Medical and Neurologic Complications and Comorbidity Management
Anticipate, screen, and differentiate
After stabilization, the rehabilitation clinician's job is complication surveillance. Seizures: early seizures (<7 days) are common and justify up to 7 days of prophylaxis (levetiracetam or phenytoin), which does not prevent late post-traumatic epilepsy. Late epilepsy risk rises with cortical contusion, intracranial hematoma, depressed skull fracture, penetrating injury, and a seizure in the first 24 hours. Post-traumatic hydrocephalus presents with gait decline, incontinence, and cognitive worsening - often weeks later - and is evaluated with imaging plus a lumbar drain or CSF tap trial. Heterotopic ossification (hip, shoulder, elbow) shows swelling, warmth, and reduced range with elevated alkaline phosphatase; triple-phase bone scan is sensitive early, and NSAIDs such as indomethacin are used for prophylaxis in high-risk patients. Paroxysmal sympathetic hyperactivity produces paroxysmal tachycardia, hypertension, tachypnea, fever, diaphoresis, and dystonic posturing; it is a diagnosis of exclusion.
Also screen for VTE, aspiration and dysphagia, ventilator-associated pneumonia, urinary infection, pressure injury, contracture, endocrine dysfunction, sleep apnea, pain, and cranial nerve deficits. Carotid-cavernous fistula after base-of-skull fracture causes pulsatile proptosis and chemosis; CSF leak causes positional headache and clear rhinorrhea.
Traps: calling every fever-plus-tachycardia 'dysautonomia' without a sepsis workup; treating HO as DVT; assuming early prophylaxis prevents late epilepsy.
Rule of thumb: new neurologic decline after TBI means scan, then consider hydrocephalus, seizure, medication effect, and infection.
Worked example: six weeks after severe TBI, a patient develops sweating, HR 132, BP 168/96, temperature 38.4°C, and extensor posturing during turns. Exclude infection, PE, and withdrawal first; if cultures and imaging are negative, treat as PSH with scheduled gabapentin or clonidine plus trigger avoidance, and document response.