H. Incorporate injury prevention into daily practice.Physicians can incorporate injury prevention as a core part of daily clinical practice. Trauma patients can be especially receptive to one-on-one prevention counseling from health care providers during the “teachable moment” that follows an injury. A helpful first step is to doc- ument risk factors that potentially contributed to the injury episode. Again, one consideration is to separate risk factors into host, agents, and environments. Doc- umenting specific risk factors will guide potential interventions and might lead to appropriate strategies to reduce future injuries. These strategies can include counsel- ing, teaching, and referrals to abuse counselors.
I. Systematize routine screens to identify patients at risk.Physicians should put systematic routine screens in place to identify patients at risk for recidivism.
Screens to capture the presence of interpersonal violence (domestic and child abuse);
use of illegal drugs (biologic screens); elderly falls (physical surroundings, comorbid conditions, medications); and abuse of alcohol (CAGE, biologic screens) can help identify patients at high risk. For example, the CAGE screen is one that has proved effective in identifying patients with an alcohol problem. CAGE is a mnemonic of the following four items: Have you ever felt you shouldcut down on your drinking?
Have peopleannoyed you by criticizing your drinking? Have you ever felt bad or guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)? A positive reply to any of these questions suggests the need for intervention and a positive response to two or more of these questions should prompt a referral for alcohol treatment.
J. Reduce recidivism by referring patients at high risk to appropriate ser- vices.Linking patients identified as high risk with established community services, either through positive routine screens or as indicated by the circumstances sur- rounding the injury event, allows the routine initiation of appropriate interventions to lessen the potential for recidivism. Such interventions include but are not limited to individual counseling of at-risk patients (e.g., seatbelt and helmet use, safe firearm storage); group counseling by capable professionals; referral to suitable inhospital
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Chapter 19rInjury Prevention 201 services (e.g., substance abuse, psychiatric follow-up); and linkages to community- based resources (e.g., domestic abuse hotlines and shelters). Although it will not be possible for all physicians, forays into the community, to visit front-line services and see the living conditions and actual risk factors that generate injuries for patients, are highly educational and will enhance any hospital-based injury prevention program.
V. SUMMARY
Physicians perform a key role in the prevention of injury. Individual physicians can focus on one aspect of prevention that is either clinically or research oriented. The prevention strategist who uses tested interventions in clinical practice is as pivotal as the research- based prevention strategist whose focus is largely in building generalizable knowledge about injury prevention. Prevention activities are a rewarding extension of the acute care trauma mission and hold the promise of greatly reducing the magnitude of injury morbidity and mortality.
Suggested Readings
Anderson GF, Chu E. Expanding priorities – confronting chronic diseases in countries with low income.
New Engl J Med 2007;356(3):209–211.
Baker SP, O’Neill B, Ginsburg MJ, et al. The Injury Fact Book. New York, NY: Oxford University Press;
1992:14–15.
Bonnie RJ, Fulco CE, Liverman CT, eds. Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: Institute of Medicine, National Academy Press; 1999.
Branas CC, Nance ML, Elliott MR, et al. Urban-rural shifts in intentional firearm death: Different causes, same results. Am J Public Health 2004;94(10):1750–1755.
Branas CC, Richmond TS, Schwab CW. Firearm homicide and firearm suicide: Opposite but equal. Public Health Rep 2004;119(2):114–124.
Branas CC. Injury prevention in the developing world. Italian J Public Health 2010;7(2):172–175.
Centers for Disease Control and Prevention. Ten great public health achievements—United States, 1900–
1999. Morb Mortal Wkly Rep 1999;48(12):241–243.
Cherpitel CJ. Screening for alcohol problems in the emergency department. Ann Emerg Med 1995;26(2):158–166.
Haddon W. The basic strategies for reducing hazards of all kinds. Hazard Prev 1980:8–12.
Haukeland JV. Welfare consequences of injuries due to traffic accidents. Accid Anal Prev 1996;28:63–72.
