Sign-in to Ask A Doctor - 24x7
OR
Sign in with Google
How Long Does Recovery From Shoulder Dislocation Take?
Question: My father is a Doctor and he is 85 years of age. He was in good health.
He slipped and fell on 28 th of September2016.He dislocated his shoulder and sling was put after that.He walked on his own after the fall.
On 4 th September 2016 ( after a week ) afternoon he could not get up from his bed and could not walk on his own.
Doctors checked the blood and urine and said that he has a mild bacteria infection and augmentine, panadol & citracine was given.
On Tuesday night he has taken diazipam ( 5 mg) pills overdose ( Although next morning he said 3 pills exact number not known.)He was admitted to hospital.
CT scan on the brain was normal . Other vital statistics were normal. He was drowsy and was admitted to ICU on Thursday night,
He had breathing problems and infection and pneumonia was also observed during the weekend. He was on the ventilator
A urine sample was tested on Saturday & diazipam was positive. When we talk to him he opens his eyes but shuts them immediately.
However no other movements were observed.
On Wednesday he was breathing mostly on his own & depended on the ventilator only a little. Reports have improved and other vital statistics are normal now.
However, he does not move his arms or legs. Only opening eyes when we talked to him. According to Doctors he should come out his drowsiness & wake by now.
Doctors are going to do a lumber punch to see whether any germs have entered the brain today.
Can we get diagnosis and what to do next given the situation.
He slipped and fell on 28 th of September2016.He dislocated his shoulder and sling was put after that.He walked on his own after the fall.
On 4 th September 2016 ( after a week ) afternoon he could not get up from his bed and could not walk on his own.
Doctors checked the blood and urine and said that he has a mild bacteria infection and augmentine, panadol & citracine was given.
On Tuesday night he has taken diazipam ( 5 mg) pills overdose ( Although next morning he said 3 pills exact number not known.)He was admitted to hospital.
CT scan on the brain was normal . Other vital statistics were normal. He was drowsy and was admitted to ICU on Thursday night,
He had breathing problems and infection and pneumonia was also observed during the weekend. He was on the ventilator
A urine sample was tested on Saturday & diazipam was positive. When we talk to him he opens his eyes but shuts them immediately.
However no other movements were observed.
On Wednesday he was breathing mostly on his own & depended on the ventilator only a little. Reports have improved and other vital statistics are normal now.
However, he does not move his arms or legs. Only opening eyes when we talked to him. According to Doctors he should come out his drowsiness & wake by now.
Doctors are going to do a lumber punch to see whether any germs have entered the brain today.
Can we get diagnosis and what to do next given the situation.
Brief Answer:
Read below
Detailed Answer:
I read your question carefully and I understand your concern.
It is true that Diazepam's effect should be over by now. However Diazepam has a longer effect than other drugs of the same class, it is stored in the fatty tissue and may be released slowly in the blood in the following days. For that reason the half life of its active metabolite (desmethyldiazepam) can be up to seven days, but remember that in the elderly because of differences in metabolism that half life can be much longer.
Furthermore there is the issue of the breathing problems and the infection you mention over the weekend, fever and changes in blood arterial gases as well as in electrolytes can all lead to diminished level of consciousness. That is even more true in the elderly which are more fragile to these alterations.
So for the moment I would say that there shouldn't be any other diagnostic steps, only close monitoring, checking continuously vital parameters and repeat lab tests.
Whether there is the possibility of there being some primary lesion of the brain (as opposed to it suffering due to diazepam, metabolic changes and infection)? ...it can not be excluded, a CT scan does not completely exclude that, especially for lesions of the posterior part of the brain, the brain stem and cerebellum which are not well visualized by the CT. For that purpose if all the other systems remain stable and he still is not improving, in time a MRI should be done. However for the moment I would wait some more given that there are the other possible explanations I mentioned above. In the meanwhile the lumbar puncture will exclude the possibility of infection which would warrant urgent treatment.
I remain at your disposal for further questions.
Read below
Detailed Answer:
I read your question carefully and I understand your concern.
