Title: The Role of Specialist Rehabilitation in Polytrauma Management
1The Role of Specialist Rehabilitation in
Polytrauma Management
- Dr James Graham (Consultant Radiologist)
- Dr Rachel Reaveley (SPR in Neurological
Rehabilitation)
2Objectives
- 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
service - Assessing the psychological impact of poly-trauma
in the context of concurrent head injury -
3Case 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
4Trauma CT
5Trauma CT
6Trauma CT
7Trauma CT
8A few days later
- Gradual clinical deterioration
- Lactate 1.3
- Amylase 439
- WCC 20
- CRP 116
- Bilirubin 63
- ALP 335
- ALT 282
9Follow up CT
10Follow up CT
11Gastric appearances
12Angiogram
13What Happened next?
14Rehabilitation 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
15Dizziness 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
16Benign Paraoxysmal Positional Vertigo
17Orthostatic Hypotension
18Coeliac 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.
19Rehabilitation 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
20Epleys Manouvre
21People 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
22Out 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
23Rehabilitation 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.)
24In Patient Admission to WGP Cognitive Assessment
Bed February 2014
- Increasing concern about ongoing depressive
episodes with psychological trauma- type
symptoms post RTA
25Psychology 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
26Other 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
27Limitations of current processes
- Weve 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
28(No Transcript)
29Summary
- 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
30Thank you!