Kaufmann CR, Branas CC, Brawley ML. A population-based study of trauma recidivism. J Trauma 1998;45(2):325–331; discussion 331–332.
Krug EG, Sharma GK, Lozano R. The global burden of injuries. Am J Public Health 2000;90(4):523–526.
Meyer M. Death and disability from injury: A global challenge. J Trauma 1998;44(1):1–12.
National Center for Injury Prevention and Control. WISQARS (Web-based Injury Statistics Query and Reporting System). http://www.cdc.gov/injury/wisqars/index.html. Accessed June 2011.
Peterson CL, Burton R. U.S. Health Care Spending: Comparison with Other OECD Countries. CRS Report for Congress, September 17, 2007.
Richmond TS, Schwab CW, Riely J, et al. Effective trauma center partnerships to address firearm injury:
A new paradigm. J Trauma 2004;56(6):1197–1205.
Richmond TS, Thompson H, Deatrick J, Kauder DK. The journey towards recovery following physical trauma. J Adv Nurs 2000;32:1341–1347.
Rivera FP, Britt J. You Can Do It: A Community Guide to Injury Prevention. Available at:
http://www.aast.org/YouCan.html. Accessed August 2000.
World Health Organization. Injury: A Leading Cause of the Global Burden of Disease. Geneva: World Health Report; 1999.
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20 Rehabilitation
John A. Horton III and Gary N. Galang
I. INTRODUCTION
A. Trauma results in injury that can impact the functioning of those involved. Spinal cord injury (SCI), traumatic brain injury (TBI), and severe multiple trauma are among the most life-altering events. These create a need for rehabilitation services during and after acute care to minimize or avoid impairments that affect the ability to care for themselves, to fulfill customary social roles, and to return to daily activities.
Some injuries (e.g., SCI, TBI) affect numerous physiologic, psychological, social, and vocational functions to the degree that the individual loses functional independence.
The rehabilitation team is responsible to teach the patient the skills and to provide the necessary equipment to optimize function, maximize the return to independence, and enable a reestablishment of a meaningful existence. Beginning this process in the acute care setting and carrying forward into the post-acute continuum is essential to optimize outcomes and ease the adjustment for the patient.
B. Prevention of disabling complications during the acute care phase of treatment minimizes required interventions during the rehabilitation phase of treatment. Sec- ondary injury results in decrement in function and complicates care. Commonly, sec- ondary debility is the result of the prolonged immobilization of the patient. Although rarely life threatening, these secondary concerns can limit eventual functional recov- ery, can delay patient progression and can contribute to total health care cost.
II. GENERAL EFFECTS OF NEUROTRAUMA AND IMMOBILIZATION AFTER INJURY
A. Cardiovascular deconditioning occurs rapidly with any period of inactivity, with the heart and peripheral vascular mechanisms losing the capacity to respond to stressors.
With certain types of injury (e.g., SCI with its associated loss of sympathetic nervous system control), the inability to maintain perfusion pressure with changes in posture can inhibit attempts to mobilize the patient.The most important approach to this problem is to minimize immobilityand get the patient upright as soon as possible. Additional benefits from this early mobilization include improved respira- tory functioning, with decreased atelectasis and complications.
1.A recumbency-induced rise in the resting heart rate of 0.5 beats/min/day adds to any stress rate changes. The combined effect of these changes is resting tachycardia and a reduced ability to meet oxygen demands with activity; this effect is persistent for up to 2 months after return to activity.
2.Many peripheral factors, including decreases in vascular volume, loss of adaptive baroreceptor reflex responses to the upright posture, and increased pooling of blood in lower limb veins, contribute to the intolerance of the patient to an upright posture after immobility.
a.In healthy individuals, the adaptive response to upright positioning can be totally lost after 3 weeks of complete bed rest. Older patients lose this capacity to respond even more quickly, and return to baseline is slower. Concomitant premorbid disease (e.g., cerebrovascular or cardiovascular lesions) makes older individuals less tolerant of this postural drop in blood pressure.
