S249 S290
right anterior choriodal infarction developed severe right hip pain 1
week after discharge to inpatient rehabilitation. Upon physical ex-
amination all provocative maneuvers of the right hip were negative
except for reproducible pain on internal and external rotation as well
as a positive scour test. The nature of the pain prompted plan radio-
graphs to be obtained which showed only mild narrowing of the hip
joint space as well as no presence of fractures. Days after initial
evaluation she was found unresponsive with a hemoglobin and he-
matocrit of 4.2 and 13.1 respectively, prompting emergent blood
transfusions and computed tomography (CT) of the abdomen and
pelvis.
Setting:
Inpatient Academic Rehabilitation.
Results:
CT demonstrated a large atraumatic retroperitoneal hema-
toma which was successfully treated with embolization of the two
branches of the superior gluteal artery by interventional radiology.
After stabilization the patient was eventually restarted on anti-
platelet therapy and was able to fully participate in the remainder of
her inpatient rehabilitation stay.
Discussion:
Retroperitoneal hematoma is an accumulation of blood
found in the retroperitoneal space most commonly secondary to a
traumatic event. Although bleeding can occur post rt-PA administra-
tion, it commonly presents as intracerebral hemorrhage with retro-
peritoneal hematoma rarely being mentioned in the literature,
represented in 2% of documented systemic hemorrhage. Patients
should initially be managed in a higher acuity setting or intensive care
unit with careful monitoring, fluid resuscitation, blood transfusion,
normalization of coagulation factors, and arterial embolization of the
site of bleeding.
Conclusions:
Although a rare occurrence, retroperitoneal hematoma
should be considered in the differential of patients presenting with
acute hip pain especially receiving anticoagulation or thrombolytic
therapy. Furthermore, it should be highly suspected in patients who
quickly decompensate after rt-PA therapy as it can lead to severe
morbidity and possible mortality.
Level of Evidence:
Level V
Poster 369:
Bilateral Peroneal Compartment Syndrome in a Post-
Partum Patient: A Case Report
Ingrid Yang (Rehabilitation Institute of Chicago, Chicago, IL, USA),
Christopher D. Reger, MD, Kristen T. McCormick, DO, MS,
Jason R. Koh, DO
Disclosures:
Ingrid Yang: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 31-year-old woman in the immediate
post-partum period presented to the physiatry consult service 7
days after a complicated full-term delivery with failure to progress,
requiring an emergent cesarean-section complicated by a retro-
peritoneal bleed and ureteral injury necessitating a 6-hour open
laparotomy repair. Post-operatively, she had bilateral foot drop,
foot paresthesias, and significant pain with initial diagnosis of
bilateral peroneal nerve injuries. Lumbar imaging was within
normal limits. Unresolved symptoms led to PM&R consultation,
where examination showed significant muscle swelling in the lateral
compartment of the lower legs, skin tension, and pain out of pro-
portion to exam. This prompted emergent orthopedic consultation
to rule out compartment syndrome. Intra-operative pressures were
measured at 70mmHg, necessitating bilateral fasciotomies and
fixation.
Setting:
Non-profit community hospital.
Results:
After her bilateral fasciotomies, patient was transferred to
acute inpatient rehabilitation for ongoing wound care, pain manage-
ment, and functional upgrade. She was successfully discharged home
at a modified-independent functional level.
Discussion:
Acute compartment syndrome (ACS) often occurs soon
after significant trauma, but may also develop from non-traumatic
and, in this case, iatrogenic causes. Pathognomonic symptoms
include: pain out of proportion to injury, parasthesias, paralysis,
pallor and pulselessness. However, all of the symptoms may not be
present, and the lack of one symptom does not rule out
compartment syndrome, as severe deficits may occur if not diag-
nosed early. Thorough knowledge and understanding of the
anatomical structures within the fascial compartments can prevent
severe disability and possibly death due to missed compartment
syndrome.
Conclusions:
This case highlights the importance of a wide differen-
tial and thorough examination when consulted on a patient with
complex presentation. Indeed, any tense painful muscle compartment
represents a possible ACS, and the importance of serial physical and
neurological examinations must be emphasized.
Level of Evidence:
Level V
Poster 370:
Acute Inpatient Rehabilitation Following a Diagnosis
of New Onset Refractory Status Epilepticus (NORSE):
A Case Report
Joseph G. Dadabo (McGaw Medical Center of Northwestern Uni, Cary,
IL, USA), Daniel A. Goodman, MD
Disclosures:
Joseph Dadabo: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
The patient was a previously healthy
woman who originally presented with lower extremity numbness
that later progressed to non-convulsive status epilepticus (NCSE).
She was intubated, admitted to neurointensive care, and started on
steroids and an antiepileptic drug (AED) regimen that included
phenobarbital, levetiracetam, lacosamide, and clonazepam with
gradual improvement. Her acute hospitalization lasted 35 days.
Upon admission to inpatient rehabilitation, the patient required
maximum assistance for self-care and activities of daily living.
Manual muscle testing was notable for 3/5 strength throughout all
extremities. She scored 13/30 on the Montreal Cognitive Assess-
ment. She was transferred to acute care three times during inpa-
tient rehabilitation for visual hallucinations and lethargy concerning
for NCSE. Electroencephalography was negative for new seizure
activity and in each case she was diagnosed with a urinary tract
infection. AED’s were slowly reduced during inpatient rehabilita-
tion. Her course was complicated by two mechanical falls without
injury. Following the third transfer to acute care the patient
received five days of plasmapheresis and discharged directly to
home.
Setting:
Urban Rehabilitation Hospital.
Results:
Despite a complicated course, the patient made functional
gains during her 26 days of inpatient rehabilitation. She achieved
minimum assistance for bathing; contact guard for dressing, toi-
leting, and mobility; and set-up for eating and grooming. She had
ongoing limitations with safety awareness and impulsivity, but was
determined safe for return home with family and 24-hour
supervision.
Discussion:
Patients with NORSE frequently require prolonged hospi-
talization and intensive medical intervention. Even then, prognosis is
typically poor and survivors face a protracted recovery with myriad
functional deficits. This case demonstrates the utility of inpatient
rehabilitation to optimize neurological, motor, and psychological re-
covery in patients with this rare diagnosis.
Conclusions:
A comprehensive inpatient rehabilitation program can
improve functional recovery in patients with NORSE.
Level of Evidence:
Level V
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Abstracts / PM R 9 (2017) S131-S290