Complications in Assessment and Treatment in Disasters and Conflicts

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Introduction

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Wound Infections

Wound and surgical site infection is common in disaster and conflict settings and result in negative effects on wound healing, increased impairment and patient morbidity. While most common in the early phases of disasters and conflict, this can continue to be an ongoing issue in the longer term as a result of damage and disruption to water supplies, infrastructure, and health systems, with people living in overcrowded, high density, insanitary settlements with reduced access to consumables (Hygiene Products) and Medications (Antibiotics) exacerbate the risks of infections within these settings, the effects of which 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) - 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 Insanitary conditions with poor access to clean water
• Early discharge with wound care being undertaken by non-medically trained individuals secondary to reduced community nursing access 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 to better understand these procedures. Remember that wound care is a specialised skill and should not be performed without the proper training.

Missed injuries

Faced with overwhelming numbers of patients, and often with limited access to medical assessment tools including laboratory, imaging and nerve conduction studies, it is to be expected that some conditions will be missed by medical teams when providing lifesaving care. As therapists may be one of the first members of a medical team to review patients following stabilisation or surgery, they may also become aware of missed injuries or other conditions. Commonly, these may include peripheral nerve injuries, non-displaced fractures or mildmoderate brain injuries. Sometimes these may be identified several days (or even weeks) after the injury occurred. Therapists always need to report any unexplained symptoms to a supporting medical team member, and to be aware of signs of deterioration in their patients.

Poor Pain Control

Pain management is frequently neglected in emergency settings. Rehabilitation professionals may be involved in assessing pain, advising on needs for analgesia, as well as delivering non-pharmacological pain treatments. Some therapy treatments (such as after burn injuries) should be timed to coincide with optimum pain management and dressing changes to optimise pain management. In the first days of a response, or in constrained conflict situations, adaptive approaches to anaesthesia and pain management may be used by the clinical team, as the type and quantity of medications available may be limited. Surgically, nerve blocks and ketamine are commonly used instead of general anaesthesia in conflict and disaster settings. Paracetamol, non-steroidal anti-inflammatories and opioid based analgesics are all on the WHO essential drugs list and so are more likely to be available than other pain medication, as is as amitriptyline, which can be used (if appropriately prescribed) for neuropathic pain. For those responding as part of a classified EMT, your patients should have access to adequate supplies of analgesia. EMT specialist rehabilitation cells are not required to provide medication so should develop links with other local providers. Knowing what drugs are available locally, and if patients need to pay for them, can be helpful. Even if medication is available over the counter in some countries, rehabilitation professionals should not prescribe or advise on medication use beyond their scope of practice. Note that, for extended scope rehabilitation prescribers, you may not be able to prescribe in another country if this is not within the defined scope of your profession in that country. Visual pain charts can be used to assess pain:

Pressure Areas

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 is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A pressure sore 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, while Intrinsic factors relate to the condition of the patient, such as sepsis, local infection, decreased autonomic control, altered level of consciousness, increased age, vascular occlusive disease, anemia, malnutrition, sensory loss, spasticity, and contracture.

Read more here about the prevention and management of Pressure UlcersA pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A pressure sore 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, such as sepsis, local infection, decreased autonomic control, altered level of consciousness, increased age, vascular occlusive disease, anemia, malnutrition, sensory loss, spasticity, and contracture.

Many traumatic injuries can increase the risk of pressure ulcers developing, in particular 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 as a result 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 outbreak 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

Malnutrition

Malnutrition leads to lower natural immunity, which often results in increased risk of infectious disease and increased progression of disease, and in disaster and conflict settings can impair recovery and healing and increase morbidity and mortality. In disaster and conflict settings the drivers of malnutrition will vary 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. Stimulative therapy and play involving caregivers are recommended once these children are medically stabilised.

Key Points

1. Rehabilitation professionals should be aware of the importance of good nutrition post injury, and should work with the team to ensure patients are appropriately nourished
2. Rehabilitation professionals should be able to identify patients suffering from severe acute malnutrition (SAM), including the use (or referral to the medical team) of Mid Upper Arm Circumference (MUAC) as a reference for this. These patients should be referred to specialist centres for nutrition support
3. Severe micronutrient deficiencies (most commonly iron and Vitamin A) can also impact on recovery. It is good to be aware of common deficiencies in the areas where you are working, and how to identify them
4. Malnutrition also includes obesity. In countries where the population has high obesity levels, there are likely to be more patients affected by non-communicable diseases, such as diabetes and cardiovascular disorders.

Co-morbidities and Pre-existing Health Conditions

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

Disasters and conflicts also disproportional affect people with a disability, as a result of inaccessible environment, 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 persons organisations to identify those most at risk to address their needs.

