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!