Complications in Assessment and Treatment in Disasters and Conflicts

Original Editors - Naomi O'Reilly

Top Contributors - Naomi O'Reilly, Kim Jackson, Jess Bell, Rucha Gadgil and Olajumoke Ogunleye      

Introduction

As highlighted in the Early Rehabilitation in Conflicts and Disasters Field Manual, secondary complications are much more prevalent in disaster and conflict settings because of damage and disruption to health systems and infrastructure. However, they can also be related to inadequate access to health care and follow-up in emergency situations. Being able to recognise and mitigate for these risks factors for complications following disasters and conflicts is vital if we are to minimise and prevent further impairment.

Wound Infections

Wound and surgical site infection is common in disaster and conflict settings and can negatively impact wound healing, and increase impairment and patient morbidity. While most common in the early phases of disasters and conflict, this can continue to be an ongoing, longer-term issue if there is damage and disruption to water supplies, infrastructure, and health systems. Living in overcrowded, high density, insanitary settlements with reduced access to consumables (hygiene products) and medications (e.g. antibiotics) exacerbates the risks of infections. The effects of these infections can be devastating, creating risks to life and limb. Risk factors for wound and surgical site infection include diabetes , older age and smoking, but in disaster and conflict settings, the following types of injuries and conditions significantly increase the risk of infections:

• Open injuries with high levels of contamination (crush or blast injuries) - associated with a very high risk of infection.
• Small skin lacerations that come in to contact with untreated water (tsunamis, flooding).
• Minor burns / wounds and post-operative patients.
• Open fractures and prolonged external fixation can significantly increase the risk of osteomyelitis.
• Overcrowded and unsanitary conditions with poor access to clean water.
• Early discharge with wound care completed by non-medically trained individuals who may lack the resources or understanding to adhere to high standards of wound, graft or external fixation care.

Understanding the expected timeline of wound healing and the body's response to injury is vital in patient education and differentiating normal wound healing from the signs and symptoms of infection. This article also contains links to wound assessment and wound debridement, so you can better understand these procedures. Remember that wound care is a specialised skill and should not be performed without the proper training.

Infectious Disease

Infectious diseases are those that are spread from one person to another through a variety of methods. Vaccine-preventable (Measles), food-borne (Salmonella, E-coli), zoonotic (Ebola), and healthcare-related infectious diseases pose significant threats to human health and may sometimes threaten international health security. How these diseases spread depends on the specific pathogen or infectious agent and means of transmission. Infectious disease outbreaks may occur as secondary consequences of disasters and conflicts and are often due to an exacerbation of endemic diseases. Factors associated with outbreaks include contamination of water supplies, destruction of health services or displacement of people with consequential overcrowding, as well as longer-term disruption of vaccination and treatment programmes in conflict settings.

Common communicable diseases seen in emergencies include diarrhoeal diseases (including cholera), acute respiratory infections (pneumonia), measles, and vector-borne diseases (such as dengue fever and malaria). Access to safe drinking water, vaccination programmes and rapid case identification and case management are vital to preventing outbreaks of infectious disease.

Read more here about Communicable Disease and check out our Communicable Disease Category which provides information on many other common and not so common infectious conditions.

Inadequate Pain Control

The most widely accepted and current definition of pain is "an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage." Pain is complex and multi-dimensional and is often considered an inevitable consequence of physical injury in disaster and conflict setting. However, pain management is often neglected within these settings, particularly in the early days of a response, or in conflict situations, where adaptive approaches to analgesia and pain management are often used due to reduced assess to medications. The World Health Organization includes paracetamol, non-steroidal anti-inflammatories and opioid-based analgesics within the essential drugs lists, so they are more likely to be available than other pain medication, such as amitriptyline, which can be used (if appropriately prescribed) for neuropathic pain.

Rehabilitation professionals play a key role in assessing and managing pain. Management includes non-pharmacological pain treatments and advising the medical team on need for analgesia. In particular, they need to ensure that optimum pain relief coincides with dressing changes or treatment. Rehabilitation professionals should not prescribe or advise on medication use beyond their scope of practice.

Note: Extended scope rehabilitation prescribers may not be able to prescribe in another country if this is not within the defined scope of your profession within that country. You must ensure you are familiar with what is allowed within the country you are working in.

