Acute Care Management of a Patient with Multiple Trauma

Original Editor - Rebecca Downey

Top Contributors - Ewa Jaraczewska and Jess Bell  

Introduction

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. Patients with multiple traumas who require critical care are often exposed to interventions that "promote long periods of immobilization", such as mechanical ventilation, sedatives, analgesics, and drugs to control anxiety and agitation. Patients in ICU are at risk of intensive care unit-acquired weakness (ICU-AW), which is associated with a number of complications, including joint contractures, thromboembolism, pressure ulcers, atelectasis, pneumonia, an extended period weaning off mechanical ventilation, delirium, and the development of disabilities. Prolonged hospitalisation also has a significant social impact, including increased days without income, inability to provide for family and an inability to fulfil previously established social roles. This article provides an overview of the assessment of a patient with a complex injury in an acute care setting.

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 together the squares of the three highest AIS scores. A score greater than 15 defines 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 hospital 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 orthopaedic surgeons, other medical specialities, nursing staff, physiotherapists, occupational therapists, respiratory therapists, speech-language therapists (pathologists), and social workers.

Patient Management in the Intensive Care Unit

Before initiating the assessment, physiotherapists must obtain information that will help to determine the patient's appropriateness for physiotherapy intervention. This is completed via a chart review and discussion with the members of the team. The following discussion relates to patients with multi-trauma, including orthopaedic injuries

Chart Review

The patient's chart should provide the following information:

• movement precautions and weight-bearing restrictions
• plan to manage fracture/s - this can be used to determine the patient's functional mobility progression
  • please note that patients with a high risk of complications tend to receive early temporary stabilisation followed by delayed definitive fixation when their risk of systemic complications decreases
• information on medical stability
  • ventilator settings and plans for extubation
  • additional complications
  • lab values and vitals
    • haematocrit
    • haemoglobin
    • markers for acute infection: C-reactive protein (CRP) and procalcitonin (PCT)
  • vitals
    • blood pressure
    • heart rate and rhythm
    • temperature
    • respiratory rate
  • trends in arterial blood gases (ABG)
    • pH
    • PaCO2
    • PaO2
    • bicarbonate (HCO3)
    • base excess (BE)
• level of sedation / alertness
  • Richmond Agitation Sedation Scale (RASS)
    • allows for tracking the level of sedation
    • ranges between +4 and -5

If you would like to learn more, please watch the following optional video for a demonstration on how to use the Richmond Agitation and Sedation Scale.

Multidisciplinary Team Discussions

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

Frequent discussions with multidisciplinary team members enable the following:

• establishing a team communication plan
• increased understanding of social factors that will impact discharge planning
• obtaining information on a patient's access to resources
• coordinating the timing of therapy sessions with nursing staff to optimise a patient's medication level
• gathering additional information on a patient's cognition, agitation, and ability to follow commands
• updating 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, the clinician 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 following tools can help you to determine the patient's level of confusion:
  • Confusion Assessment Method for the ICU (CAM-ICU)
  • Alert, Voice, Pain, Unresponsive scale (AVPU)

Please watch this optional video if you would like to see a demonstration of how to use the Confusion Assessment Method for the ICU (CAM-ICU):

You might also be interested in this optional video on how to use the Alert, Voice, Pain, Unresponsive scale (AVPU):

• the following strategies can help you to establish consistent and reliable communication with the patient:
  • check if they can consistently nod / shake their head, blink for yes or no, etc.
  • picture communication boards
  • letter spelling boards

Body Systems Assessment

Table 1 provides a summary of the body systems assessment to be completed during physiotherapy intervention:

Table 1. Body Systems Assessment

Body Systems	What to assess?
Cardiovascular system	Check blood pressure and heart rate response with activity: The transition from a supine to a sitting position The transition from a sitting to a standing position
Pulmonary system	Check oxygen response and changes in respiratory rate with activity
Integumentary system	Assess the skin around the surgical site Look for signs and symptoms of the infection Assess for pressure injuries
Musculoskeletal system	A general range of motion and strength assessment, if appropriate It may be hypothesised based on the patient's social history (type of work) It may be completed based on the observation of the patient's moving

Outcome Mesures

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

• Perme ICU Mobility Scale
• ICU Mobility Scale

Interdisciplinary Goals

1. Increase tolerance for upright mobility
2. Complete basic activities of daily living in a sitting
3. Incorporate breathing technique with upright mobility
4. Incorporate strategies for delirium prevention and delirium management
5. Use alternative approaches to decrease agitation and increase patient's participation
6. Incorporate positioning strategies for pressure sore prevention and pain and oedema reduction
7. Family and friends education on delirium prevention strategies:
   • Perform frequent reorientation
   • Keep the lights on and the windows open during the daytime
   • 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 the patient's transfer from the intensive care unit to a general ward, the focus of physiotherapy intervention should include the following:

• Reassessment due to the changes in the patient's medical status
• Establishing specific goals with the patient
• Completing a systems review
• Increasing the patient's independence with functional mobility.
• Assessing the need for an assistive device

Interdisciplinary Assessment

The patient's assessment in the post-intensive care unit stay should include the following:

• Basic functional mobility, including bed mobility, transfers, and gait
• Outcome measures to track the patient's progress:
  • Activity Measure for Post-Acute Care "6-Clicks" Short Form (AM-PAC "6-Clicks")
    • Any provider can complete it
    • Allows increased communication and tracking of mobility between members of the interdisciplinary team
• Balance assessment
  • Dynamic Gait Index
• Functional activity tolerance assessment
  • 2-Minute Walk Test or a 6-Minute Walk

Interdisciplinary Goals

• To improve independence
• To improve activity tolerance
• To improve breathing mechanics and secretion management
• To ensure a safe return home

Interdisciplinary Interventions

The multidisciplinary team interventions focus on the following:

• Improving patient's functional mobility
• Patient's education regarding the continued need to progress weight-bearing
• Trials of the least restrictive devices
• Progressive ambulation
• Education on productive cough:
  • Active cycle of breathing, huff coughing, incentive spirometer, inspiratory muscle training
• Education on continued post-concussive syndrome support strategies:
  • 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
• 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 the acute care hospital

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.