Northern Trauma System Regional Conference 2014

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Northern Trauma System Regional Conference 2014

• High quality trauma care from
• Roadside to Recovery

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The Role of Specialist Rehabilitation in
Polytrauma Management

• Dr James Graham (Consultant Radiologist)
• Dr Rachel Reaveley (SPR in Neurological
  Rehabilitation)

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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
• Assessing the psychological impact of poly-trauma
  in the context of concurrent head injury
• Reflect together on potential gaps in the
  service

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Case History

• 50 year old driving instructor
• High speed head on collision 10/10/12
• Brought to MTC

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Trauma CT
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Trauma CT
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Trauma CT
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Trauma CT
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Case History - summary

• 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

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A few days later

• Gradual clinical deterioration
• Lactate 1.3
• Amylase 439
• WCC 20
• CRP 116
• Bilirubin 63
• ALP 335
• ALT 282

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Follow up CT
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Follow up CT
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Gastric appearances
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Angiogram
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Endoscopy
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What Happened next?
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Rehabilitation Assessment Planning

• First seen by Rehabilitation Consultant on
  General Surgery Ward 21/11/12
• Referred by Head Injury Sister small frontal
  contusion
• Dizziness
• Nausea
• Back pain
• ? Change in personality

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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

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Benign Paraoxysmal Positional Vertigo
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Orthostatic Hypotension
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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 1599-1621 Sir Roger
Bannister. Autonomic Failure. A Textbook of
Clinical Disorders of the Autonomic Nervous
System. Second Edition.
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Rehabilitation Medicine Review as Outpatient May
2013

• Dizziness - diagnosed with BPPV treated with
  Epleys 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

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Epleys Manouvre
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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

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Out patient Review May 2013

• Assessment of frontal brain injury vs mood
  disturbance-
• Subtle changes in character
• Loss of sense of humour
• Concrete thinking
• Short term memory impairment
• Easily provoked by loud noises and crowds
• Lack of initiation

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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.)

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In Patient Admission to WGP Cognitive Assessment
Bed February 2014

• Increasing concern about ongoing depressive
  episodes with psychological trauma- type
  symptoms post RTA

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Psychology and Psychiatry Input

• Changes in cognition reported largely explained
  by mood disorder
• Concrete thinking
• Slowness in mental speed both associated with
  depression
• Anxiety also may have contributed to
  under-performance
• Cognitive assessment noted only very mild
  problems in verbal abstract reasoning. Working
  memory unimpaired

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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 assessment
• Cognitive communication skills largely intact,
  however some reading comprehension difficulties
• With prompting to slow down his reading rate and
  check his responses, accuracy improved

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Limitations of current processes

• Weve had no help at all since being at home
• Comment from patients wife 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

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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

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Thank you!
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Northern Trauma System Regional Conference 2014

• High quality trauma care from
• Roadside to Recovery

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Transforming Trauma Rehabilitation

• Recommendations for the North East Region

• Sharon Smith
• Paula Dimarco

NHS Presentation to XXXX Company Type Date
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Overview of talk

• Purpose of project
• Background of project
• Best practice pathway
• Key findings
• Recommendations

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Purpose of project

• On behalf of NE SHA
• Provide information and recommendations
• Develop a best practice pathway
• Support commissioning for development of
  rehabilitation services following major or
  serious trauma

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The Project

• Regional steering group
• Two work streams, JCUH and RVI
• Review of MSK and neurological rehabilitation
• Map of current pathway
• Data collection and analysis
• Stakeholder consultations
• Identify models of best practice
• Gap analysis

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Best practice pathway
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Key findings
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No consultants in Rehabilitation Medicine in MSK
and insufficient within neurotrauma

• National Standards Recommend
• 6 WTE per million population
• No single handed consultants
• Current Regional Provision
• 3.8 WTE in level 1 Services
• 3 WTE in level 2 services all working single
  handed
• There is a 2/3 Shortfall on the national
  standards.

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Lack of communication, co-ordination and
leadership across the pathway leading to
disjointed care and inadequate management of
patients

• RVI has head injury nurse specialist
• JCUH has acquired brain injury coordinator
• No formal coordinated MDT rehab specifically for
  TBI at either MTC
• No coordinator for MSK at either MTC
• Rehabilitation needs to be well planned across
  the whole pathway, including TUs and community
  services

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No specialist inpatient beds for MSK
rehabilitation resulting in longer lengths of
stay in acute beds or transfer to inappropriate
settings

• Case example
• 55 year old male MSK polytrauma including ITU
  stay
• MTC also patients local hospital
• NWB for 6 months, remained on an acute ortho ward
• Transferred to intermediate care at 7 months
  little experience of younger patients and ortho
  rehab