Ensure that during your subjective assessment you gain a full medical history and infuriation about current access to medication, assistive technology and therapy for pre-exisiting conditions and where possible identify referral pathways for follow-up in relation to these conditions. Replacement of damaged or lost assistive technology , or provision of new assistive technology to address new injuries should be considered where possible.

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 as secondary consequences of disasters and conflicts are often exacerbations of endemic diseases caused by the impact of the emergency, whether as a result of damage through 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 Category:Communicable Diseases

Paediatric Considerations

Though in many countries paediatrics is considered a clinical speciality, in conflicts and disasters all therapists are likely to encounter paediatric patients. Children must be considered as a distinct population. Condition-specific considerations will be mentioned in each chapter, but below are some general considerations: Children are typically injured alongside family members or friends. This has serious psychological and safeguarding implications, which must be addressed concurrently with medical care and rehabilitation. Managing an injured child’s distress should be a priority – don’t force rehabilitation. Children have anatomical and physiological differences to adults. Specifics in relation to injuries will be addressed in the coming chapters. From a respiratory perspective, up to the age of 3, ventilation/perfusion (VQ) matching in children is the opposite to adults: Due to chest wall compliance, the dependent lung is poorly ventilated. To improve VQ matching, position the child with their good lung UP. More information on respiratory therapy in children is contained in the respiratory therapy cheat sheet. Blast injuries in particular often result in poly-trauma, making early rehabilitation more complex. Younger children in particular are more likely to present with associated head and thoracic injuries, while the presence of certain explosive remnants of war (such as cluster munitions) can increase the likelihood of upper limb injuries in children by being mistaken for toys or objects of interest. In some contexts, children with impairments may be socially disadvantaged 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. Injured children may have experienced destruction of their communities, deprivation, forced displacement from their homes, schools and communities and separation from, or loss of, loved ones, including parents. While specific agencies often take overall responsibility for child protection and education, keeping children safe is everybody’s role in humanitarian response. Refer back to Chapter 2 for information about protecting children in your care. 1. Children will require paediatric-sized assistive devices and other equipment. Access to paediatric-specific equipment (such as wheelchairs, crutches, orthotics and prosthetics) is often limited. Where children require assistive devices over extended periods of time, these need to be re-fitted regularly while the child is still growing 2. Carry some child friendly treatment equipment. Carrying some basic toys as part of a treatment bag (even if just bubbles, balloons, and a mobile phone with music or videos) can be really helpful 3. Treatment approaches need to be modified. Consider distraction, play and ageappropriate, activity-based approaches with younger children 4. Where possible, involve family and caregivers in all aspects of the child’s care. This reinforces stability to a child and protects them against further psychological distress. Appreciate who should give consent in a family, according the specific context 5. For continuity and to enhance feelings of protection and stability, try to keep the same staff and translators involved in a child’s care. National staff members may be less intimidating than unfamiliar international staff. 6. Peer support can be invaluable. Children feel more relaxed in the presence of other young people and can offer each other support. Try to group paediatric beds/treatment sessions together and incorporate interactive group games.

Condition Specific Complications

Fractures

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

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

Read more here about Fracture Complications

Peripheral Nerve Injury

Secondary complications of peripheral nerve injury can be a significant issue and impact on the rehabilitation process, particularly during the early rehabilitation phase.

Read more here about Complications with Peripheral Nerve Injury

Burns

Normal physiologic response to burns frequently places the patient in a life threatening situation, 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 are all encountered frequently within disaster and conflict settings as a result of delayed, inadequate treatment including follow up.

Read more here about Complications Post Burns

Amputation

Having an amputation, like any surgery, carries a risk of complications, and 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 but 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 and Heterotophic Ossification.

Read more here about Complications Post Amputation

Acquired Brain Injury

Medical and neurological complications determine the final functional outcome, community reintegration as well as employment potential after a traumatic brain injury. Therefore, it is important to recognise the potential risks of those 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, while severe injuries increase the risk of a greater number of more-severe complications. Presence of complications and injury related impairment impacts the quality of life of a person living with a traumatic brain injury. These problems can cause frustration, conflict and misunderstanding of people with a traumatic brain injury as well as family members or friends. An individual’s risk of suicide as well as mood and anxiety disorders might be increased due to a combination of symptoms and neuropsychiatric factors which are often aggravated by the trauma.

Key signs to monitor for during the early rehabilitation of individuals following disaster and conflicts are deterioration in AVPU, which may be a sign of worsening or missed brain injury or sudden changes in blood pressure (either increase or decrease) that 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 here about Complications in Traumatic Brain Injury

Spinal Cord Injury

Spinal cord injury results not only in motor and sensory deficits but also in autonomic dysfunctions as a result of the disruption between higher brain centers 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 here about Complications in Spinal Cord Injury