It is true that Diazepam's effect should be over by now. However Diazepam has a longer effect than other drugs of the same class, it is stored in the fatty tissue and may be released slowly in the blood in the following days. For that reason the half life of its active metabolite (desmethyldiazepam) can be up to seven days, but remember that in the elderly because of differences in metabolism that half life can be much longer.
Furthermore there is the issue of the breathing problems and the infection you mention over the weekend, fever and changes in blood arterial gases as well as in electrolytes can all lead to diminished level of consciousness. That is even more true in the elderly which are more fragile to these alterations.
So for the moment I would say that there shouldn't be any other diagnostic steps, only close monitoring, checking continuously vital parameters and repeat lab tests.
Whether there is the possibility of there being some primary lesion of the brain (as opposed to it suffering due to diazepam, metabolic changes and infection)? ...it can not be excluded, a CT scan does not completely exclude that, especially for lesions of the posterior part of the brain, the brain stem and cerebellum which are not well visualized by the CT. For that purpose if all the other systems remain stable and he still is not improving, in time a MRI should be done. However for the moment I would wait some more given that there are the other possible explanations I mentioned above. In the meanwhile the lumbar puncture will exclude the possibility of infection which would warrant urgent treatment.
I remain at your disposal for further questions.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Hi Dr. Olsi Taka.
Thank you very much for your respond Dr. Taka, Although doctors suggested to do a lumber puncture it was not done due to blood clotting problem. (On the second day of the overdose antidote flumaznil was given
I could not mention this in my previous mail).
However, he responded on 16th Friday.He was moving his hands & head responded to questions asked by nodding his head. Ventilator was removed.On Sunday evening he was put to a
general ward from ICU. He has been put on nasal feeding and has a oxygen mask now. Yesterday ( 20th) there was increase of white cells and
he has been given antibiotics. He does not talk ( may be due to the mask) but keeps his eyes open sometimes.& moves his hands.
However, he does not seem to move his legs.
Can you please diagnose the problems and what steps to be taken next. Further can you suggest things that can be given since he must be weak now.
He has been hospitalized for 2 weeks.
Thank you very much for your respond Dr. Taka, Although doctors suggested to do a lumber puncture it was not done due to blood clotting problem. (On the second day of the overdose antidote flumaznil was given
I could not mention this in my previous mail).
However, he responded on 16th Friday.He was moving his hands & head responded to questions asked by nodding his head. Ventilator was removed.On Sunday evening he was put to a
general ward from ICU. He has been put on nasal feeding and has a oxygen mask now. Yesterday ( 20th) there was increase of white cells and
he has been given antibiotics. He does not talk ( may be due to the mask) but keeps his eyes open sometimes.& moves his hands.
However, he does not seem to move his legs.
Can you please diagnose the problems and what steps to be taken next. Further can you suggest things that can be given since he must be weak now.
He has been hospitalized for 2 weeks.
Brief Answer:
Read below.
Detailed Answer:
Thank you for the additional information. I was actually wondering why had they not given Flumazenil, but since it would be too late to give it at that stage didn’t mention it.
Since his white blood cell count has increased then there is an active infection. Antibiotics have been started only yesterday so they may need some time to work. Also at times the initial antibiotics may not be effective enough that is why blood cultures are also needed to evaluate whether antibiotic changes are needed.
Regarding the lumbar puncture, whether it is really necessary or not depends on whether there are signs of brain infection on physical exam, signs like neck rigidity for example. If there are no such findings then no need to suspect such an infection. If there is doubt from physical exam and lumbar puncture can’t be done then a MRI with contrast can also evidence brain infections.
It is also unclear what do you mean by blood clotting problem. I have been assuming that all blood tests had been normal but now that you mention that, I wonder if that is the case. Remember that suffering of all other systems may affect the brain as well, the kidney, liver, blood, lung etc can all affect the work of the brain. So I wonder what the results of his other blood tests are.
Apart from brain conditions which can be excluded with MRI there is also another neurological diagnosis which must be considered by your doctors, that of critical illness neuropathy and myopathy. It is as a result of the inflammatory state in the body leading to damage to the peripheral nerves and muscles, manifesting weakness. It is common in patients with prolonged illness especially coming from the ICU. That is diagnosed by evaluating motor strength, reflexes and if suspected with nerve conduction studies.