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No specialist community MDT for MSK
rehabilitation leading to sub-optimal outcomes
and longer lengths of rehabilitation

• If there were community MSK trauma rehab teams,
  the outcome of the previous example may have been
  somewhat different

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Insufficient level 1 and 2 inpatient
rehabilitation facilities for neurotrauma patients

• BSRM guidelines recommend 60 level 2 beds per
  million population
• Currently 47 in the North East and Cumbria
• Level 1 facility is Walkgate Park 35 beds

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Insufficient specialist community teams for
neurotrauma patients

• Only available in 3 areas
• Northumberland (3 therapies in one team)
• Gateshead (no physiotherapy)
• Cumbria
• Different models at each locality
• All teams work across health and social care

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No robust system for data collection to indicate
the number of patients requiring specialist and
non-specialist Recovery, Rehabilitation and
Reablement

• TARN can provide a list of injuries and ISS, but
  these dont tell us what the patients
  rehabilitation needs are and are retrospective
• UKROC not used by all aspects of the pathway
• Rehabilitation prescription yet to function as a
  data recording tool

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Lack of vocational rehabilitation resulting in no
focus on reablement, return to work and social
integration

• No vocational rehab for MSK trauma
• Limited for neurotrauma
• All have access to statutory services not
  always appropriate
• Momentum for neuro patients

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No standardised or consistent approach to the use
of outcome measures which makes it difficult to
evaluate rehabilitation

• Different emphasis at each stage of rehab,
  therefore a variety of outcome measures are used
• No standardised approach
• Work is being undertaken to determine best
  outcome measures to use

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Recommendations
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Recommendations

• Provide additional Consultant level leadership in
  rehabilitation in order to promote
  inter-speciality working and improve patient
  management and outcomes e.g. Consultants in
  Rehabilitation Medicine/Consultant Allied Health
  Professionals.

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Recommendations

• Explore workforce options to improve coordination
  and communication across the whole pathway for
  example Rehabilitation Coordinators/Facilitators.
• Devise robust, flexible, fit for purpose systems
  to collect data and inform future commissioning
  and service provision.

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Recommendations

• Develop specialist rehabilitation inpatient beds
  for major trauma MSK patients. This would also
  ensure the capacity to provide intensive therapy.
  Further work is recommended to identify the
  number of beds required.
• Create specialist MDTs which would deliver
  specialist rehabilitation for MSK major and
  serious trauma patients (inpatient and
  outpatient/community).

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Recommendations

• Provision of more level 1 and 2 rehabilitation
  beds for Neurotrauma patients in line with
  national recommendations.
• Increase the current number of specialist
  community teams for rehabilitation of Neurotrauma
  patients to cover all areas.

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Recommendations

• Undertake robust and committed service redesign
  to deliver a best practice pathway, with
  particular focus on strengthening Recovery,
  Rehabilitation and Reablement services.
• Ensure regional implementation of the
  rehabilitation prescription process for all major
  trauma patients across all services, from injury
  to re-enablement. This should include the
  redesign of the current Rehabilitation
  Prescription.

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Recommendations

• Integrate vocational rehabilitation into the
  trauma pathway.
• Undertake further work to develop recommendations
  for the use of outcome measures for the trauma
  rehabilitation pathway.

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Recommendations

• Develop a Directory of Rehabilitation Services
  with identified administrative support to
  maintain and update.
• Implementation of these recommendations requires
  a coordinated approach involving commissioners,
  expert clinicians and service users.

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Amputation Rehabilitation

• Mr Yogendra Jagatsinh
• MBBS. M.S. (Tr Orth), MRCS Ed
• Consultant in Rehabilitation medicine

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• Amputation one of the meanest, and yet one of
  the greatest operations in surgery
• mean when resorted to where better may be
  done
• great, as the only step to give comfort and
  prolong life.
• Sir Willliam Ferguson 1865

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• The principle of a patient receiving specialist
  care appropriate for their injuries is
  fundamental to Networks of Trauma care. To
  abandon this at the point at which rehabilitation
  is required is illogical and compromise patient
  outcomes. It is wrong to assume that specialist
  rehabilitation techniques will be carried out on
  a general orthopaedic or general surgical ward in
  DGH
• 
  Regional Network for Trauma
• NHS
  CAG Report

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Incidence and Prevalence

• Prevalence62000 Incidence 5000/year
• LL92, UL5 Cong def3
• 50 of all amputees are gt 65 yrs 25 gt 75yrs
• Females30, median age of males66 females
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• 50 of all referrals are transtibial amputees
• 72 of all referrals are PVD 41 of them
  diabetic
• 60 of UL referrals are lt 55 yrs old.