Read more here about the Pain Assessment, Pain Medications, Pain Modulation, Pain Management of the Amputee and Pain Management in Spinal Cord Injury.

Missed Injuries

Given the overwhelming numbers of patients, the complexity of injuries, and the disruption and damage to health systems and infrastructure, including reduced access to medical diagnostic tools such as laboratory, imaging and nerve conduction studies, some injuries, including those that can cause significant impairment, are missed in the early phase of a disaster and conflict emergency response.

Rehabilitation professionals may be the first to assess individuals following stabilisation and surgery. Thus, they may be the first to recognise or identify missed injuries or other conditions, such as peripheral nerve injuries, non-displaced fractures or mild to moderate brain injuries, sometimes days or even weeks after the injury has occurred. The rehabilitation professional needs to always look out for any unexplained symptoms or signs of deterioration in their patient, and always report these to the medical and surgical team.

To monitor for signs of missed conditions or injuries, rehabilitation professionals can:

• Check with caregivers for unexplained symptoms
• Check with the patient for unexplained symptoms
• Monitor for any changes in symptoms at each patient review

Pressure Ulcers

The National Pressure Ulcer Advisory Panel, U.S (NPUAP) defines a pressure ulcer as an area of unrelieved pressure over a defined area, usually over a bony prominence, resulting in ischemia, cell death, and tissue necrosis. A pressure ulcer can develop in a few hours, but the results can last for many months and even cause death. A number of contributing or confounding factors are associated with pressure ulcers, but the significance of these factors is yet to be elucidated. Tissue injury is related to both extrinsic and intrinsic factors:

• Extrinsic factors include pressure, shear, friction, immobility, and moisture

• Intrinsic factors relate to the condition of the patient - i.e. sepsis, local infection, decreased autonomic control, altered level of consciousness, increased age, vascular occlusive disease, anaemia, malnutrition, sensory loss, spasticity, and contracture.

Many traumatic injuries can increase the risk of pressure ulcers developing, particularly in conditions that combine reduced sensation (like spinal or peripheral nerve injuries or brain injury) with reduced movement (like spinal injuries, brain injuries, amputations, or patients on traction). There is evidence of an increase in pressure ulcers in patients, particularly in those with spinal cord injury, and traumatic brain injury in conflicts and disasters, because of inadequate pressure relief, staff shortages, lack of education for carers, poor nutrition and hydration, poor bladder and bowel care.

Read more here about the prevention and management of Pressure Ulcers

Respiratory Complications

There are multiple ways in which conflicts and disasters can affect the respiratory system. There are obvious direct causes, such as flooding and tsunami (aspiration pneumonia was a significant issue following the 2004 Indian Ocean tsunami in Aceh), actual chest trauma, inhalation of smoke or volcanic smog. In situations of displacement, overcrowding and damp, insanitary living conditions, acute respiratory infections are also a major cause of morbidity. Patients who are immobile following injury or surgery are also at risk of respiratory complications, as are those who have suffered neurological injury, such as a spinal cord injury or stroke. Disease outbreaks like measles can also lead to respiratory complications, such as pneumonias, particularly in children. Finally, recent re-emerging trends in conflicts have included the use of poisonous gases, including chlorine, which can cause respiratory complications.

Read more here about Respiratory Assessment, Respiratory Management for Traumatic Brain Injury, Respiratory Management in Spinal Cord Injury and Signs of Respiratory Distress in Children.

Malnutrition

Malnutrition means ‘poor nutrition’. It occurs when there is a deficiency of energy and nutrients in the diet which causes a measurable clinical outcome or impact on body composition or function. As such, malnutrition can apply to people who are both overweight and underweight. Malnutrition leads to lower natural immunity, which often results in increased risk of infectious disease and increased progression of disease. In disaster and conflict settings, it can impair recovery and healing and increase morbidity and mortality. The drivers of malnutrition will vary in disaster and conflict settings depending on the level of food security, nutrition practices and pre-emergency health services, as well as how these structures are now affected. Children under five suffering from severe acute malnutrition are at high risk of suffering long-term cognitive and physical impairments, with play-based therapy vital once these children are medically stable.

