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Acute Care Management of a Patient with Multiple Trauma

Original Editor - Rebecca Downey

Top Contributors - Ewa Jaraczewska and Jess Bell  

Introduction

It is estimated that multi-trauma or polytrauma is present in as many as 40% of individuals admitted to hospital with trauma.[1] Many patients with multi-trauma will require intensive care. While in intensive care, patients with multiple traumas are often exposed to interventions that promote extended periods of immobilisation, such as mechanical ventilation, sedatives, analgesics, and medications to control anxiety and agitation.[2] These patients are also at risk of intensive care unit-acquired weakness (ICU-AW). ICU-AW is associated with a range of complications, including joint contractures, thromboembolism, pressure injuries, atelectasis, pneumonia, prolonged weaning from mechanical ventilation, delirium, and long-term disability.[2] Prolonged hospitalisation can also have a significant social impact, including lost income, an inability to provide for family and a disruption to previously established social roles.

Early acute care rehabilitation initiated in the intensive care unit (ICU) can positively affect a patient's functional status, muscle strength, time spent on mechanical ventilation, walking ability at discharge, and health-related quality of life.[2][3] Moreover, a multidisciplinary rehabilitation approach appears to be an effective way of improving outcomes for trauma patients.[4]

Multiple Trauma

The terms multi-trauma, multiple trauma and polytrauma are often used interchangeably to describe patients with significant injuries across two or more body regions or organ systems.

Major trauma is a related term. It is defined as an injury with an Injury Severity Score (ISS) of greater than 15.[5][6] The ISS is an anatomical scoring system used to classify the severity of trauma. It is mainly used for research, trauma registry, and benchmarking purposes rather than for bedside decision-making. In the ISS, the body is divided into six anatomical regions. The most severe injury in each region is given an Abbreviated Injury Scale (AIS) score. The final ISS score is the sum of the squares of the AIS scores from the three most severely injured regions.[7][8]

Multidisciplinary Team Approach

Patients with complex trauma admitted to ICU benefit from early rehabilitation interventions to prevent complications and promote recovery. The acute care trauma and rehabilitation teams form a multidisciplinary team, with team members working together to set goals and create care plans. Ideally, there will be clinical collaboration between all members of the team to ensure the successful integration of medical, rehabilitative, psychosocial, and financial resources available across various specialities. Patients with multiple injuries often require input from physicians, orthopaedic surgeons, nursing staff, physiotherapists, occupational therapists, respiratory therapists, speech-language therapists (pathologists), and social workers.

The following sections provide an overview of key considerations for physiotherapists treating patients with multi-trauma in the acute care setting.

Patient Management in the Intensive Care Unit

Before initiating an assessment, physiotherapists must obtain information that will help to determine if the patient is an appropriate candidate for physiotherapy. This is completed via a chart review and discussion with other members of the multidisciplinary team.

Chart Review

Key information to gather from the chart includes any movement or weight-bearing precautions/restrictions and the fracture management plan, since the timeline of planned surgical interventions will influence a patient's functional mobility progression.[9]

Reviewing the patient's medical status and stability is also essential. This includes ventilator settings and plans for extubation, the presence of chest tubes/drains or other complications, and relevant lab values, such as haematocrit, haemoglobin and markers for acute infection (e.g. C-reactive protein (CRP) and procalcitonin (PCT)).[10]

Vital signs should also be reviewed, checking for any trends. Vital signs include blood pressure, heart rate and rhythm, temperature and respiratory rate. Trends in arterial blood gases (ABGs) must also be considered (i.e. pH, PaCO2, PaO2, bicarbonate (HCO3), and base excess (BE)).[11]

The patient's level of sedation and alertness can be assessed using the Richmond Agitation Sedation Scale (RASS). Scores range from +4 (combative) to -5 (unarousable) with 0 = awake and calm.[9]


Multidisciplinary Team Discussions

Frequent multidisciplinary discussions help physiotherapists understand social factors that affect discharge planning, identify the patient's access to resources, coordinate therapy sessions with nursing staff to support engagement in treatment, and gather additional information on the patient's cognition, agitation, and ability to follow commands. They can also gain insight into the patient's ability to participate, their haemodynamic response to activity, and the plan for ongoing medical interventions.