In terms of what else to do, if unless the tests show something specific treatment remains supportive, by feeding and keeping him hydrated and manage complications like infections and metabolic changes. Nutritional supplements may be given if it is deemed that feeding by nasogastric tube is not enough, they can be given by the tube or intravenously.
Let me know if I can further assist you.
Read below.
Detailed Answer:
Thank you for the additional information. I was actually wondering why had they not given Flumazenil, but since it would be too late to give it at that stage didn’t mention it.
Since his white blood cell count has increased then there is an active infection. Antibiotics have been started only yesterday so they may need some time to work. Also at times the initial antibiotics may not be effective enough that is why blood cultures are also needed to evaluate whether antibiotic changes are needed.
Regarding the lumbar puncture, whether it is really necessary or not depends on whether there are signs of brain infection on physical exam, signs like neck rigidity for example. If there are no such findings then no need to suspect such an infection. If there is doubt from physical exam and lumbar puncture can’t be done then a MRI with contrast can also evidence brain infections.
It is also unclear what do you mean by blood clotting problem. I have been assuming that all blood tests had been normal but now that you mention that, I wonder if that is the case. Remember that suffering of all other systems may affect the brain as well, the kidney, liver, blood, lung etc can all affect the work of the brain. So I wonder what the results of his other blood tests are.
Apart from brain conditions which can be excluded with MRI there is also another neurological diagnosis which must be considered by your doctors, that of critical illness neuropathy and myopathy. It is as a result of the inflammatory state in the body leading to damage to the peripheral nerves and muscles, manifesting weakness. It is common in patients with prolonged illness especially coming from the ICU. That is diagnosed by evaluating motor strength, reflexes and if suspected with nerve conduction studies.
In terms of what else to do, if unless the tests show something specific treatment remains supportive, by feeding and keeping him hydrated and manage complications like infections and metabolic changes. Nutritional supplements may be given if it is deemed that feeding by nasogastric tube is not enough, they can be given by the tube or intravenously.
Let me know if I can further assist you.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
On Thursday evening my father was admitted to icu because of intestinal bleeding. Yesterday he was conscious and complained that he is hungry. Now because of the bleedind they dont give him food. They are giving him plasma. They say that they cannot do coronoscopy given his situation. Can you please tell what other tests that can be done to verify the point of bleeding and the treatments that can be done to improve his condition.
--
--
Brief Answer:
Read below.
Detailed Answer:
Hello again! I am sorry that new complications have appeared. That is at times the case with the elderly where one issue may often lead to another given their more fragile state and lower capacity to react to situations with increased needs.
If no colonoscopy is possible, among other tests which may be considered would a scintigraphy, where red blood cells containing a tracer are injected in order to visualize their course and the pint of bleeding.
Other alternatives would be an angiography or angio CT.
As for management if no colonoscopy may be done it usually is only supportive management. Of course if he has a clotting problem that should be addressed.
At times vasopressin injection, a drug which constricts blood vessels is used but there are risks of complications like cardiac infarction especially in an elderly individual. If a precise site is identified from testing in some centers embolization is done, through angiography a tiny catheter is inserted in the bleeding vessel to inject a substance to close the vessel.
Read below.
Detailed Answer:
Hello again! I am sorry that new complications have appeared. That is at times the case with the elderly where one issue may often lead to another given their more fragile state and lower capacity to react to situations with increased needs.
If no colonoscopy is possible, among other tests which may be considered would a scintigraphy, where red blood cells containing a tracer are injected in order to visualize their course and the pint of bleeding.
Other alternatives would be an angiography or angio CT.
As for management if no colonoscopy may be done it usually is only supportive management. Of course if he has a clotting problem that should be addressed.
At times vasopressin injection, a drug which constricts blood vessels is used but there are risks of complications like cardiac infarction especially in an elderly individual. If a precise site is identified from testing in some centers embolization is done, through angiography a tiny catheter is inserted in the bleeding vessel to inject a substance to close the vessel.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
Get personalised answers from verified doctor in minutes across 80+ specialties
