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The Role of Specialist Rehabilitation in Polytrauma Management

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The Role of Specialist Rehabilitation in Polytrauma Management Dr James Graham (Consultant Radiologist) Dr Rachel Reaveley (SPR in Neurological Rehabilitation) – PowerPoint PPT presentation

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Title: The Role of Specialist Rehabilitation in Polytrauma Management


1
The Role of Specialist Rehabilitation in
Polytrauma Management
  • Dr James Graham (Consultant Radiologist)
  • Dr Rachel Reaveley (SPR in Neurological
    Rehabilitation)

2
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
    service
  • Assessing the psychological impact of poly-trauma
    in the context of concurrent head injury

3
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

4
Trauma CT
5
Trauma CT
6
Trauma CT
7
Trauma CT
8
A few days later
  • Gradual clinical deterioration
  • Lactate 1.3
  • Amylase 439
  • WCC 20
  • CRP 116
  • Bilirubin 63
  • ALP 335
  • ALT 282

9
Follow up CT
10
Follow up CT
11
Gastric appearances
12
Angiogram
13
What Happened next?
14
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

15
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

16
Benign Paraoxysmal Positional Vertigo
17
Orthostatic Hypotension
18
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.
19
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

20
Epleys Manouvre
21
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

22
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

23
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.)

24
In Patient Admission to WGP Cognitive Assessment
Bed February 2014
  • Increasing concern about ongoing depressive
    episodes with psychological trauma- type
    symptoms post RTA

25
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

26
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

27
Limitations 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)
29
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

30
Thank you!
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