Assessment

To improve assessment accuracy, clinicians should determine the patient's level of alertness, screen for delirium, assess the patient's ability to follow basic commands, and establish consistent, reliable communication.[9]

The Confusion Assessment Method for the ICU (CAM-ICU)[12] can be used to screen for delirium. Please watch this video if you would like to see a demonstration of the CAM-ICU:

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[13]

The Alert, Voice, Pain, Unresponsive Scale (AVPU)[14] can be used to assess a patient's level of alertness. This scale is demonstrated in the following video:

[15]

Strategies to help establish consistent and reliable communication with a patient include checking whether the patient can consistently nod/shake their head, or blink for yes or no, and using picture or letter spelling boards.[9]

Body Systems Assessment

Table 1 provides a summary of key body systems to assess during a physiotherapy intervention, but for more information on assessing patients in ICU, please see: Physiotherapy Assessment of the Patient in ICU.

Table 1. Key Body Systems Assessment.
Body systems What to assess?
Cardiovascular

system

  • Monitor blood pressure and heart rate response to activities, such as:
    • transitioning from a supine to a sitting position
    • transitioning from a sitting to a standing position
Pulmonary system
  • Monitor oxygen response and changes in respiratory rate with activity
Integumentary system
  • Assess skin for pressure injuries
  • Assess the skin around the surgical site
  • Look for signs and symptoms of infection
Musculoskeletal system
  • Range of motion and strength, if appropriate:
    • may be hypothesised based on the patient's social history (type of work)
    • may be assessed based on a general observation of the patient's movements

Outcome Measures

The Perme ICU Mobility Scale and ICU Mobility Scale can be used to help track changes in a patient's functional mobility over time.[16][17][18]

General Rehabilitation Goals

Rehabilitation goals in the ICU may include increasing tolerance for upright mobility, completing basic activities of daily living in sitting, and incorporating breathing techniques with upright mobility. Other goals include using non-pharmacological approaches to reduce agitation and improve engagement, and applying positioning strategies to reduce pressure injury risk, pain, and oedema.

Delirium and Concussion Management Strategies

Delirium prevention and management strategies should be incorporated and shared with family and friends, including frequent reorientation, reassurance and appropriate lighting for the time of day.[19][20]

Some patients with multi-trauma may have also sustained a concussion. For these patients, strategies to reduce over-stimulation may include limiting the number of lights used and external noise (e.g. closing the door, turning off the television), restricting activities that require concentration, limiting the number of people speaking to the patient at one time, and providing mental breaks after periods of high stimulation.[21]

Patient Management Post-Intensive Care Unit

After transfer from ICU to a general ward, physiotherapists should reassess the patient (including a more detailed social history), establish specific goals with the patient, complete a systems review, work to increase independence with functional mobility, and assess the need for an assistive device.

Assessment

Assessments post-ICU should include:

Vital signs should be monitored throughout. It is also important to track the patient's progress. The Activity Measure for Post-Acute Care "6-Clicks" Short Form (AM-PAC "6-Clicks") can be useful for this; it can be completed by any provider, and it supports communication and tracking of mobility between members of the interdisciplinary team.[22]

General Aims

Rehabilitation on the ward typically focuses on improving independence, activity tolerance, breathing mechanics and secretion management. It also aims to achieve a safe return home.

Interventions

Interventions at this stage may include progressing functional mobility, educating the patient on weight-bearing status, transitioning to the least restrictive assistive device as mobility improves, and progressively increasing duration and then speed of ambulation.[9]

Pulmonary education should be delivered as needed. Topics may include the use of a cough pillow or towel roll for pain management when coughing, the active cycle of breathing, huff coughing, incentive spirometry, and inspiratory muscle training.[9]

For patients with concussion, support strategies may include visual task reminders, taking cognitive breaks during the day, and placing time limits on activities, especially those that require a lot of concentration or a lot of in-depth thought.[9]

Multidisciplinary planning supports safe community reintegration and follow-up care on discharge.[9]

