Handbook of Polytrauma Care and Rehabilitation David X. Cifu Henry L. Lew
Handbook of Polytrauma Care and Rehabilitation
Handbook of Polytrauma Care and Rehabilitation David X. Cifu, MD Chairman and Herman J. Flax, M.D. Professor Department of Physical Medicine and Rehabilitation Executive Director, Center for Rehabilitation Sciences and Engineering Virginia Commonwealth University Richmond, Virginia National Director for Physical Medicine and Rehabilitation Services U.S. Department of Veterans Affairs Washington, DC Henry L. Lew, MD, PhD Professor, John A. Burns School of Medicine University of Hawaii at Manoa Honolulu, Hawaii Rehabilitation Consultant Defense and Veterans Brain Injury Center (DVBIC) Professor, Department of Physical Medicine and Rehabilitation Virginia Commonwealth University Richmond, Virginia New York
Visit our website at www.demosmedpub.com ISBN: 9781936287550 e-book ISBN: 9781617051005 Acquisitions Editor: Beth Barry Compositor: diacritech 2014 Demos Medical Publishing, LLC. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. Medicine is an ever-changing science. Research and clinical experience are continually expanding our knowledge, in particular our understanding of proper treatment and drug therapy. The authors, editors, and publisher have made every effort to ensure that all information in this book is in accordance with the state of knowledge at the time of production of the book. Nevertheless, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the contents of the publication. Every reader should examine carefully the package inserts accompanying each drug and should carefully check whether the dosage schedules mentioned therein or the contraindications stated by the manufacturer differ from the statements made in this book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Library of Congress Cataloging-in-Publication Data Cifu, David X. Handbook of polytrauma care and rehabilitation / David X. Cifu, Henry Lew. p. ; cm Includes index. ISBN 978-1-936287-55-0 ISBN 978-1-61705-100-5 (ebook) 1. Post-traumatic stress disorder Patients Rehabilitation. 2. Psychic trauma Patients Care. 3. Traumatic neuroses Patients Rehabilitation. I. Lew, Henry L., author. II. Title. RC552.P67C54 2014 616.85 21 dc23 2013020955 Special discounts on bulk quantities of Demos Medical Publishing books are available to corporations, professional associations, pharmaceutical companies, health care organizations, and other qualifying groups. For details, please contact: Special Sales Department Demos Medical Publishing, LLC 11 West 42nd Street, 15th Floor New York, NY 10036 Phone: 800-532-8663 or 212-683-0072 Fax: 212-941-7842 E-mail: specialsales@demosmedpub.com Printed in the United States of America by Gasch Printing. 13 14 15 16 17 / 5 4 3 2 1
Contents Preface ix I II POLYTRAUMA BASICS 1. What Is Polytrauma? 3 2. Taking a History 6 3. Performing a Physical Examination 11 Overview 11 Detailed Procedures in Performing a Physical Examination 13 4. Ordering Tests 34 Neuroimaging 34 Neuropsychological Evaluation 35 Diagnosis and Management of Common Sequelae of TRAUMATIC Brain Injury 5. Focal Weakness and Hypotonia 43 6. Spasticity 47 7. Coordination and Balance Deficits 52 8. Tremors 56 9. Dysphagia 58 10. Numbness 63
vi Contents 11. Pain 66 12. Vision Deficits 69 13. Hearing Deficits 73 14. Cranial Nerve Deficits 77 15. Aphasia 80 16. Executive Function Deficits 84 17. Akinetic Mutism and Locked-In Syndrome 87 18. Posttraumatic Amnesia 90 19. Perceptual Deficits 93 20. Neglect 97 21. Agitation, Irritability, and Emotional Lability 101 22. Depression 106 23. Hypoarousal 110 24. Sexual Dysfunction 113 25. Neurogenic Bladder 117 26. Neurogenic Bowel 121 27. Postconcussive Syndrome 125 28. Postdeployment Syndrome in Combat-Related TBI 129 29. Headaches 133 30. Insomnia 137 31. Penetrating Brain Injuries 141 32. Disorders of Consciousness 144 33. Posttraumatic Seizures 148 34. Craniotomy/Craniectomy/Cranioplasty 152 35. Hydrocephalus 154 36. Neuroendocrinologic Abnormalities 158 37. Geriatric and Aging Issues 163 38. Dementia and Brain Injury 166 39. Disability Determination and Medico-Legal Issues 171 40. Return to Driving 174 41. Return to Sports 177 42. Return to Work 182
Contents vii III Diagnosis and Management of Common Sequelae of POLYTRAUMA With TBI and AMPUTATION, Burns, or Spinal Cord Injury 43. Dual Disability TBI With SCI, Amputation, or Burns 187 44. Amputation Care and Prosthetic Fitting 192 45. Spinal Cord Injury 196 46. Burns 199 47. Deep Venous Thrombosis 204 48. Heterotopic Ossification 209 49. Contractures 213 50. Pressure Ulcers 217 IV Appendices Ten Essential Assessments 1. Assessment of Agitation 222 2. Assessment of Amnesia, Orientation, Attention, Level of Consciousness, and Coma Recovery After TBI 224 3. Assessment of Balance 236 4. Assessment of Bowel and Bladder Function 239 5. Assessment of Concussion and Postconcussion Symptoms (PCS) 240 6. Assessment of Cognition 246 7. Assessment of Dizziness and Vertigo 249 8. Assessment of Sleep 252 9. Assessment of Smell 254 10. Assessment of Tinnitus 255 Three Essential Medical Treatments 1. Medical Treatment of Agitation 258 2. Medical Treatment of Depression 262 3. Medical Treatment of Spasticity 265 Index 267
Preface With advancements in body armor technology and battlefield trauma care, the health care system is faced with an increasing number of combat survivors who have sustained a combination of multiple physical injuries and psychological trauma. In a 2005 directive, the Veterans Health Administration (VHA) coined the term polytrauma to describe injury to the brain in addition to other body parts or systems resulting in physical, cognitive, psychological, or psychosocial impairments and functional disability (Department of Veterans Affairs, Veterans Health Administration Directive, 2005) (1). There are many textbooks on critical care and traumatic brain injury (TBI), as well as physical medicine and rehabilitation (PM&R), which health professionals have relied on to take care of this growing cohort of military service members and veterans with polytrauma. In the context of clinical care and effective teaching, the authors felt the need to develop a practical, pocket-sized handbook that focuses on polytrauma care and rehabilitation. This handbook was written in a reader-friendly style, with succinct text and flow charts to highlight the key concepts.
