Episode 79: Ortho trauma case is a Cardiopulm Case in Disguise

Today we discuss a recent acute care evaluation of a 52yo male s/p motocycle crash, despite multiple orthopedic injuries, both the lung and the heart played a bigger role than the initial case synopsis would think.

Let’s dive into a cardiopulmonary assessment and treatment interventions for this fun and complex orthopedic case.

In this episode:

• Lung Auscultation
• Chest wall Assessment
• Breathing exercises
• Cough Techniques
• Rib fractures
• Transfer techniques

Join my main newsletter:  https://allthingscardiopulm.ck.page/9bb2730421

Want to sign up for a mentoring call with Dr. Burriesci? Sign up here: https://www.allthingscardiopulm.com/mentoring

Interested in Jane?
Jane, is an all-in-one practice management software with helpful features to power your practice.  Head to jane.app/burriesci to book a personalized demo.  Don't forget, you can use the code CARDIOPULM1MO at the time of sign-up for a 1-month grace period applied to your new account

Find me on:

IG: @all_things_cardiopulm
Threads: @all_things_cardiopulm
Website: www.allthingscardiopulm.com
Twitter: @allcardiopulm
Linked-In: Rachele Burriesci
Text at 913-308-4494

Chapters

• 0:04 Awkward Apple Pay Fiasco
• 9:05 Ortho Trauma to Cardiopulmonary Case
• 25:15 Optimizing Mobility and Breathing Strategies

Transcript

Rachele Burriesci: 0:04

Welcome to Talking All Things Cardiopulm. I am your host, r Rachel Barisi, physical therapist and board-certified cardiopulmonary clinical specialist. This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions and patient experiences. The goal is to learn, inspire and bring cardiopulm to the forefront of conversation. Thanks for joining me today, and let's get after it. Today's episode is sponsored by Jane, a clinic management software and EMR. The Jane team knows that when your workday is spent providing care to your patients, it can feel like there aren't enough hours in the day for the rest of your administrative tasks. That's why Jane has designed user-friendly online booking so you can give your patients the freedom to book their appointments at their own convenience. They also can fill out intake forms, enable SMS and email reminders from their secure online portal, which saves you from having to do it manually. To see how Jane can help you reclaim your nights and weekends, head to the show notes. Click that link to book a personalized demo and, if you're ready to get started, you can use the code Cardiopalm1MO at the time of signup for a one month grace period applied to your new account. Thanks again, Jane. All right, welcome back. Before we get into today's episode.

Rachele Burriesci: 1:26

I was going to share one of those horrific, getting old scenarios that played out yesterday. So I was trying to take Rem on a walk and she has been on a walking hiatus with just one person since spring and if you follow me on Instagram, we typically walk daily and we had a really hard time with sound sensitivity. A few years back. She turned one and it was like someone flipped a switch. She was scared of everything. She stopped walking on leash. She was very skittish during storms and any loud noises, and so we did a lot of training and we overcame a ton and for four years we were going strong with our walks. With that being said, we would always navigate around bad weather. We are very cautious about what places we go. For instance, if we were to go downtown to a brewery, there are certain places that have like bus stops right, bus stops right outside, or like construction work. It's not going to go well. So we just avoid things that we know will trigger her fear and just create a bad experience. With that being said, we've been doing great. We literally train twice a day. Every meal is training, all of the things. In the spring she stopped walking, but it seemed to be correlated with bad storms. So we assume that once the storm season ended we would kind of get back into our normal routine, and we just never really quite got there.

Rachele Burriesci: 2:57

I think over the summer I was able to get her out three times by myself where she just kind of took off and go. So she's essentially made the decision. So she's essentially made the decision that she's not walking with one person, with me and Nicki. She is happy as can be tail so high up, she like can't even contain herself because I know she like wants to do this, but she will not pass the grass of our house and turn the corner. It's actually quite frustrating and insane. So yesterday it seemed like she wanted to go and she hadn't been on a walk in a while. So I was like, well, let's see if she'll, let's see if it happens. We walk out the door, looking good, make it down three steps, looking good, puts on the brakes, lays on her side. Like you know she's, she is a ton of brakes and the only way to go I would be dragging her on her side, which we've learned different techniques from the trainer, and they essentially tell you to keep walking right, fly pressure, keep walking. Well, you cannot do that. When you're like dragging her, and even if you're trying to like get her out of it, you have people walking by. They're like what's happening there. So it's 100%, totally embarrassing, but it's not worth creating a worse experience.

Rachele Burriesci: 4:12

So she has been walking in the cul-de-sac for whatever reason. So I literally said to her all right, let's check the mail. She pops up like she's ready to go and she's walking the cul-de-sac, like you know, confident as can be, soon as we get to our house, puts on the brakes, wants to go inside. It is what it is. I only have so much, so much strength to like overcome this.