Nutrition has a significant impact on an individual's health throughout the life-span, and has an impact not only on healing and recovery in acute injury but on many chronic conditions. While rehabilitation professionals may not be specifically involved in providing nutritional advice, they should understand the importance of nutrition and recognise when it may be necessary to refer a patient on for nutritionist support

Rehabilitation professionals should have a basic understanding of the role of nutrition and severe micronutrient deficiency post injury on healing and recovery, and where possible, work with the team to ensure provision of adequate nutrition. Being aware of common nutritional deficiencies in the area you are working in and how to identify them is important so you can make onward referral to address any specific needs. Rehabilitation professionals should be able to assess for malnutrition, particularly Severe Acute Malnutrition through the use of the Mid Upper Arm Circumference (MUAC) in order to be able to identify those who require further specialist nutritional support.

Co-morbidities and Pre-Existing Health Conditions

Comorbidity or pre-existing health conditions are associated with worse health outcomes, more complex clinical management, and increased healthcare costs. Damage and disruption to health systems and infrastructure in disaster and conflict settings can result in exacerbations of chronic conditions (such as diabetes, and cardiac, cardiovascular and respiratory diseases). This can impact the management of traumatic injuries, with diabetes of particular concern for wound healing.

Disasters and conflicts also have a disproportional affect people with a disability because of inaccessible environments, loss of assistive technology or medication, loss of carer support and lack of access to regular rehabilitation and therapy services. People with a disability also have a higher incidence of traumatic injury in disaster and conflict settings. Rehabilitation professionals play a major role in ensuring active inclusion of people with disabilities in the emergency response and should work with local organisations, including disability organisations, to identify those most at risk and then to address their needs.

Ensure that during your subjective assessment, you gain a full medical history and understanding of current access to medication, assistive technology and therapy for pre-exisiting conditions. Where possible, identify referral pathways for follow-up in relation to these conditions. It is important to consider replacing damaged or lost assistive technology, or providing new assistive technology to address new injuries where possible.

Paediatric Considerations

Children make up a significant number of the patients in disasters and conflicts. There is evidence to suggest that children sustain a substantial proportion of conflict-related injuries, accounting for 34.7% of injured patients. This has serious psychological and safeguarding implications, and these must be addressed concurrently with their medical care and rehabilitation.

While in many countries, paediatrics may be considered an area of specialisation for rehabilitation professionals, in disasters and conflicts you will encounter children. Thus, it is important that you have some understanding of child development and consider children as a distinct population with anatomical and physiological differences to adults, rather than purely as mini adults. As is obvious, in paediatrics we are dealing with an immature skeletal system and hence issues related to growth are of primary importance. With the rapid changes in growth, there are also biomechanical and orthopaedic challenges throughout development that need to be anticipated and managed.

• Respiratory Considerations: Pneumonia is a leading cause of morbidity and mortality in children aged under 5 years worldwide. Up to age 3, ventilation/perfusion (VQ) matching in children is opposite to adults, with the dependent lung poorly ventilated, due to chest wall compliance. Therefore, position children good lung UP to improve VQ matching.
• Blast Injuries: Younger children in particular more likely to present with associated head and thoracic injuries. The presence of certain explosive remnants of war (such as cluster munitions) can increase the likelihood of upper limb injuries in children as they may be mistaken for toys or objects of interest.
• Socially Disadvantaged: Children with impairments may be excluded as a result of their injury, resulting in them not attending school, being kept at home or being perceived as being unable to work or marry later in life. Early education with family members and links to peer support can help mitigate this.
• Paediatric Equipment: Children require paediatric size equipment, but there may be limited availability of this equipment in disaster and conflict settings. Equipment will also need to be changed as the child grows, so there is need more frequent monitoring.
• Toys: Use of basic toys (e.g. bubbles, balloons, balls, and a mobile phone with music or videos) can be really helpful during your assessment and treatment as a distraction tool for children. Treatment needs to be modified to be play-based, activity-based and age appropriate to the child - rehabilitation should not be forced upon the child, but should be collaborative.
• Support Structures: Always involve family and support structures into all aspects of a child's care to reinforce stability. Where possible, continuity in staff and translators is important, with a preference for local staff.
• Peer and Group-Based Treatment: Peer support and group-based activities are invaluable when working with children, allowing social interaction and support.

