Many facilities may have multiple services – often, the same facility will offer subacute rehab and long-term care and memory care services

Level of care dependent on the need of assistance as per PT/OT/Speech evaluation

Instrumental Activities of Daily Living (IADLs) = managing house, finances, transport, medications, shopping

Activities of Daily Living (ADLs) = walking, toileting, bathing, feeding, transferring

Starting to talk about rehab in the ED:

• Is this a rehab-able condition?
  • Rehab-able condition examples: stroke, hip fracture, deconditioning after serious illness
  • Potentially not rehab-able examples: any progressive, gradual degenerative disease in which the patient is expected to continue to decline
• Why does this matter?
  • Insurance will stop paying for rehab if patient is not improving or making progress based on their PT/OT/ST notes
  • There is a daily copay for patients after 21 days in rehab and the full cost is on the patient after 100 days
    • PT is amazing but cannot fully reverse a months-long decline in 21 days!

• Will the patient be able to physically and cognitively participate in rehab?
  • Acute inpatient rehab = 3 hours therapy/day
  • Subacute rehab = 3 hours/week
• Patients are not rehabbed until they can go home safely – patients are rehabbed until they can safely live in a one-story home.
  • So what is the goal after rehab? What is the backup plan if they still can’t go home after 21 days? Will they still need help?

References:

https://www.genworth.com/aging-and-you/finances/cost-of-care.html

https://www.medicare.gov/care-compare/

https://www.aarp.org/caregiving/

Flint LA, David DJ, Smith AK. Rehabbed to Death. N Engl J Med. 2019;380(5):408-409. doi:10.1056/NEJMp1809354

Flint LA, David D, Lynn J, Smith AK. Rehabbed to Death: Breaking the Cycle. J Am Geriatr Soc. 2019;67(11):2398-2401. doi:10.1111/jgs.16128

Burke RE, Jones J, Lawrence E, et al. Evaluating the Quality of Patient Decision-Making Regarding Post-Acute Care. J Gen Intern Med. 2018;33(5):678-684. doi:10.1007/s11606-017-4298-1

Halifax E, Bui NM, Hunt LJ, Stephens CE. Transitioning to Life in a Nursing Home: The Potential Role of Palliative Care. J Palliat Care. 2021 Jan;36(1):61-65. doi: 10.1177/0825859720904802. Epub 2020 Feb 27. PMID: 32106767; PMCID: PMC8127871. 

References:

Makdisi G, Wang IW. Extra Corporeal Membrane Oxygenation (ECMO) review of a lifesaving technology. J Thorac Dis. 2015;7(7):E166-E176. doi:10.3978/j.issn.2072-1439.2015.07.17

https://www.nni.com.sg/news/patient-care/for-physicians-ecmo-life-support-option

References:
Nickson, C. “Improving Oxygenation in Ards.” Life in the Fast Lane • LITFL, 3 Nov. 2020, litfl.com/improving-oxygenation-in-ards/.
Hess, D. R. “Recruitment Maneuvers and PEEP Titration.” Respiratory Care, vol. 60, no. 11, 21 Oct. 2015, pp. 1688–1704, https://doi.org/10.4187/respcare.04409.

Key Questions

How long ago was is placed? Is it a tracheostomy vs a laryngectomy?

Infections

Mediastinitis, tracheitis, pneumonia, lung abscess/aspiration, sternal septic arthritis, cellulitis, fungal infections

Consider a tracheal aspirate culture, suction, hypertonic saline, humidified oxygen

Mechanical Complications

Decannulation or Dislodgement

Tracheostomies < 7 days old require replacement with direct visualization (fiber optic visualization)

Tracheostomies > 7 days old may be re-inserted blindly (but should confirm with fiber optic visualization)

Tracheal Stenosis

Can occur at any point along trachea -> look for stridor

Location of stenotic lesions may make mechanical ventilation or criccothyrotomy difficult, or may require a much smaller airway (consider pediatric sizing). This is a surgical emergency! Consider Heliox to improve laminar flow for oxygenation.

Bleeding

Tracheoinnominate artery fistula & hemorrhage

Majority within 4 weeks of trach placement

Even if small amount of bleeding, take seriously as these are often sentinel bleeds and can lead to massive hemorrhage in 24-48 hours

Treat with external compression to sternal notch, over inflated tracheostomy cuff, consider intubation from above. Consult your surgical/ENT colleagues for evaluation and assistance

References:

https://www.emrap.org/corependium/chapter/reckOdDn9Ljn7sBLy/Complications-of-Tracheostomies

https://rc.rcjournal.com/content/50/4/542.short

https://www.enteducationswansea.org/trachy-lary-differenceshttps://basicmedicalkey.com/larynx-and-respiratory-system/

Definition: Hypertension (diastolic >120)  + end organ dysfunction

History Pearls

Neurological	Visual changes, vomiting, seizures, focal motor or sensory deficits, confusion
Cardiac	Chest pain, abdominal or back pain, palpitations, syncope, dyspnea
Renal	Anuria, hematuria, peripheral edema

Exam Pearls

Neurological	Focal neurological deficits, papilledema, retinal exudates or hemorrhages, AMS
Cardiac	Unequal pulses or BP, pulsatile abdominal mass, new murmurs, carotid bruits, rales
Renal	Peripheral edema

Manifestations of Damage

Neurological	Retinopathy, encephalopathy, SAH, intracranial hemorrhage, acute ischemic stroke
Cardiac	Aortic dissection, AMI or ACS, acute heart failure, pulmonary edema
Renal	Acute renal failure

Special Considerations

• Pre-eclampsia, eclampsia, HELLP in pregnant or postpartum patients 
• Sympathetic crisis in setting of sympathomimetic drug use, pheochromocytoma, MAOI-tyramine reaction, or withdrawal of short acting antihypertensives

References:

1. Johnson, Nguyen, M.-L., & Patel, R. (2012). Hypertension Crisis in the Emergency Department. Cardiology Clinics, 30(4), 533–543. https://doi.org/10.1016/j.ccl.2012.07.011
2. Judith E. Tintinall, et al. (2020). Tintinalli’s Emergency Medicine : A Comprehensive Study Guide (Ninth Edition). New York: McGraw-Hill.