Rachele Burriesci: 4:33

But she stopped at the car and she likes to go for car rides and I was like you know what? Let's just let's run to Starbucks. I haven't had a pumpkin spice latte and it feels like fall. So it feels like the right time to do this. So I jumped in the car. It's only a few blocks away. So I order my basic pumpkin spice latte and there's no one in front of me, right? So like there's not a line, there's literally. I order, I'm at the window and as I'm approaching the window, I'm opening my swing pack and I realized that I took my wallet out of my swing pack to put her treats in.

Rachele Burriesci: 5:11

No big deal, it's the world of technology. So I quickly, I was like, just give me a second, I'm going to open up my Starbucks app because you could pay off of that. I opened the Starbucks app and it has logged me out. Problem is it's Nikki's account and I don't have her password written down. So you know, face ID is not working. I don't have the login. I don't have time to text her because I'm literally at the window.

Rachele Burriesci: 5:37

So I asked do you take Apple Pay? They do, which is wonderful. It has literally saved me like three times in these random episodes and all three times I have no idea how I've gotten to the little scanny-do to pay with Apple Pay. So I pull up my Apple wallet, I get to my Apple card, I can pay my card. In this part of the app I can do all sorts of things. I can give my credit card number if I needed to, but I don't have an instruction on how to actually pay with Apple Pay.

Rachele Burriesci: 6:12

And you know, when you're like I wasn't panicking, but I was like starting to get there, like the stress is rising. She's already handed me my damn coffee? I haven't. I'm like this is a stupid question. Do you know how to get to Apple Pay? She's like, yeah, just double click the button. And she pulls up her phone. She shows me which button to click. I'm like, oh great, Okay, I do it. It locks me out. It literally closes out my phone. I'm like it put me to the lock screen. So I'm like, oh, I must've just not got a double click. I do it again, locks me out again.

Rachele Burriesci: 6:44

She, and like the most you know calm Gen Z voice, tells me you just double click it twice. Like this Boom, boom. I understand what you're saying. I'm clicking the freaking button. It's not happening, all right. So I'm like, trying to not panic, I finally get the damn thing up with a double click after the seventh attempt.

Rachele Burriesci: 7:08

She hands me the little thing to scan. I face it down and nothing's happening. I'm like, here we go, here we go. I like am showing my age. Right now I can't freaking use Apple Pay. Every little scanner is different. Sometimes it's on the top, sometimes it's on the side, sometimes it's on the bottom. Well, apparently there was a question for adding a tip which she didn't actually like. Show me. So I'm just holding it against the screen. She's like just put it face down. I'm like all right, here we are.

Rachele Burriesci: 7:39

Listen, in real life I'm typically pretty technologically sound. Apparently, I cannot use Apple Pay. I can run my mother's computer in New Jersey from Kansas City. I can fix her printer across the country. I can't freaking use Apple Pay. So, needless to say, now I know how to do that. If anyone here is in the same predicament where you're like, I have no idea how to access Apple Pay. Literally, if you have an iPhone, you double click the button on the right side and yes, if you don't click it twice, good enough, it's going to lock your screen right side. And yes, if you don't click it twice, good enough, it's going to lock your screen. Second piece of advice if you don't have Apple Pay set up on your phone, it might be worth doing, because it has literally saved me three different times when I've walked out of the house without a wallet. So there's my two cents on Apple Pay and technology.

Rachele Burriesci: 8:35

But I had one of those embarrassing panicky moments and I can just see Rems in the back. She's like you know what? This is ridiculous. Now you've just embarrassed all of us at this episode. So pumpkin spice latte was good, I was able to pay for it, I felt really old and hopefully I have taught you something. If you did not know how to do that, and if you do and you're judging me wholeheartedly, you're welcome for this conversation.

Rachele Burriesci: 9:05

All right, I wanted to jump into today's episode. I was actually going to go over a case. I've had some fun patients in the last few weeks that are not and I'm using air quotes cardiopulmonary patients, who are very much cardiopulmonary patients, and one person in my mind really sticks out who was an ortho trauma case. So he's a 52 year old male. Uh sat as post motorcycle crash. So he had a high speed crash and he has a number of injuries, considering minor but left-sided injuries nonetheless. So what do we got on our list? We have left scap fracture. We have left medial malleolar fracture, a left distal fib fracture. The distal fib fracture was reduced in the emergency department. They called it non-operative but they were planning on fixating later. So he has a planned OR for the fibula in the future.

Rachele Burriesci: 10:15

He was in a cast or a splint when we came in. He also had small left hemoneumothorax. He also had multiple left rib fractures from rib three to seven and he had a mild pulmonary laceration of his left upper lobe. So this ortho trauma case that really is, you know, left lower extremity non-weight bearing type case, he's now a true cardiopulmonary case. So he was non-weight bearing left lower extremity. He was weight bearing as tolerated left upper extremity with that left scap fracture, but they wanted him in a sling. We needed some more confirmation on range of motion restriction or privileges but we had not received that yet. So left upper is in a sling but he's weight-bearing as tolerated in theory.

