or MI may be managed medically: Optimize blood pressure through medications, weight loss,...

Sit in a new part of the room next to someone you normally don’t sit with.  ISCHEMIC CONDITIONS AND MED/SURG MANAGEMENT Lora Packel PT, PhD 2024  MEDICAL MANAGEMENT Patients with CAD and or MI may be managed medically: Optimize blood pressure through medications, weight loss, exercise Optimize myocardial oxygen demand through medications that lower heart rate and/or lower contractility Optimize coronary blood flow through medications that thin blood Manage cholesterol Optimize physical activity *we will have a more in depth lecture on pharmacology later in this module!  SURGICAL INTERVENTIONS FOR CAD & MI PTCA - Percutaneous Translumenary Coronary Angioplasty (“balloon angioplasty”) Balloon tipped catheter fed into coronary artery that is occluded Balloon compresses plaque, restores flow Stent – Used in conjunction with PTCA – Re-stenosis – blood thinners https://youtu.be/e13TGGccvT4  SURGICAL INTERVENTIONS -CABG CABG - Coronary Artery Bypass Graft – Take saphenous vein, internal mammary/internal thoracic artery, or brachial vein – Bypass occlusion to return flow https://youtu.be/Cp59BCMVHHc SURGICAL TREATMENTS: CORONARY ARTERY BYPASS GRAFT (CABG) Harvest a vessel from the body (Saphenous vein, ulnar artery). Connect vessel from aorta to distal to area of occlusion. MID-CAB: INDICATIONS AND CONTRAINDICATIONS Indications 1-2 blocked arteries on ANTERIOR surface of heart High risk for bypass surgery Benefits No sternotomy – less functional impairment Shorter length of stay Lower risk than with heart-lung machine CHART REVIEW: SURGERY ▪ Look for ▪ Type of surgery ▪ Method of surgery ▪ Where vein was harvested ▪ Anything unusual in the perioperative or operative period  PT EXAMINATION In addition to the typical examination components inclusive of cognition, ROM, Strength, integument, balance, gait, a PT should perform: Cardiovascular screen Heart auscultation Observation of color/perfusion Sternal stability Sternal precautions teaching Tests for cardiorespiratory fitness Education about risk factor reduction Referral to cardiac rehabilitation Vital sign or cardiorespiratory response to activity ECG/telemetry (more to come) EXAMINATION CONTINUED: SPECIAL TESTS CV Special Test: Heart Auscultation Special Test: Capillary refill Special Test: Peripheral pulse strength Special Test: Lung Auscultation Special Test: Blood Pressure orthostatic hypotension Special Test: Sternal stability  EXAMINATION – STERNAL INCISION Wound evaluation (more to come in fall P2) ▪ Color, Odor, Discharge Sternal Stability Risk factors for dehiscence: Older age Smoking Diabetes Overweight or Obese Poor nutritional status https://www.google.com/url?sa=i&source=images&cd=&ved=2ahUKEwjA9oG4uuTiAhXLMd8KHR0MAqoQjRx6BAgBEAU&url=https%3A%2F%2 Faneskey.com%2Fminimally-invasive-cardiac-surgery%2F&psig=AOvVaw1Sgu4h-kj7Azh8zhAX8yRU&ust=1560446472589442  1. Palpate between the sternal halves using the 2nd, 3rd and 4th digits during: shoulder flexion (unilaterally and/or bilaterally) Method trunk lateral flexion and/or rotation coughing and deep inspiration/expiration STERNAL INSTABILITY 2. To further challenge the sternum, an additional optional movement is contrary shoulder 3. During movement record grade movement (i.e., one shoulder of motion, bony gap (size), and flexing and externally rotating, tenderness. while the other shoulder extends and internally rotates).  STERNAL INSTABILITY SCALE Clinically stable sternum (no 0 detectable motion) – normal Minimally separated sternum (slight increase in 1 motion upon special testing#) Moderately separated sternum – (moderate 2 increase in motion upon special testing#) Completely separated sternum – entire length 3 (marked increase in motion upon special testing#) STERNAL PRECAUTIONS Standard Sternal Precautions: ▪ No pushing, pulling, lifting, or carrying > 5-10 pounds for 8 weeks ▪ No bilateral shoulder elevation past 90 for 8 weeks ▪ Unilateral unweighted shoulder elevation past 90 is allowed within pain limits ▪ No reaching behind back ▪ Splinted coughing ▪ No driving x 8 weeks TIME TO STAND WITH STANDARD STERNAL PRECAUTIONS https://youtu.be/33KIISGSDfs?feature=shared MODIFIED STERNAL PRECAUTIONS “MOVE IN THE TUBE” An alternate to sternal precautions being piloted in several institutions Patients should keep their moves within the “tube” or green area Allowed to move out of the green area for open chain activities such as ADLs  STERNAL PRECAUTIONS – MOVE IN THE TUBE 1.Bilateral movements of the arms in the horizontal level, backwards or over the shoulder level, should only be performed within pain-free limits during the initial 10 days following sternotomy or until the wound is healed. 2.Loaded movements of the arms should only be done at a pain-free level. 3.In general, patients should keep the upper arms close to the body for 6-8 weeks. 4.Patients with BMI≥35 should wear a supportive vest to protect the sternum for 6-8 weeks. 