Acute Care Management of a Patient with Multiple Trauma

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Introduction

Early acute care rehabilitation initiated on the Intensive Care Unit has a positive effect on patient's functional status, muscle strength, mechanical ventilation duration, walking ability at discharge, and health quality of life. Patients with multiple trauma must often overcome the effects of the use of mechanical ventilation, administration of drugs, sedatives, analgesics, and drugs to control their anxiety and agitation. The secondary complications may include joint contractures, thromboembolism, pressure ulcers, pneumonia, difficulties with weaning off the ventilator, delirium, and development of disabilities. There is a social impact of a prolonged hospitalisation with increased days without income, inability to provide for family and inability to fulfill previously established social roles. This article provides an overview of the multiple systems assessment of a patient with a complex injury during an acute care hospitalisation.

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 to describe severity of injury in a trauma patient. It includes the assessment of 6 body systems that receive scores according the Abbreviated Injury Scale. A score greater that 15 defines major trauma.

Interdisciplinary Team Approach

Patients with complex orthopaedic trauma admitted to the hospital benefit from early rehabilitation interventions to prevent complications and promote recovery. Acute care trauma team and rehabilitation team form an interdisciplinary team when the team members work together in treatment and goal setting. The optimal approach for the management of a patient with complex orthopaedic trauma requires clinical collaboration between the members of the interdisciplinary team to ensure successful integration of medical, rehabilitative, psychosocial, and financial resources available across various specialties. The care of the patient with multiple orthopaedic injuries often necessitates the involvement of the orthopaedic surgeon, nursing staff, physiotherapist, occupational therapist, respiratory therapist, speech-language pathologist, and social worker.

Patient Management on the Intensive Care Unit

Before initiating the assessment, physiotherapist must obtain information that will help to determine patient's appropriateness for physiotherapy intervention. This is completed via 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 fractures to determine patient's functional mobility progression
  • Patients at a high risk of complications receive early temporary stabilisation followed by delayed definitive fixation
• 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, and respiratory rate
  • Trends in arterial blood gases (ABG)
    • pH, pCO2, pO2, bicarbonate (HCO3), base excess (BE), Lactate
• Level of sedation
  • Richmond Agitation Scale (RASS)
    • Allows for tracking level of sedation
    • Ranges between +4 and -5
• Members of the Interdisciplinary Team
  • May include primary physicians, surgeons, neurologists, pulmonologists, physiotherapists, occupational therapists, nursing staff, social work, case management, and speech therapy

Interdisciplinary Team Members Discussions

Frequent discussions with interdisciplinary team members allows for the following:

• To establish team communication plan
• To understand social factors impacting discharge planning
• To obtain information about patient's access to resources
• To coordinate with nursing staff the timing of therapy session to optimise patient's medication level
• To gather additional informations on patient's cognition, agitation, and ability to follow commands
• To update information about the patient's ability to participate, haemodynamic response to activity, and plan for ongoing medical interventions

Interdisciplinary Assessment

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

1. Determine patient's level of confusion:
   • The Confusion Assessment Method for the ICU (CAM-ICU)
   • Alert, Voice, Pain, Unresponsive scale (AVPU)
2. Establish consistent and reliable communication with the patient:
   • Head nod, a head shake, blinking for a yes or for a no
   • Picture communication boards
   • Letter spelling boards

Body Systems Assessment

Table 1 provides a summary of 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 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 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 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 patient's medical status
• Establishing specific goals with the patient
• Completing a systems review
• Increasing the patient 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")
    • Can be completed by any provider
    • 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 safe return home

Interdisciplinary Interventions

The interdisciplinary team interventions focus on the following:

• Improving patient's functional mobility
• Patient's education regarding 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 postconcussive 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 a follow-up care and reintegration into the community for the patient upon discharge from the acute care hospital

Resources

• Quatman-Yates CC, Hunter-Giordano A, Shimamura KK, Landel R, Alsalaheen BA, Hanke TA, McCulloch KL. Physical Therapy Evaluation and Treatment After Concussion/Mild Traumatic Brain Injury. J Orthop Sports Phys Ther. 2020 Apr;50(4):CPG1-CPG73.
• Piccione F, Maccarone MC, Cortese AM, Rocca G, Sansubrino U, Piran G, Masiero S. Rehabilitative management of pelvic fractures: a literature-based update. Eur J Transl Myol. 2021 Sep 17;31(3):9933.
• Kalmet P, Maduro C, Verstappen C, Meys G, van Horn Y, van Vugt R, Janzing H, van der Veen A, Jaspars C, Sintenie JB, Blokhuis T, Evers S, Seelen H, Brink P, Poeze M. Effectiveness of permissive weight bearing in surgically treated trauma patients with peri- and intra-articular fractures of the lower extremities: a prospective comparative multicenter cohort study. Eur J Orthop Surg Traumatol. 2024 Apr;34(3):1363-1371.