Rachele Burriesci: 11:12

Left lower is non-weight-bearing 52 years old, acute care ortho trauma case. You know, when you have both arms involved, painful wise. Oh, and he also has road rash. He has 10% of his body is covered in road rash, primarily upper extremities, but I did not visualize chest as well. Actually the burn team was finishing up when we were going in.

Rachele Burriesci: 11:41

So from an acute care perspective, right like this, is that transfer case that you're trying to figure out what's going to be his best mode of independence moving forward. At this moment he's either going to be a squat pivot transfer or a slideboard transfer to his right and, pending range of motion information for left upper, maybe would be able to progress something in the stand, pivot, maybe short distance ambulation. But it really all depends on what they want for that left upper extremity scab fracture if they're going to allow range of motion as tolerated since they're allowing weight bearing as tolerated. So we didn't get clarification on that. So primary thing right now is, you know, squat, pivot versus slideboard transfer. Great, he did wonderful, popped right over, didn't need the slideboard, was able to control it Okay and overall, considering he had high pain overnight, he was tolerating pretty well.

Rachele Burriesci: 12:45

But his primary complaint was pain in his left ribs, especially with deep breathing, and he was terrified to cough. I am so excited to teach you this thing. So you know, on paper he does have some cardiopalm diagnostic things. He actually has a lung laceration, he has rib fractures. But big picture acute care, don't just get stuck on the ortho trauma transferring stuff or gait training stuff or gait training stuff. He needed a ton of cueing. He was a fun cardiopalm assessment and he did better right Once he had some cues. So from an assessment perspective, we did chest wall assessment just watching his rib cage motion. Rib cage motion I performed anterior upper and anterior lower. I did not assess posterior, but that's what I would do.

Rachele Burriesci: 13:57

The next session, especially with scap involvement, had decent diaphragm excursion but I didn't want to test via the sniff technique because that would increase pain to left ribs and potentially lose some of that. You know rapport and trust in what we were going to do. Next, auscultation diminished left side compared to right. Otherwise good breath sounds clear but left side super diminished. On assessment he had minimal excursion left, lateral, lower as well as upper, just very guarded. All of his movement was to the right for the most of it.

Rachele Burriesci: 14:38

So primary thing that we did was lateral costal breathing and segmental breathing. So in the beginning I just had both hands on his chest and I talked him into what that would look like and just explaining that my hand is just going to be placed here and to think about my hand placement. So I kept it lateral costal, both sides to allow him to take a big breath and expand bilaterally. Once we were starting to get motion on both sides and again, no overpressure on the left because we have multiple active fractures I switched just to segmental breathing and so I had flat hand along the lateral three, four, five, six, seven. I kind of adjusted as we went and primary concentration was just breathing into that hand, full concentration, calm breathing.

Rachele Burriesci: 15:36

Once he was getting more excursion, we moved into inspiratory holds with segmental breathing. So I had him inhale, hold long, slow, exhale out. We started super low, one to two, build the trust, one to two, we got as far as two to four and I left it there because he was getting good movement and he was not in extraordinary pain. Before we actually moved into lateral costal breathing, segmental breathing, I had him do incentive spirometer just to see his effort. His effort was pretty good but he didn't get a lot of motion and his inhale attempt wasn't very long. After we did lateral costal breathing, segmental breathing, he was able to increase up to. I believe we were at 750 to start and he went up to 1500 post. So just a little bit of cueing him to take a bigger inhale Post breathing exercises.

Rachele Burriesci: 16:46

Left side had better air movement. Was it equal? No, it was still diminished upper and lower but it was more than the start. So pre and post assessment can be super helpful with auscultation and or incentive spirometer and you can show that pre post. We also practice coughing. So he has multiple rib fractures. They were non-displaced. He has left scap fracture on that side.

Rachele Burriesci: 17:22

So we have a number of things that are going to be painful with a cough. So placed a pillow under his arm, under his sling chicken wing style, and discussed how splinting would work. Now the difficult part with this one is that his left arm is painful to squeeze. So kept the pillow in that left side and had him use his right hand to hold the pillow as a splinting technique to allow him to actually provide pressure, because the left side was painful to hold even the pillow but was comfortable to rest. So we went through education on splinting positioning, just left the pillow right there while he was sitting up in the chair. And, of course, what did we do for cough technique that is less painful? I taught him a huff cough so he did great. He had fantastic technique. He was able to follow all the commands. He was able to get a good airy breath. He did it low in the beginning, less of an effort. He was able to get coached up to like a medium effort. He was pretty dry overall, so he doesn't have any active mucus yet, but now he has some strategies. If he does have to cough, if he has to sneeze, for that matter, he has some things that he can do.