Condition Specific Complications

Fractures

Complications following fractures are common in disaster and conflict settings and generally fall into two categories:

• Early Complications include shock, fat embolism, rhabdomyolysis, compartment syndrome, deep vein thrombosis, thromboembolism (pulmonary embolism), disseminated intravascular coagulopathy, and infection.
• Delayed complications include delayed union, nonunion, avascular necrosis of bone, reaction to internal fixation devices, complex regional pain syndrome, and heterotrophic ossification.

Read more about Fracture Complications.

Peripheral Nerve Injury

If left untreated, peripheral nerves injuries are a significant cause of impairment and disability. In disaster and conflict settings, there may be no nerve surgery or surgery might be delayed for those with neurotmesis. Common complications of peripheral nerve injuries can include swelling, painful neuromas, paralysis, possible contractures and incomplete sensory recovery, which can be a trigger for the development of complex regional pain syndrome (CRPS). CRPS can significantly impact the rehabilitation process, particularly during the early rehabilitation phase. Prevention and management of these associated complications and increasing function should be addressed by all rehabilitation professionals in the team.

Read more about Complications with Peripheral Nerve Injury.

Burns

The normal physiologic response to burns frequently places patients in life threatening situations, which can be compounded by a wide array of complications including musculoskeletal/orthopaedic complications, neurological complications, skin complications, respiratory complications, gastrointestinal complications and infection/sepsis, which may occur in the resuscitative, recovery, or rehabilitative phases. All these complications are encountered frequently within disaster and conflict settings as a result of delayed or inadequate treatment, including follow-up.

Read more here about Complications Post Burns.

Amputation

Like any surgery, having an amputation carries the risk of complications. In disaster and conflict settings the risks of many complications are increased due to the austere conditions medical professionals are working under. Surgeons will aim to reconstruct the limb to the best of their ability, taking into account soft tissue viability, bone length and other anatomical considerations. However, complex traumatic amputations following disasters and conflicts often make reconstruction more difficult. Rehabilitation professionals also need to consider the impact of underlying disease state and post-operative management on complications which can include:

• Wound infection
• Delayed healing
• Oedema
• Deep vein thrombosis
• Pain
• Pressure ulcers
• Muscle weakness
• Contractures
• Joint instability
• Autonomic dysfunction
• Bone spurs
• Heterotophic ossification

Read more about Complications Post Amputation.

Acquired Brain Injury

Medical and neurological complications determine the final functional outcome, community reintegration, and employment potential after a traumatic brain injury. Therefore, it is important to recognise the potential risks of these pathologies and to follow evidence-based protocols to minimise the risk and extent of secondary complications. Several complications can occur immediately or soon after a traumatic brain injury during the early rehabilitation phase. Severe injuries increase the risk of a greater number of more-severe complications. The presence of complications and injury related impairment impacts the quality of life of persons living with a traumatic brain injury. These problems can cause frustration, conflict and misunderstanding (for people with the traumatic brain injury as well as family members or friends). Mood and anxiety disorders and suicide risk might be increased by a combination of symptoms and neuropsychiatric factors that are often aggravated by the trauma associated with the injury.

Key signs to monitor for during the early rehabilitation of individuals following a disaster or conflict are deterioration in AVPU(which may be a sign of worsening or missed brain injury) or sudden changes in blood pressure (either increased or decreased). These may indicate a serious medical condition including excess pressure in the brain, resulting in increased intracranial pressure, or insufficient blood supply to the brain, resulting in hypoxaemia and hypoxia, all of which require immediate medical attention.

Read more about Complications in Traumatic Brain Injury.

Spinal Cord Injury

Spinal cord injury causes motor and sensory deficits, as well as autonomic dysfunctions because of the disruption between higher brain centres and the spinal cord. Autonomic dysfunction can include compromised cardiovascular, respiratory, urinary, gastrointestinal, thermoregulatory, and sexual activities. Maintaining optimal health and well-being after sustaining a spinal cord injury can be a challenge. Common secondary health conditions like pressure sores, spasms, chronic pain, and urinary tract infections often negatively affect quality of life and social participation.

Read more about Complications in Spinal Cord Injury.

Resources

Early Rehabilitation in Conflict and Disasters, Humanity and Inclusion

Rehabilitation in Sudden Onset Disasters, Humanity and Inclusion