Case Study - Acquired Brain Injury in Disasters and Conflicts

Original Editors - Naomi O'Reilly

Top Contributors - Naomi O'Reilly, Kim Jackson, Rachael Lowe and Jess Bell      

Title

Poly-trauma with traumatic brain injury and multiple fractures following building collapse post Earthquake.

Thanks to Humanity and Inclusion for Case Study taken from Early Rehabilitation in Conflicts and Disasters.

Abstract

32-year-old female ten days post poly-trauma with traumatic brain injury, facial injuries and multiple fractures pulled from the rubble of a collapsed building 3 hours post Earthquake. Now presenting with right-sided weakness and loss of sensation due to left-sided brain injury, indicating likely parietal and frontal lobe involvement with rib pain limiting assessment currently.

Key Words 

Poly-trauma, Traumatic Brain Injury, Facial Injury, Earthquake, early Rehabilitation

Patient Characteristics

Background

The patient is a 32-year-old female who was pulled from the rubble of a collapsed building three hours post-earthquake, ten days ago. She sustained an injury to the head and multiple fractures (left humerus, left tibia/fibula, ribs 7, 8, 9 on the right-hand side) and some facial injuries. Her sister, who was present when the patient was rescued, reports temporary loss of consciousness on the way to the hospital and the patient was confused. She reports no vomiting or seizures. The nurse accompanying the patient to the rehabilitation department reports the medical notes are not available and she does not know the patient well.

Examination Findings

Observation

Patient is lying in bed, she appears tired, emotional and cries easily, but consents to treatment.

She is wearing a left, below-knee cast and her left arm is in a sling.

Physical Assessment

Range of Movement

Active ROM: Unable to assess on left side due to fractures, but able to wriggle fingers and toes. Asked the patient to do simple movements, bending her right knee and taking her hand to her mouth.

• Can move her right leg, but not through its full range of movement
• No movement seen in right arm.

Passive ROM: Tested in all joints (free from casting) on both sides with no problems noted.

Tone

Tested Right Side Only, since Left Side Immobilised by Cast and Sling.

• Upper Limb Floppy
• Some Resistance to dorsiflexion at Right Ankle

Power

Oxford MRC Scale

• 0/5 All Major Muscle Groups Right Upper Limb
• 2/5 All Major Muscle Groups in Right Lower Limb

Sensation

On testing, reduced sensation to light touch was noted in the right arm and leg, proprioception was normal in all limbs.

Coordination

Not tested due to fractures on the left side and extensive weakness on the right.

Speech and Comprehension

Patient seems to be communicating normally and following basic commands in her own language.

Functional Assessment

The patient is reluctant to roll due to pain, especially around her ribcage. Lying to sitting without a full roll required the assistance of two people – one to support the lower limbs and one to manage the trunk and arm.

Once up, the patient does not report any dizziness and can sit unsupported. The patient’s legs do not reach the floor, and so were supported on a block. Sitting balance during movement was not tested due to lack of arm function and pain on trunk movement. At this time, the patient requires full assistance with all basic tasks, such as eating and drinking and personal care, and is being supported by family members.

Transfers, standing and walking were not assessed due to power of 2/5 in right leg. A non-weight-bearing status on the left leg and arm is initially assumed, due to the lack of medical notes.

Clinical Impression

Right-sided weakness and loss of sensation due to left-sided ABI, indicating likely parietal and frontal lobe involvement. Rib pain is a limiting factor to assessment and a likely limitation for treatment unless better controlled. Right upper limb is low-toned, lacking activity and at risk of shoulder subluxation and development of shoulder pain. Increased tone in plantar flexors on right-hand side and at risk of muscle shortening. Patient is currently fully dependent for all transfers and daily activities. Noted that the patient was tearful and may need further assessment due to recent psychological trauma and frontal lobe involvement.

Treatment

Goals (Short-term)

Get patient out of bed for sitting and clarify weight-bearing status on the left leg and precautions for left upper limb.

Approach

Build time in upright sitting for now and allow weight bearing in sitting through the right foot while maintaining good ankle positioning. Patient to sit out in a chair regularly but requires a lift transfer to the chair at present.

Avoid complications related to immobility by regular position changes, advice to the patient to wriggle fingers and toes and maintain movement in the left side as pain and fracture sites allow.

Confirm weight-bearing status on left leg with medical team. If the patient is non-weight bearing, consider splint for right ankle to maintain muscle length during rest.

Start regular, repeated right leg exercises to improve activity and power. Once right gluteal and quadriceps are 4/5 on the Oxford MRC Scale, the patient can single leg stand on this leg with assistance.

Begin sensory re-education of right side.

Education

Advise and teach the patient’s sister about the importance of and how to change position regularly.

Teach her sister to do safe, daily, passive range of motion exercises for right arm, noting that abduction and forward flexion should remain below horizontal level.

Inform her about the risk of developing shoulder pain and how to care for the arm by supporting its weight when upright and avoiding pulling on the arm.

Inform her about the possibility of ongoing altered or low mood. Use her sister to identify motivating/interesting stimuli for meaningful activities and to monitor mood.

Inform her about the possible development of shoulder pain and how to care for the arm. Ensure her sister is aware of the patient’s need for assistance with daily activities.

Outcome

As the rib pain decreases, the patient can become more actively involved in bed mobility. Once patient has enough power in her right lower limb to stand and/or fractures have healed or weight-bearing status has changed to full weight bearing (whichever is first), she should then be in a position to work on standing and stepping.

At this time, it is not possible to predict the outcome of her right arm function, but once the left arm fracture is healed, she should be more independent in daily activities.

Resources

Early Rehabilitation in Conflict and Disasters, Humanity and Inclusion