Rachele Burriesci: 18:50

One more piece of the cardiopulmonary picture with this guy was his blood pressure. So he has a history of hypertension. He has not had his hypertension hypertensive meds since. The day before he was sitting in was pretty high at the start of our session. So he was at 180 over. I think he was low 90s, 180 over, 92 is what I have here. So we're right at the top of, you know, hypertensive urgency. Now the reason why this might not be considered a crisis a couple of reasons. Number one they're aware that his blood pressure is high. Number two he has not been appropriately medicated yet. Number three he's had a big trauma episode and has increased pain. So the team was aware, let them know.

Rachele Burriesci: 19:58

During the session. Actually he was asymptomatic for the most part and after transferring to the chair he actually dropped by 10. So on paper sometimes you might hear words like oh, his numbers look better, right, but technically it's an inappropriate response because he dropped by 10. It's not technically orthostatic hypotension, but it's an inappropriate decrease in blood pressure with activity. So after our session I did one more reassessment just to make sure he wasn't continuing to drop and he was staying right at that 170 over. I think it was high 80s, low 90s on the last take Still enough to be aware of.

Rachele Burriesci: 20:48

Now a couple of things here. If he didn't have upper extremity involvement and he was fully, weight-bearing is tolerated range of motion, tolerated bilateral opportunities and we're actually going to be working on non-weight-bearing gait. It is super important to have that in mind because the aerobic capacity that it takes to maintain non-weight bearing is very high. It is a high aerobic load and it will increase blood pressure, heart rate, all of the things, especially if you have a history and now we throw trauma, pain, everything else on top of that, you can have an over-exaggerated response. So just another plug take vitals, pay attention to them, get a starting number, because if you don't get a starting number you don't have anything to refer back to. You have no sense of where was it right. So if we just took the blood pressure in the chair and it was 170 over 80s, what does that tell us? It doesn't tell us a lot. Besides that it's elevated, the fact that he was higher than that and then dropped now says that he had a hypotensive response with activity and that he was near hypertensive urgency numbers. It's important. It's important to track it. So the reason why I said he was not fully symptomatic, he wasn't dizzy, but he did have a headache. He had a headache throughout the session. So he is hypertensive. He has a headache. Technically that could be a symptom, but he just had a pretty traumatic crash. That could also be, you know, the cause of the headache. So there are multiple layers to this thing.

Rachele Burriesci: 22:47

What's really important for me and I think part of the reason why I even started this podcast is that we have to be able to feel empowered to utilize our skills right. I've talked about the stereotypes in acute care. I've seen the stereotypes in acute care. I do not want to do just the minimum. I want to use my license and I think it's important for us to continue to push and use our license to our full extent. My only job in the hospital is not to get someone to the chair or to ambulate someone. My job is to assess this person physically to then potentially rehabilitate them to get them to the next level of care. My job is to help this person optimize their overall potential, not just two. So this person is a great example where you can say ortho trauma and stick to orthopedic, msk type stuff. Yes, there's a ton of it, but there's also a lot of cardiopulmonary and I think it's important to address it. I think it's important to give your patient strategies and those things are going to make a difference for your person.

Rachele Burriesci: 24:17

Even while we were transferring, there was education on using breath control to help with pain control in order to do that transfer successfully. So he did wonderful. He was an awesome sport, he was able to mobilize really well, he was down for all of the breathing exercises and assessment techniques and he did better overall after. He was very appreciative to that and it made a big difference, right? Because that lung laceration, that hemoneumothorax, those rib fractures they're going to take time too and they're part of this picture and it cannot be overlooked Assess, auscultate, teach breathing exercise, use your hands-on skills, teach them how to splint, be a part of that process, because that's going to maximize this person's potential.

Rachele Burriesci: 25:15

We needed more clearance on his left scap, but there are a ton more things that we can do in the world of range of motion, paired breathing, segmental breathing, posteriorly, but the first day wasn't the day to do that. We definitely needed more information on the orthopedic side in order to address the cardiopulmonary side and to further progress, mobility, right. So so many cool things there. One more thing road rash. If he has road rash on his ribs, his back, his chest, that healing process is also going to affect his breathing. It's just like a burn right. Keeping pliability of that skin is going to help the long-term picture. Giving strategies to handle pain is going to help the long-term picture. Giving strategies to discourage atelectasis is going to help the overall picture. So assess chest wall mobility, auscultate, teach the things that you know to maximize your person's overall potential, not just mobility.

Rachele Burriesci: 26:30

All right, that's all I have for you today. I hope that was helpful. I hope you got something out of this. If you have any questions, please reach out to me. If you learned something new or just enjoyed this podcast, drop me some stars, write a great review. It is 100% appreciated. I hope you all have a wonderful day and whatever you have to do, I get after it.