145: Polytrauma Rehabilitation

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CHAPTER 145

Polytrauma Rehabilitation

Marissa McCarthy, MD; Robert Kent, DO, MHA, MPH; Neil Kirschbaum, DO; Gail Latlief, DO; Rafael Mascarinas, MD; Bryan Merritt, MD; S. Jit Mookerjee, DO; Steven Scott, DO; Joseph Standley, DO; Jill Massengale, MS, ARNP

Synonyms

Blast injury

Multiple injuries

Multiple trauma

ICD-9 Codes

344.0  Quadriplegia and quadriparesis

344.1  Paraplegia

804  Multiple fractures involving skull or face with other bones

850  Concussion

854.0  Intracranial injury of other and unspecified nature without mention of open intracranial wound

854.1  Intracranial injury of other and unspecified nature with open intracranial wound

905.0  Late effect of traumatic amputation

906.8  Late effect of burn of unspecified site

907.0  Late effect of intracranial injury without mention of skull fracture

997.63  Infection (chronic)

ICD-10 Codes

G82.50  Quadriplegia, unspecified

G82.20  Paraplegia, unspecified

S02.91  Unspecified fracture of skill

S02.92  Unspecified fracture of facial bones

Add seventh character for S02 (A—initial encounter for closed fracture, B—initial encounter for open fracture, D—subsequent encounter for fracture with routine healing, G—subsequent encounter for fracture with delayed healing, K—subsequent encounter for fracture with nonunion, P—subsequent encounter for fracture with malunion, S—sequela)

S06.0  Concussion

S06.9X  Unspecified intracranial injury; add seventh digit for duration of loss of consciousness

Add seventh character to S06 for episode of care

B99.9  Unspecified infectious disease

Definition

In 2005, the U.S. Department of Veterans Affairs officially adopted the term polytrauma, originally defined as an injury to the brain in addition to other body parts. The definition changed in 2009 to be more encompassing: “two or more injuries sustained in the same incident that affect multiple body parts or organ systems and result in physical, cognitive, psychological, or psychosocial impairments and functional disabilities [1,2].”

The sequelae of polytrauma may include physical, cognitive, and psychological impairments. If a brain injury is involved, the severity typically guides the course of rehabilitation [3]. Other common disabling conditions include limb extremity trauma or amputation, spinal cord injury, neurosensory impairments, mental health disorders, and extreme soft tissue injury.

Because of the nature of modern military combat and violence in society, there is an increased risk for polytrauma injuries. Current combat-related polytrauma injuries are frequently caused by exposure to high-energy blasts or explosions [4]. Other causes of polytrauma may include severe motor vehicle accidents, falls, suicide attempts, accidental drug overdoses, and assaults. Advanced trauma life support permits increased survival among those with even the most devastating injuries (Table 145.1).

Polytrauma war-related injuries as well as civilian-based injuries occur more frequently in the younger population and predominantly in males. In noncombat conditions, active-duty men are 2.5 times more likely to have a traumatic brain injury. Military reports indicate that more than 27,000 service members serving in the current conflicts were injured between December 2001 and April 2012; of those, 49% sustained injuries classified as polytrauma. Of those injured as a result of combat operations, 62% had polytrauma injuries (K. Gross, personal communication, February 1, 2013). In the military polytrauma population, 1581 amputees have been treated in the military treatment facilities [5]. Civilian polytrauma frequency statistics are not available at this time [6,7].

Symptoms

Whereas many symptoms of polytrauma are immediately recognized, others are more subtle. Symptoms related to traumatic brain injury include cognitive, emotional, and physical impairments (see Chapter 162).

Cognitive deficits in patients with moderate to severe brain injury may include difficulties with speech and language, executive function, memory, concentration, and judgment. Irritability, anxiety, depression, and emotional lability are commonly observed. Physical symptoms of polytrauma commonly include motor and sensory deficits as well as more subtle complaints, such as headache, dizziness, fatigue, and dyssomnias. Pain is common and arises from multiple causes, complicating pain management.

Physical Examination

A thorough physical examination is essential in the evaluation of a patient who has sustained polytrauma. A mechanism of injury–directed review of systems is suggested [5]. If the mechanism of injury is blast related, the examination emphasizes testing for barotrauma to air- or fluid-filled organs. A thorough neurologic examination with complete assessment of cranial nerves (including olfactory), motor strength, sensation, reflexes, and coordination and a neuropsychological evaluation are recommended when central nervous system involvement is suspected.

A multidisciplinary approach commonly requiring specialty consultants to participate in the assessment is necessary for comprehensive care of these complex patients. Special attention is paid to the assessment of skin and soft tissue. The ideal approach is a patient-centered interdisciplinary evaluation and treatment plan coordinated by physiatry.

Functional Limitations

Polytrauma patients have multiple functional limitations based on the severity and number of physical and cognitive impairments. Hearing and visual field deficits affect everyday life functions and can make educational and vocational goals difficult to achieve. Lower extremity muscle weakness often impairs ambulation and creates a safety risk from falls. Upper extremity weakness and spasticity impair the patient’s ability to do everyday activities such as dressing, hygiene, and handwriting. Cognitive deficits affect the ability to work and to perform roles related to parenting and living independently. Particularly in the early phase of recovery, some patients may require continuous surveillance to prevent wandering or self-injurious behavior. Later in recovery, driving can be achieved in some patients after passing of a driving evaluation, which may identify necessary modifications to the current vehicle. Many polytrauma patients will experience psychosocial problems. Traumatic brain injury, stress, and mental health–related issues predispose patients to depression, anger, and mood swings. Those with brain injuries may experience significant personality changes affecting interpersonal relationships, vocational rehabilitation, and quality of life.

Diagnostic Studies

Imaging Studies

Because of the complex nature of injuries, several different imaging modalities are used to assess the central nervous system in the polytrauma patient. In general, central nervous system injury is assessed by a combination of computed tomography and magnetic resonance imaging. Magnetic resonance imaging may be challenging in both military and civilian populations because of the higher incidence of retained fragments or past medical history involving a metal implant. Post-traumatic encephalomalacia, hydrocephalus, intracranial hemorrhage, diffuse axonal injury, cerebral contusions, mass effect, degree of atrophy, and spinal cord injury can be assessed by magnetic resonance or computed tomographic imaging.

Routine radiographs are often sufficient to assess axial, musculoskeletal, and visceral injuries. Other imaging techniques, such as computed tomography, bone scan, magnetic resonance, and ultrasonography, can be used when more detailed examination is necessary or for assessment of secondary complications.

Electrodiagnostics

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