Acute Care Management of a Patient with Multiple Trauma

Original Editor - Rebecca Downey

Top Contributors - Ewa Jaraczewska and Jess Bell  

Introduction

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. These patients are also 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. In addition to the physical effects, prolonged hospitalisation can have 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.

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 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 orthopaedic surgeons, other medical specialities, 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 seeing patients with multi-trauma, including orthopaedic injuries, in an acute care setting.

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.

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
    • 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
    • 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 key body systems to assess during a physiotherapy intervention.

Table 1. Key Body Systems Assessment.

Body systems	What to assess?
Cardiovascular system	Check blood pressure and heart rate response in response to activity: transiting from a supine to a sitting position transitioning 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 infection Assess for pressure injuries
Musculoskeletal system	A general range of motion and strength assessment, if appropriate: may be hypothesised based on the patient's social history (type of work) 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

For more information on assessing patients in ICU, please see: Physiotherapy Assessment of the Patient in ICU.

General Goals

Goals might include:

• increase tolerance for upright mobility
• complete basic activities of daily living in a sitting position
• incorporate breathing techniques with upright mobility
• incorporate strategies for delirium prevention and delirium management
• use alternative approaches to decrease agitation and increase a patient's participation
• incorporate positioning strategies for pressure sore prevention and pain and oedema reduction
• educating family and friends on delirium prevention strategies:
  • perform frequent reorientation
  • keep the lights on and the windows open during the day
  • 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, the physiotherapist will look at the following:

• reassessing the patient due to 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 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
  • e.g. Dynamic Gait Index
• functional activity tolerance assessment
  • e.g. 2-Minute Walk Test or 6-Minute Walk Test

General Goals

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

Interventions

Rehabilitation interventions may focus on the following:

• improving the patient's functional mobility
• providing education for the patient on the continued need to progress their weight-bearing
• trialling the least restrictive mobility device
• progressive ambulation
• education on productive cough; potential treatments include:
  • 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.