Increasing periods of sitting with the feet in a dependent position helps reconditioning efforts for those unable to stand. The use of tilt or recline systems on wheelchairs can facilitate the tolerance to this activity. In severe
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Chapter 20 rRehabilitation 203 cases, a tilt table can be used to progressively place the person in an upright position while blood pressure is monitored.
b.Compressive garments, full-length elastic stockings, (e.g., TED hose, JOBST stockings, Tubigrip stockings, etc.) and abdominal binders may limit venous pooling and provide blood pressure support while adaptation occurs.
c.Pay attention to nutrition to maintain plasma protein levels, immune system function, and proper hydration to aid combatting hypotension.
d.In severe cases unresponsive to compression garments, increasing salt intake (up to 1 g PO QID), using sympathomimetic agents (pseudoephedrine, ephedrine, midodrine, or phenylephrine), or giving mineralocorticoids (flu- drocortisone) may assist.
e.In persons with TBI and elevations or fluctuations in intracranial pressure, be careful with aggressive mobilization.
B. Joint contractures result when a joint is not subjected to frequent passive or active range of motion.Contractureformation is most often a consequence of untreated muscular spasm because of upper motor neuron impairment.Spasticityis defined as a response to velocity-dependent stretch. This involuntary movement causes sus- tained, uncontrolled muscle tension creating unopposed shortening of the mus- cles crossing the joint. Muscular tension becomes unbalanced, thereby reducing the mobility of the affected joint. When this limitation of joint range persists, the soft tissues of the joint itself can also become contracted. Remodeling of the con- nective tissue around the joint contributes to decreased elasticity. The subsequent contracture that is produced is the result of this prolonged shortening and increased stiffness of the soft tissues of the joint.
1.Contractures contribute to increased morbidity.
a.Difficulties in positioning the patient can lead to the formation of decubitus ulcers.
b.Hygiene, particularly in the perineum, palms of the hands, and axillae, is dif- ficult.
c.Contractures also inhibit functional recovery as motor function or control is regained. This leads to prolonged rehabilitation, potential need for surgical intervention, and higher costs. Contractures may also limit patient long-term functionality, preventing achievement of the full potential for recovery.
2.Contractures should be prevented.
a.Fully ranging all joints twice a day is often enough to prevent the formation of these deformities. Active ranging by the patient is preferred when possible as it helps maintain strength and motor control. If weak but voluntary muscle power is present, use active assisted range of motion as the next in preference.
In cases of paralysis or coma, use passive range of motion. This may be difficult if severe spasticity or rigidity exist already.
b.Positioning the patient can help reinforce the gains of therapy after range of motion has been performed. A prone position provides a prolonged stretch to hip flexors. Splinting of the wrists, hands, and ankles is also useful in rein- forcement of range of motion gains and prevention of further deformation.
Use splints intermittently (not continuously) to avoid skin breakdown in areas of splint contact.
c.Other physical modalities, in conjunction with range of motion, allow a greater stretch.
i. Deep heat via use of ultrasound can increase the elasticity of collagen, but may be contraindicated in areas with metallic implants.
ii. Cooling of the muscle helps to decrease the activity of the muscle spindle mechanism, and thus decrease muscle tone.
d.Serial casting of an extremity is useful to provide a prolonged stretch. A plaster or fiberglass cast is applied, but must be prepared to pad prominences to prevent skin lesion. Stretch is maintained as the cast material cures. The cast is typically left in place for 3 to 5 days before removal. Once desired positioning is achieved through a series of progressive cast applications, the cast can then be cut into halves longitudinally (bivalve) and used as a resting splint.
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204 The Trauma Manual: Trauma and Acute Care Surgery
e.Focal neurolysis is another tool in the arsenal against contracture forma- tion. Temporary reduction of muscle tone by employment of motor point or peripheral nerve blocks using neurolytic agents (e.g., phenol—approximately 6- to 12-month duration of effect) or neuromuscular blocking agents (e.g., botulinum toxins—approximately 1- to 3-month duration of effect) is useful in cases where tone prevents full range of a joint. These should be performed under EMG, ultrasound, or stimulator guidance and may be required before splinting or serial casting can be successful. Phenol produces a direct neurolysis.