5.Patients should be taught to hug a pillow over the surgical incision when coughing and sneezing for 6–8 weeks. SPLINTED COUGH 6.Patients who cough frequently should wear a sternal vest supporting the entire circumference of the thorax. 7.Patients with large breasts should use a supportive bra that fastens in the front.  Each institution or surgeon will determine which sternal precautions are to be used with their patients. EITHER Traditional precautions OR Move in the tube…not both! https://youtu.be/e4Oz6RGfMNI ISCHEMIC CONDITIONS: MEDICAL & SURGICAL MANAGEMENT Video & Movement System History Systems Review Outcome measures Task analysis Speed of movement (time to complete task) Amount of movement (amplitude, ROM needed to complete the task) Symmetry of movement Control (smoothness, coordination, sequencing, stability) Symptom alteration (SOB, Pain)  MOVEMENT SYSTEM What systems are contributing to this person’s movement? Using the ICF model, which of these components are activities? Participation? What would you learn from the patient interview regarding personal and environmental factors? What is your initial clinical hypothesis? To confirm or inform your hypothesis, what areas of the movement system do you want to evaluate further? Let’s take a step back to learn more about what interventions this patient may have had! Let’s watch these videos and be sure to notice the elements of the movement system. Sit to stand: start at 3:10 https://youtu.be/Zc0rQBCbMTE (cardiac surgery) Start at 3:29 https://youtu.be/7TtMWGMBcsA  Documenting Level of Assist 23 “Show Me What You Can Do” Level of Assist Description Independent (I) Patient able to transfer independently and with safe technique Supervision (S) Patient may require environmental set up and supervision, but no tactile assist Contact Guard Assist (CGA) Requires therapist to apply contact to assist with mobility, balance Minimal Assist (Min A) Patient performs 75% of the movement on their own; clinician provides 25% Moderate Assist (Mod A) Patient performs 50% of the movement on their own; clinician provides 50% Maximum Assist (Max A) Patient performs 25% of the movement on their own; clinician provides 75% Dependent (D) Clinician performs the entire transfer Online Quiz on these terms and abbreviations in the first 5 min of lab this week FUNCTIONAL MEASURES Functional Measures assist with: 1) Determining functional status 2) Determining impact of medications and/or surgery on function 3) Risk stratification for mortality, re- admissions, falls 4) Baseline data for home exercise program AEROBIC CAPACITY Six Minute Walk Test – 25 m MCID in MI/CAD Gremeaux, V. et al. (2011). Determining the minimal clinically important difference for the six-minute walk test and the 200 meter fast-wal test during cardiac rehabilitation program in coronary artery disease patients after acute coronary syndrome. Arch Phys Med Rehabil 92(4_, 611-619. 2 min Marching/step Test – time to move Functional Activities 5 times sit to stand 30 second sit to stand  READY, SET, GO! Stand up straight next to the wall while a mark is placed on the wall at the level corresponding to midway between the patella and iliac crest. March for 2 minutes lifting knees to designated height ( about 90 degrees) ? Resting is allowed and subjects may hold onto wall or chair. Count the number of times the right knee hits the mark in the 2-minute trial. *you may be asked to perform/administer this test on your practical exam. Men’s Results Age below average average above average 60-64 < 87 87 to 115 > 115 65-69 < 87 86 to 116 > 116 70-74 < 80 80 to 110 > 110 75-79 < 73 73 to 109 > 109 80-84 < 71 71 to 103 > 103 85-89 < 59 59 to 91 > 91 90-94 < 52 52 to 86 > 86 Women’s Results Age below average average above average 60-64 < 75 75 to 107 > 107 65-69 < 73 73 to 107 > 107 70-74 < 68 68 to 101 > 101 75-79 < 68 68 to 100 > 100 80-84 < 60 60 to 91 > 91 85-89 < 55 55 to 85 > 85 90-94 < 44 44 to 72 > 72 *Part of the senior fitness test protocol 2 MINUTE STEP TEST BOHANNON, R., ET AL. TWO MINUTE STEP TEST OF EXERCISE CAPACITY: SYSTEMATIC REVIEW OF PROCEDURES, PERFORMANCE, AND CLINIMETRIC PROPERTIES (2019). JOURNAL OF GERIATRIC PHYSICAL THERAPY 42(2), 105-112 PRO’s ▪ Alternative to 6MWT ▪ No equipment needed other than tape and timer! ▪ Cons ▪ Low correlation to VO2 ▪ Not enough data to determine reliability ▪ No data on responsiveness  FUNCTION Has 269 items; PT completes 6 clicks for every patient each visit Can help guide dc recommendations Used to determine therapy effectiveness and resource utilization QOL SF-36 Physical functioning Role physical Bodily pain General health Vitality Social functioning Role emotional Mental health Seattle Angina questionnaire Paul S. Chan. Circulation: Cardiovascular Quality and Outcomes. © 2014 American Heart Association, Inc. Development and Validation of a Short Version of the Seattle Angina Questionnaire, Volume: 7, Issue: 5, Pages: 640-647, DOI: (10.1161/CIRCOUTCOMES.114.000967)