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Trauma Amputations

• 30 of new amputations
• industrial accidents, farming accidents, or motor
  vehicle accidents, which include automobiles,
  motorcycles and trains
• War amputations-complicated, multiple
• Younger and active populations

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Levels of Amputations
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Phases of Rehabilitation

• Pre amputation consultation
• Healing and Starting Physiotherapy
• Visiting the Prosthetist
• Choosing an Artificial Limb
• Learning to Use your Artificial Limb
• Life as a New Amputee

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Goals of Rehabilitation

• optimize health status,
• Function
• Independence
• Quality of life of patients
• Participation in society

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Post operative Rigid Dressings-Why Use Them?

• Control edema- that otherwise would
• Delay healing
• Cause pain
• Complicate
  prosthetic fitting
• Shape the limb for optimal socket fitting
• Protects wound/incision
• Some can allow for early weight bearing
• Get the patient used to the idea of caring for
  the residual limb
• Never too early to begin educating on volume
  management
• Training in compliance
• Some can help prevent a joint contracture
• Desensitization
• Can absorb drainage

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Pain Management

• Perioperative pain control
• Pain after healing-Bony causes
• -Soft tissue
  causes
• Pain caused by prosthesis-Pressure, friction or
  skin tractioning
• Phantom limb pain
• Decrease dependence on narcotic medication

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Physical Health

• Reduce the risk of adverse effects due to
  periods of prolonged immobilization
• a. Decrease contractures
• b. Decrease incidence of
  pressure ulcers
• c. Decrease incidence of
  deep vein thrombosis
• Improve physical status (e.g., balance, normal
  range of motion especially at the hips and knees
  increase strength and endurance to maximize
  efficient use of a prosthesis)

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Function

• Improve functional status (e.g., independent bed
  mobility, independent transfer, wheelchair
  mobility, gait and safety)
• Improve ambulation (e.g., distance of ambulation,
  hours of prosthetic wearing, use of an assistive
  device, and ability to ascend/descend stairs)
• Improve quality of life/decrease activity
  limitation (e.g., activities of daily living
  ADL, recreation, physical activity beyond ADL,
  community re-integration and return to home
  environment)

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Energy use in Amputation
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Psychological adjustment

• Overwhelming feeling of lack of control
• Feeling of complete change
• Change in body image
• Grieving process-five stages denial, bargaining,
  anger, depression and acceptance.

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Traumatic amputation

• Co-morbidity from multiple trauma
• Additional injuries of peripheral nerves,
  disrupted blood vessels, retained shrapnel,
  heterotopic ossification, contaminated wounds,
  burns, grafted skin, and fractures.
• Requires modified rehabilitation strategies in
  the training of activities of daily living (ADL)
  and ambulation.

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Rehabilitation and the long-term outcomes of
persons with trauma-related amputations.

• OBJECTIVE To examine the long-term outcomes of
  persons undergoing trauma-related amputations and
  the role of inpatient rehabilitation in improving
  such outcomes.
• PARTICIPANTS Principal or secondary diagnosis of
  a trauma-related amputation to the lower
  extremity. Spinal cord injury or traumatic brain
  injury were excluded.
• RESULTS 146 patients
• 9 died during the
  acute admission and 3.5 died after discharge
• 87-Males. 80 lt40 yrs
  age
• Health profile (n 78,
  68 response rate) was systematically lower than
  that of the general US population for all SF-36
  scores.

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• 25 - severe problems with the residual limb,
  including phantom pain, wounds, and sores.
• Number of inpatient rehabilitation nights
  directly related to function in their physical
  roles, increased vitality, and reduced bodily
  pain.
• Inpatient rehabilitation- improved vocational
  outcomes.
• Pezzin LE et al. Rehabilitation and the long-term
  outcomes of persons with trauma-related
  amputations. Archives of Physical Medicine
  Rehabilitation, 01 March 2000, vol./is.
  81/3(292-300).

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Carlisle Murrison Centre

• Consultant Led Service
• Team of Prosthetic, physiotherapy, rehabilitation
  assistant, exercise therapist, Occupational
  therapist, Orthotist, Psychologist,
  rehabilitation engineer, Podiatrist all in one
  roof.

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Role of Rehabilitation Consultant

• Perioperative consultation-best outcomes
• Issues with pain, sexual function and pain-early
  period
• Physical complications such as pain, skin
  disorders, sweating, infections and venous
  thromboses,
• psychological complications such as depression
  and catastrophising
• Secondary or tertiary prevention is also a key
  function with regard to skin and foot pathology,
  cardiovascular disease,osteoporosis and drug
  complications

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• vocational rehabilitation,
• provision of wheelchairs,
• special seating,
• orthoses and
• assistive technologies.

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This is the opportunity for the us all
to take the Rehabilitation out of the ranks of
being a "Cinderella Speciality"