the role of specialist rehabilitation in polytrauma management
DESCRIPTION
The Role of Specialist Rehabilitation in Polytrauma Management. Dr James Graham (Consultant Radiologist) Dr Rachel Reaveley (SPR in Neurological Rehabilitation). Objectives. By the end of this case presentation we will have covered… Radiology of the case - PowerPoint PPT PresentationTRANSCRIPT
The Role of Specialist Rehabilitation in Polytrauma Management
Dr James Graham (Consultant Radiologist)
Dr Rachel Reaveley (SPR in Neurological Rehabilitation)
Objectives By the end of this case presentation we will
have covered… Radiology of the case Specialist Rehabilitation Interventions
How the specialist rehabilitation process worked from acute referral through to outpatient review and inpatient admission
Summary of causes of dizziness in the rehabilitation setting
Reflect together on potential gaps in the serviceAssessing the psychological impact of poly-trauma in
the context of concurrent head injury
Case History 50 year old driving instructor High speed head on collision 10/10/12 Right haemo-pnuemothorax and lung
contusion with rib fractures – 7-12 Left pneumothorax Jejunal perforation and terminal ileum
mesenteric injury- requiring laparotomy, repair and end ileostomy
Complications – chest sepsis, need for high inotropic support, abnormal kidney function, LFTs & amylase – 19 days in ICU
Trauma CT
Trauma CT
Trauma CT
Trauma CT
A few days later… Gradual clinical deterioration
Lactate 1.3 Amylase 439
WCC 20 CRP 116
Bilirubin 63 ALP 335 ALT 282
Follow up CT
Follow up CT
Gastric appearances
Angiogram
What Happened next?
Rehabilitation Assessment & Planning
First seen by Rehabilitation Consultant on General Surgery Ward 21/11/12
Referred by Head Injury Sister – small frontal contusion
DizzinessNauseaBack pain ? Change in personality
Dizziness and nausea When moving from sitting to standing and from
lying to sitting Documented drop in BP on standing Contributory factors Medications – opioids Fluid depletion (nausea) Coeliac axis injury – damage to autonomic
nerve supply to splanchnic bed ? BPPV
Benign Paraoxysmal Positional Vertigo
Orthostatic Hypotension
Coeliac Plexus
Kambadakone A et al. CT-guided Celiac Plexus Neurolysis: A Review of Anatomy, Indications, Technique, and Tips for Successful Treatment. RadioGraphics 2011; 31: 1599-1621Sir Roger Bannister. Autonomic Failure. A Textbook of Clinical Disorders of the Autonomic Nervous System. Second Edition.
Rehabilitation Medicine Review as Outpatient May 2013 Dizziness - diagnosed with BPPV – treated
with Epley’s manoeuvre Nausea and vomiting improved - Awaiting
surgical reversal of ileostomy Significant back pain – remained under
surgical review with plan for follow up physiotherapy – referral made to health psychology to support through this.
Low mood – body image issues Character change
Epley’s Manouvre
People involved/pending procedures Mr B Griffiths – General surgery – awaiting
ileostomy reversal Mr G Wynne Jones – Orthopaedics Mr Waldron – ENT Sunderland Sister Hastie – Head Injury GP – commenced sertraline for low mood Dr J Lawson - Falls & Syncope Service Mr Jenkins - Urologist UHND – admitted with
urinary sepsis shortly after discharge from RVI – 4x unsuccessful TWOC as inpatient
Out patient Review: May 2013 Assessment of frontal brain injury vs
mood disturbance:-Subtle changes in character Loss of sense of humourConcrete thinkingShort term memory impairmentEasily provoked by loud noises and crowdsLack of initiation
Rehabilitation Actions & further Progress Ileostomy reversal – health psychology at RVI
requested to provide peri-operative support Complicated by further sepsis/leakage
requiring readmission via UHND On-going back pain – waiting for orthopaedic
review and physiotherapy Continued family concerns around change in
personality (short term memory and increased irritability)
Referred to neuropsychology as outpatient ( long waiting list….)
In Patient Admission to WGP Cognitive Assessment Bed February 2014Increasing concern about ongoing depressive
episodes with psychological trauma- type symptoms post RTA
Psychology and Psychiatry InputChanges in cognition reported largely explained by
mood disorderConcrete thinkingSlowness in mental speed both associated with
depressionAnxiety also may have contributed to under-
performance
Cognitive assessment noted only very mild problems in verbal abstract reasoning. Working memory unimpaired
Other Therapies OT assessment:
independent with route finding, money handling and road safety.
independent and safe at problem solving in the kitchen. Written instructions for more complex tasks
SALT assessmentCognitive communication skills largely intact,
however some reading comprehension difficultiesWith prompting to slow down his reading rate and
check his responses, accuracy improved
Limitations of current processes‘We’ve had no help at all since being at home”
Comment from Mrs Willis at first rehab OP review
Lack of co-ordinated follow up on discharge from MTC unless head injury severe enough to require ongoing inpatient follow up or community therapies needed specific to TBI
Predictable problems – ongoing dizziness and need for Dix Hallpike. Catheter issues – reassurance of empty bladder/UTI prevention/onward referral
Mood disorder - psychological complications can be significant following trauma. Services to address these issues currently very limited – differences between psychological trauma and brain injury effect
Summary Interesting case of patient with multi-
trauma and complications Long period of rehabilitation including
inpatient stay required Illustrates that not all changes in behavior
following head injury are related to injury
Thank you!