Resources

References

  1. ↑ Bach JA, Leskovan JJ, Scharschmidt T, Boulger C, Papadimos TJ, Russell S, et al. The right team at the right time - Multidisciplinary approach to multi-trauma patient with orthopedic injuries. Int J Crit Illn Inj Sci. 2017 Jan-Mar;7(1):32-7.
  2. ↑ 2.0 2.1 2.2 Arias-Fernández P, Romero-Martin M, Gómez-Salgado J, Fernández-García D. Rehabilitation and early mobilization in the critical patient: systematic review. J Phys Ther Sci. 2018 Sep;30(9):1193-1201.
  3. ↑ Zhang L, Hu W, Cai Z, Liu J, Wu J, Deng Y, Yu K, Chen X, Zhu L, Ma J, Qin Y. Early mobilization of critically ill patients in the intensive care unit: A systematic review and meta-analysis. PLoS One. 2019 Oct 3;14(10):e0223185.
  4. ↑ Bouman AI, Hemmen B, Evers SM, van de Meent H, Ambergen T, Vos PE, et al. Effects of an integrated 'fast track' rehabilitation service for multi-trauma patients: a non-randomized clinical trial in the Netherlands. PLoS One. 2017 Jan 11;12(1):e0170047.
  5. ↑ Naess HL, Vikane E, Wehling EI, Skouen JS, Bell RF, Johnsen LG. Effect of Early Interdisciplinary Rehabilitation for Trauma Patients: A Systematic Review. Arch Rehabil Res Clin Transl. 2020 Jun 25;2(4):100070.
  6. ↑ Zonfrillo MR, Baird J, Spirito A, Scott K, Lee LK, Kiragu AW, et al. Comparing injury severity scores from trauma registries with those mapped from injury diagnosis codes in injured adolescents. Inj Prev. 2026 Mar 27;32(2):348-351.
  7. ↑ Javali RH, Krishnamoorthy, Patil A, Srinivasarangan M, Suraj, Sriharsha. Comparison of Injury Severity Score, New Injury Severity Score, Revised Trauma Score and Trauma and Injury Severity Score for Mortality Prediction in Elderly Trauma Patients. Indian J Crit Care Med. 2019 Feb;23(2):73-77.
  8. ↑ King S, Steinmetz J, Rudolph SS, Rosenkrantz O, Udby PM. Injury Severity Scoring in the resuscitation room-is preliminary Injury Severity Score accurate? Acta Anaesthesiol Scand. 2025 Jul;69(6):e70076.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 9.5 9.6 9.7 Downey R. Case Discussion on the Continuum of Care for a Patient with Multiple Trauma. Plus Course 2024
  10. ↑ Binnie A, Lage J, Dos Santos CC. How can biomarkers be used to differentiate between infection and non-infectious causes of inflammation? Evidence-Based Practice of Critical Care. 2020:319–324.e1.
  11. ↑ Langer T, Brusatori S, Gattinoni L. Understanding base excess (BE): merits and pitfalls. Intensive Care Med. 2022 Aug;48(8):1080-83.
  12. ↑ Miranda F, Arevalo‐Rodriguez I, Díaz G, Gonzalez F, Plana MN, Zamora J, Quinn TJ, Seron P. Confusion Assessment Method for the intensive care unit (CAM‐ICU) for the diagnosis of delirium in adults in critical care settings. Cochrane Database Syst Rev. 2018 Sep 10;2018(9):CD013126.
  13. ↑ Critical Care Nursing 101. Confusion Assessment Method (CAM-ICU). Available from: https://www.youtube.com/watch?v=slCX_6iV0fg [last accessed 26/4/2024]
  14. ↑ Romanelli D, Farrell MW. AVPU Scale. [Updated 2023 Apr 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538431/ [last access 26.4.2024]
  15. ↑ Top Hat Tutorials. The AVPU Scale. Available from: https://www.youtube.com/watch?olToUEk0Ayo[last accessed 26/4/2024]
  16. ↑ Lenard MH, Cechinel C, Zomer TB, Rodrigues JAM, Binotto MA, Spoladore R. Evidence of the use of the Perme Intensive Care Unit Mobility Score in hospitalized adults: a scoping review. Rev Lat Am Enfermagem. 2025 May 2;33:e4542.
  17. ↑ Tanaka K, Nakanishi N, Watanabe S, Morita Y, Sato S, Ono Y, et al. The construct and predictive validity of the Japanese version of the intensive care unit mobility scale. J Clin Med. 2025 Aug 18;14(16):5843.
  18. ↑ de Noray H, El Kaïm A, Blanchard F, Jacquens A. ICU mobility scale translation to French and validation. Anaesth Crit Care Pain Med. 2025 Aug;44(4):101532.
  19. ↑ National Institute for Health and Care Excellence (NICE). Recognising and preventing delirium. Available from: https://www.nice.org.uk/about/nice-communities/social-care/quick-guides/recognising-and-preventing-delirium (last accessed 8/5/2024).
  20. ↑ Department of Health, Victoria. Preventing and managing delirium. Available from: https://www.health.vic.gov.au/patient-care/preventing-and-managing-delirium (last accessed 8/5/2024).
  21. ↑ Low Stimulation Environment Guideline. Available from https://craighospital.org/wp-content/uploads/sites/Educational-PDFs/852.LowStimulationGuidlines.pdf [last access 26.4.2024]
  22. ↑ Herbold J, Rajaraman D, Taylor S, Agayby K, Babyar S. Activity Measure for Post-Acute Care "6-Clicks" Basic Mobility Scores Predict Discharge Destination After Acute Care Hospitalization in Select Patient Groups: A Retrospective, Observational Study. Arch Rehabil Res Clin Transl. 2022 Jul 16;4(3):100204.
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