Several serotypes of botulinum toxin have been described (A, B, C, D, and E), with only A and B commercially available in the United States.
f.Anti-spasticity medications are used to reduce hyper-reactivity of the skeletal muscle. This phenomenon is common, although usually delayed in onset, in the head-injured patient and those patients with cerebral vascular accident or SCI.
Common medications include baclofen, tizanidine, diazepam, and dantrolene sodium.
i. Baclofen and diazepam are GABA analogue agents and act to provide improved descending inhibition to otherwise disinhibited pathways in the spinal cord. Both of these agents can produce sedation, and baclofen can lower the seizure threshold. Rapid baclofen withdrawal may result in seizures, hyperthermia, and systemic collapse. In general practice, baclofen is most often employed in patients with SCI and perhaps less valuable in patients with spasticity of cerebral origin.
ii. Tizanidine is an2-adrenergic agonist, which although sedating, also pro- vides inhibition of descending pathways promoting decreases in muscle tone. Some advocate this for use in more prominent upper extremity tone situations or in decreasing dysesthetic pain. Like baclofen, tizanidine is more often used in SCI patients.
iii. Dantrolene sodium is a peripheral acting agent that acts at the level of the sarcoplasmic reticulum and appears to produce less cognitive distur- bance among those with CNS injury. Use cautiously in those with liver disturbance and monitor for hepatic necrosis (serial transaminases).
C. Decubitus ulcers are a common but preventable complication. Pressure is the primary factor in the development of a skin breakdown. Ulcers occur over bony prominences when the pressure of body weight is unrelieved for prolonged periods. Pressure causes occlusion of perforating blood vessels which results in ischemic damage to the skin and underlying soft tissues. This occurs most commonly at the bone/soft tissue inter- face. Higher pressures cause breakdown in a shorter time than lower pressures. Evi- dence of a lesion on the skin surface may only hint at the full extent of the underlying damage which has already taken place.
1.Multiple factors contribute to the development of these dangerous lesions:
a.Shear either between the skin and supporting surfaces or within the soft tissues causes ischemia at lower pressures than when shear is not present.
b.Anemia causes increased risk of ischemic damage due to lack of oxygen avail- ability in the deep tissues.
c.Excessive skin moisture from perspiration or urine reduces the resistance to skin damage.
d.Poor nutrition predisposes to poor wound healing and also impaired resistance to skin breakdown due to decreased quality of collagen formation.
e.Infection can lead to skin breakdown with sepsis increasing capillary leak and impaired blood flow to pressure prone areas.
f.Lack of sensation and altered mental status also contribute to development of pressure ulcers. The normal protective pain sensation or pain awareness, which would otherwise prompt a position change, is missing and thus the pressure is not alleviated, facilitating the development of a lesion.
2.Prevention of ulceration must be the goal.
a.Careful positioning of the patient. Frequent turning, initially on a schedule of a minimum of every 2 hours, is essential. Increased attention to the occiput, scapulae, sacrum, ischial tuberosities, greater trochanters, malleoli, and heels
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Chapter 20 rRehabilitation 205 is key given the frequency of breakdown at these sites. Pillows and foam blocks can relieve pressure over these bony prominences or distribute it to other areas.
b.Inspection of the skin regularly – at least every shift – is ideal. If signs of breakdown are seen, alleviation of pressure to the area is essential. The earliest sign of damage is an area of non-blanching erythema. Palpation may reveal induration of the underlying soft tissue. If induration is present, more extensive damage may already have occurred, making the situation more critical to treat with increased urgency.
c.Managing urinary and bowel incontinence to prevent prolonged contact between the skin and urine or feces is important to prevent skin irritation and infection.
d.For patients at high risk, use of specialized mattresses and seating surfaces are a cost-effective component of a decubitus prevention program.