Speech and Language Therapy on ACCU Laura Pathak Royal London Hospital
Case Study • Diagnoses • Code Red Polytrauma. Jump from 5th Floor. GCS 4 on scene • Injuries: • HEAD: multifocal ICH, SAH, DAI 1, R sided stroke • FACE: multiple mandibular fractures • C-Spine: Right occipital condyle fracture • CHEST: R and L haemopneumothorax, Right post 6-8 Fracture, Left post 5 and 8th rib • SPINE: T7 burst comminuted fracture with retopulsion into spinal canal. T6-T8 comminuted 3 column fracture • T1-T7 and T9-T12, transverse fractures • LOWER LIMB: Right comminuted displaced Fracture NOF, open communited displaced fracture distal femur • Left Communited Displaced fractured NOF • Difficult to ventilate in ED - decision made to transfer to theatre for surgical tracheostomy on day of admission. 20/6/19: Surgical Tracheostomy, removal of teeth fragments, closure of OMFS lacerations, BL lower limb open fracture washout • Admitted to ACCU post operatively • PMHX: Bipolar: Depressive Episode Trach/Resp status : Size 7 trache cuff up 24 hours, FIO2 21%, PSV 5/5, HR 116, RR 37, SPO2 100% FVC: 1-1.5. High subglottic volumes (>80ml per day) Awake and attempting to communicate but ? Confused. WOULD YOU REFER THIS LADY? Yes ? Explain rationale No ? Explain rationale and when would you refer?
YES PLEASE!!! • Tracheostomy: • Cuff down and PMV assessment (look at upper airway patency, secretion management, swallow function, response to airflow, voice assessment. Look at starting trache wean for swallow/communication and QOL benefits. Liaise with H&N team regarding facial fractures • Communication: Assessing communication competence, yes/no, receptive, expressive, speech, cognition, cuff up and down, types of AAC. Differential diagnosis • Dysphagia/Swallow assessment for oral intake – bedside vs FEES vs Videofluoroscopy. Therapeutic trials, swallow rehab etc
Role of SLT on ACCU To assess, diagnose, and manage; 1. Dysphagia (complex and often multifactorial on ACCU population) - Neurological: CN V, VII,IX,IX & X, XII, brainstem/cortical changes - Structural i.e. ACDF, VC palsy, spinal surgery, pharyngeal pouch etc. - Post extubation – Research variable – from 3-62%, higher rate of silent aspiration, correlation between increased length of time with ETT and increased risk of dysphagia - Cognitive behavioural (unable to self feed, bolus holding, poor awareness of task etc) - Patients with respiratory dysfunction (COPD) - ITU acquired weakness - Medications - SECRETION MANAGMENT 2. Communication – Think about areas of injury - Aphasia, apraxia, dysarthria, cognitive communication disorders, (fewer than 50% of patients with CCD are referred to SLT) - Assessments for AAC for intubated patients/patients with cuff inflated (and unable to wean). - Support capacity assessments 3. Tracheostomy Commencing trache wean, starting when on ventilator (A-L Sutt research may aid lung recruitment) Assess upper airway competence/patency, secretion management, swallow function, voice, communication, need for AAC, considerations for Above Cuff Vocalisation. 4. Instrumental assessment FEES and VFS 5. Palliative care. Eating and drinking at risk 6. DOC – commencing CRS-R/WHIM assessments
Role of SLT on ACCU To assess, diagnose, and manage; 1. Dysphagia (complex and often multifactorial on ACCU population) - Neurological: CN V, VII,IX,IX & X, XII, brainstem/cortical changes - Structural i.e. ACDF, VC palsy, spinal surgery, pharyngeal pouch etc. - Post extubation – Research variable – from 3-62%, higher rate of silent aspiration, correlation between increased length of time with ETT and increased risk of dysphagia - Cognitive behavioural (unable to self feed, bolus holding, poor awareness of task etc) - Patients with respiratory dysfunction (COPD) - ITU acquired weakness - Medications - SECRETION MANAGMENT 2. Communication – Think about areas of injury - Aphasia, apraxia, dysarthria, cognitive communication disorders, (fewer than 50% of patients with CCD are referred to SLT) - Assessments for AAC for intubated patients/patients with cuff inflated (and unable to wean). - Support capacity assessments 3. Tracheostomy Commencing trache wean, starting when on ventilator (A-L Sutt research may aid lung recruitment) Assess upper airway competence/patency, secretion management, swallow function, voice, communication, need for AAC, considerations for Above Cuff Vocalisation. 4. Instrumental assessment FEES and VFS 5. Palliative care. Eating and drinking at risk 6. DOC – commencing CRS-R/WHIM assessments Other: Attend Trache ward round Attend LTBR Project work to improve care etc
VFS/FEES
Referrals - Response Time: - Dysphagia/Trache 24 hours - Communication 48 hours We do not have blanket referrals – reliant on MDT - to refer via CRS - Swallow screen available on CRS - We aim to see patients between 1-3 sessions per week dependent on need Priority 1 Priority 2 To be seen within 1 working day To be seen within two working days Initial swallow assessment for potential dysphagia when Initial assessment of swallow for potential dysphagia with patient is NBM with no alternative feeding alternative feeding in place High risk of developing aspiration pneumonia or coughing / choking on oral intake Initial communication assessment – high patient distress or Initial communication assessment – low patient distress, able unable to meet basic needs to meet basic needs or mild deficit Initial joint assessment with physiotherapist to commence tracheostomy wean Awaiting discharge home the same day / MDT input needed to coordinate d/c plan
Swallow Screen Only administered by Nurses, Doctors and AHPs • Available on the Trust intranet (type ‘swallow screen’ into • the search engine) For any patients who you are wanting to commence • oral diet and fluids If a patient passes a swallow screen but you still have • concerns about swallow safety / chest status please do contact SLT. Patient’s can silently aspirate ! Not for patients who are already under care of SLT OR • who have already had a swallow screen and failed
Our team… - Lead SLT’s for ACCU are Laura Pathak and Lucy White (B7) - Support from rotational B6 Sarah Stagnell - ACCU also team cover Trauma wards (12C, 12D and 10F) - As a small team we also cross cover other streams dependent on need - 5 day a week service 8:30am-4:30pm. - Refer via CRS and for queries/discussion call office on 41140 or bleep 1877 - Also H&N SLT team on ext 41185
Questions…..
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