x Preface While the extent of recovery from TBI often guides the overall rehabilitation process, other comorbidities are equally important. The individual chapters focus on common conditions that polytrauma patients present with, including medical/physical issues (aphasia, burns, contractures, dysphagia, focal weakness, headache, hearing dysfunction, neglect, neuroendocrine dysfunction, neurogenic bowel/ bladder, postconcussive syndrome, posttraumatic seizure, pressure ulcers, sexual dysfunction, spasticity, visual dysfunction) and psychological issues, such as depression, posttraumatic stress disorder (PTSD). Vocational issues (ability to return to work) are also discussed. The goals are to (1) summarize the most frequent problems encountered by these patients and (2) offer a roadmap for clinicians regarding how to initiate and navigate through the continuum of care in order to achieve the best possible outcome. The Defense and Veterans Brain Injury Center (DVBIC) has been working collaboratively with the Department of Veterans Affairs (VA) and the Department of Defense (DOD) to provide continuing education for health professionals in the care of patients with polytrauma. The authors would like to thank the DVBIC leadership and staff for their continued dedication to improve the diagnosis and treatment of our wounded warriors. Reference 1. Department of Veterans Affairs, Veterans Health Administration Directive. Polytrauma Rehabilitation Centers. Washington (DC): Veterans Health Administration; 2005, June 8, p. 2.
I Polytrauma Basics
1 What is Polytrauma? 1. Conservative estimates of the incidence for traumatic brain injury (TBI) range from 1.5 to 3.0 million annually, with 80% 95% being mild in severity (ie, a concussion). While most of these injuries will have progressive recovery in the months to years after injury with excellent long-term functional outcomes, the impact of a TBI alone is usually sufficient to significantly challenge the injured individual, their family and the clinicians providing their care. Even injuries that are initially mild in severity can present with marked physical, cognitive, and behavioral dysfunction that requires considerable time and clinical expertise to recover. When a significant secondary injury (eg, amputation, burn, spinal cord injury, fracture) or medical/ psychological disorder (eg, posttraumatic stress disorder, depression, generalized anxiety disorder, substance use) occurs, the
4 I: Polytrauma Basics resulting polytrauma can have profound effects that greatly compound that seen with a TBI alone. Similarly, individuals who incur repeated TBIs (even mild TBIs) within a relatively short period of time (eg, less than 1 year apart) can have both short- and long-term difficulties that are significantly worse than would have been expected. 2. In military conflict, polytrauma is far more common than civilian injury, although the multiple injuries of polytrauma are seen in both settings. The recent conflicts in Afghanistan and Iraq generated TBIs in nearly 10% of all combat-deployed service members and polytrauma was seen in more than 90% of these individuals with TBI. Fortunately, a rapid recognition of this injury type and the extent of functional deficits that could accompany such a complex injury allowed for the development of a comprehensive polytrauma care system in the military and Veteran Affairs health care system. 3. The hallmark of care for polytrauma (as with all but the least severe TBIs) is a patient-centered, interdisciplinary approach that works with the injured individual and the family to address all aspects of the injury as they impact the person s life. While the acute assessment and management of most traumatic injuries are well circumscribed and coordinated in both the military and civilian trauma systems, the initial period of recovery ( rehabilitation ) that focuses on symptom management and a return to home independence is less standardized and consistently managed. Even less attention is paid to the long-term recovery of community reintegration, a return to productivity (work, school, leisure), and a focus on overall wellness.
1: What is Polytrauma? 5 4. While optimal care for polytrauma is delivered by compassionate, experienced, interdisciplinary teams of specialty clinicians with a holistic approach and an emphasis on patient engagement, the key to success lies in a thorough understanding of the types of difficulties seen and the effective means of managing them. Unfortunately, the research evidence supporting much of polytrauma rehabilitation is limited, thus consensus and expert opinion remain the state of the art for care.