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 poly-trauma is present in as many as 40% of individuals admitted to hospital with trauma. Many patients with multiple traumas will require intensive care. While in intensive care, patients with multiple traumas are often exposed to interventions that "promote long periods of immobilization", such as mechanical ventilation, sedatives, analgesics, and medications to control anxiety and agitation. These patients are also at risk of intensive care unit-acquired weakness (ICU-AW), which is associated with various complications, including joint contractures, thromboembolism, pressure ulcers, atelectasis, pneumonia, an extended period weaning off mechanical ventilation, delirium, and the development of disabilities. In addition to the physical effects, prolonged hospitalisation can have a significant social impact, including increased days without income, an inability to provide for family and an inability to fulfil 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. Moreover, a multidisciplinary rehabilitation approach seems to "offer the best way to improve trauma patient outcomes".

Multiple Trauma

"Major trauma refers to physical injury or a combination of injuries where there is a strong possibility of death or disability and is commonly defined using an Injury Severity Score."

The Injury Severity Score allows clinicians to describe the severity of injury in a trauma patient. The body is divided into six anatomical areas, and each injury is rated using the Abbreviated Injury Scale (AIS). Only the most severe injury in each region is considered in the final ISS calculation. The final ISS is calculated by adding the squares of the three highest AIS scores. A score greater than 15 = major trauma.

For more information, please see: 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.

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 members of the multidisciplinary 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, including orthopaedic injuries, in an 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

Check the patient's chart for information on the following:

• movement precautions and weight-bearing precautions / restrictions
• fracture management plan
  • the timeline for planned surgery and anticipated surgical interventions can influence a patient's functional mobility progression
  • patients with a high risk of complications may be managed with early temporary stabilisation, followed by delayed definitive fixation when their risk of systemic complications decreases
• information on medical status / stability, including:
  • ventilator settings and plans for extubation
    • for more information, please see: Ventilation and Weaning and Non Invasive Ventilation
  • additional complications (e.g. placement of chest tubes / drains)
  • lab values
    • haematocrit
    • haemoglobin
    • markers for acute infection: C-reactive protein (CRP) and procalcitonin (PCT)
  • vitals (consider trends)
    • blood pressure
    • heart rate and rhythm
    • temperature
    • respiratory rate
  • trends in arterial blood gases (ABGs)
    • pH
    • PaCO2
    • PaO2
    • bicarbonate (HCO3)
    • base excess (BE)
• level of sedation / alertness
  • Richmond Agitation Sedation Scale (RASS)
    • allows clinicians to track the level of sedation
    • scores range from +4 to -5
    • 0 = awake and calm
    • moving up in a positive direction indicates increasing agitation
    • moving down through the negative numbers indicates increasing sedation

If you would like to learn more about the RASS, please please watch the following optional video:

Multidisciplinary Team Discussions

Members of the multidisciplinary team may include physicians, surgeons, neurologists, pulmonologists, physiotherapists, occupational therapists, nursing staff, social workers, case managers, and speech language therapists.

Frequent discussions between multidisciplinary team members help the team establish a communication plan. Working with the multidisciplinary team helps physiotherapists to:

• increase their understanding of social factors that will impact discharge planning
• obtain information on a patient's access to resources
• coordinate the timing of therapy sessions with nursing staff to ensure optimal engagement in treatment
• gather additional information on a patient's cognition, agitation, and ability to follow commands
• obtain information on a patient's ability to participate, their haemodynamic response to activity, and the plan for ongoing medical interventions

Assessment

To increase the accuracy of the assessment, clinicians should: (1) determine the patient's level of confusion and (2) assess the patient's ability to follow basic commands and establish consistent and reliable communication.

The Confusion Assessment Method for the ICU (CAM-ICU) can be used to help determine the patient's level of confusion / delirium. Please watch this optional video if you would like to see a demonstration of the CAM-ICU:

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

The following strategies can be used to help establish consistent and reliable communication with a patient:

• check if the patient can consistently nod / shake their head, blink for yes or no, etc.
• use picture communication boards or letter spelling boards

Body Systems Assessment

Table 1 provides a summary of key body systems to assess during a physiotherapy intervention, but for more information on assessing a patient 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 Mesures

The following outcome measures can help track changes in a patient's functional mobility over time:

• Perme ICU Mobility Scale
• ICU Mobility Scale

General Goals

General rehabilitation goals in the ICU might include:

• increase tolerance for upright mobility
• complete basic activities of daily living in a sitting position
• incorporate breathing techniques with upright mobility
• use alternative approaches to decrease agitation and increase a patient's participation
• incorporate positioning strategies for pressure sore prevention and pain and oedema reduction
• incorporate strategies for delirium prevention and delirium management and educate family and friends on delirium prevention strategies (frequent reorientation and reassurance, appropriate lighting for the time of day, etc)
• where appropriate, educate family and friends on techniques related to post-concussive syndrome; the following strategies can help to reduce over-stimulation:
  • limit the number of lights used
  • limit activities that require a lot of concentration
  • limit the number of individuals speaking to a patient at a time
  • limit external noises (close the door, turn off the television)
  • provide mental breaks after periods of high stimulation

Patient Management Post-Intensive Care Unit

After a patient transfers from ICU to a general ward, physiotherapists should:

• reassess the patient (this includes obtaining a more specific social history)
• establish specific goals with the patient
• complete a systems review
• work to increase the patient's independence with functional mobility
• assess the patient's need for an assistive device

Assessment

Assessments post-ICU should include the following:

• basic functional mobility, including bed mobility, transfers, and gait
• outcome measures to track the patient's progress:
  • e.g. Activity Measure for Post-Acute Care "6-Clicks" Short Form (AM-PAC "6-Clicks")
    • can be completed by any provider
    • enables increased communication and tracking of mobility between members of the interdisciplinary team
• balance assessment if indicated
  • e.g. Dynamic Gait Index
• functional activity tolerance assessment
  • e.g. Two Minute Walk Test or Six Minute Walk Test
  • vitals must be monitored throughout

General Aims

Rehabilitation on the ward often focuses on:

• improving independence
• improving activity tolerance
• improving breathing mechanics and secretion management
• ensuring a safe return home

Interventions

Rehabilitation interventions at this stage of care may focus on the following:

• improving the patient's functional mobility
• providing education for the patient on their weight-bearing status
• as mobility improves, progressing to the least restrictive assistive device
• progressing activity tolerance and endurance (i.e. increase duration of ambulation and then speed of ambulation)
• pulmonary education as needed; topics may include:
  • using a cough pillow / towel roll to help manage pain when coughing
  • active cycle of breathing
  • huff coughing
  • incentive spirometer
  • inspiratory muscle training
• education on post-concussive syndrome support strategies where necessary:
  • visual task reminders
  • taking cognitive breaks during the day
  • placing time limits on activities, especially those that require a lot of concentration or a lot of in-depth thought
• multidisciplinary / interdisciplinary conversations to ensure a successful and safe discharge into the community
• establishing follow-up care and reintegration into the community for the patient upon discharge from acute care

Resources

• Al Hanna R, Amatya B, Lizama LE, Galea MP, Khan F. Multidisciplinary rehabilitation in persons with multiple trauma: A systematic review. J Rehabil Med. 2020 Oct 2;52(10):jrm00108.