Polytrauma refers to injuries that affect two or more body systems or organs, with one of the injuries usually being a traumatic brain injury (TBI), and at least one of the injuries being potentially life-threatening in severity. These injuries can lead to impairments in physical, cognitive, psychological, or psychosocial functioning.1,2,3
Polytrauma is a term that has been around for decades4. Its widespread use was coined by a 2005 directive within the Veterans Health Administration to describe a prominent clinical phenomenon. In combat sites including Afghanistan and Iraq, a confluence of factors led to a surge in polytraumatic injuries. Unprecedented exposure to blasts, advances in battlefield trauma care and effective body armor, among other factors, led to a new set of collective wounds with protracted and complex recovery periods.1
Common injury mechanisms include crashes involving motor vehicles, motorcycles, bicycles and other vehicles. Assault and other blunt injuries, if associated with sufficient force, can also result in polytrauma. Falls, blunt trauma, and penetrating injuries, particularly from multiple gunshot or stab wounds, are other possible culprits.5
Blasts, and their multiple associated mechanisms of injury, are an all-too common etiology for polytraumatic injuries. Blast sources can include artillery, rocket and mortar shells, mines, aerial bombs, improvised explosive devices, and rocket propelled grenades. The severity of injury is related to the type of explosive, distance from blast, and whether or not there were protective barriers in place. Mechanisms of blast injury include high-order shock wave moving through body and gas-filled organs, such as the lungs, ears, and gastrointestinal tract. Bomb fragments and other objects propelled by the explosion can also cause harm. Individuals can be injured when they are thrown by a blast wind. Burns, crushing injuries, and respiratory injuries can also occur. At least 60% of blast injuries result in traumatic brain injury either from direct impacts, forces associated with the blast, or some combination.6
Epidemiology including risk factors and primary prevention
Polytrauma, a significant cause of morbidity and mortality, commandeers extensive resources. In the United States, trauma accounts for more than 40 million emergency department visits and more than 2 million hospital admissions every year.7 Trauma is a causative factor in more than 120,000 deaths in 2010.8 It is the leading cause of death for Americans aged one to 46 and is the third most common cause of death overall. The economic burden of trauma has been estimated at more than $585 billion annually.7
Trauma is also a significant issue for military personnel. Of the 2.5 million service members who served in combat in the Middle East and Southwest Asia between 2003 and 2013, there were more than 7,000 deaths. The number of combat-related injuries varies by report, but by one very conservative estimate there were more than 55,000.9
Immediate and early trauma deaths are generally due to primary TBI, acute blood loss, and hemorrhagic shock. Subsequent mortality can be related to secondary brain injury issues or other physiologic sequelae. For example, impaired perfusion in the setting of hypoxia and hypotension can further damage organs. Surgical complications or infections can also contribute to post injury mortality and morbidity following the acute injury. Pathological inflammatory responses and their effects pose even more peril.10
Specific injuries have different pathological bases. TBI and spinal cord pathology depend largely on the region affected. Musculoskeletal injuries have different potential sequelae depending on injury location.11 The processes underlying other complex injuries, including traumatic limb loss, burns, genital trauma, ocular trauma, facial and neck injuries, soft tissue injuries, and damage to internal organs, similarly vary by injury type.6,10
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
Rehabilitation of patients with multiorgan injuries is complex. TBI-related sequelae can include cognitive impairment, motor and sensory impairment, headache, visual dysfunction, vestibular and hearing issues and sleep disturbances.5 Patients recovering from musculoskeletal injuries, who may require multiple additional surgeries to optimize bone healing, often experience pain and impaired mobility.11,13 Injuries to other organ systems, and the additive effects of the injuries, can all significantly affect current and subsequent function.2,6
Specific secondary or associated conditions and complications
Psychosocial issues are a crucial component of polytrauma rehabilitation. Common psychological sequelae, including post-traumatic stress disorder (PTSD) and depression, require effective assessment and treatment.14
2. ESSENTIALS OF ASSESSMENT
Rehabilitation of the polytrauma patient begins with a thorough history. The mechanism of injury provides important information about the forces involved and likely severity. Injuries sustained, including whether there was a traumatic brain injury, musculoskeletal injuries, damage to internal and vital organs, are also significant markers. It is helpful to consider early vital signs for any evidence of hemodynamic instability and/ or hypoxia, which can affect progress later. An initial reliable Glasgow Coma Scale score can provide insight into how severe the TBI may have been.3,12
The Injury Severity Score (ISS), developed to provide quantifiable information about an injury’s anatomic scope and severity, is particularly useful for characterizing patients with damage to multiple organs or systems. The ISS allows for objective description and comparison of patients with multiple traumatic injuries. As an independent predictor of functional outcome, ISS also has an important role in prognostication, both acutely and throughout the patient’s course.3,15
A patient’s prior medical and surgical history are also relevant since these may serve as co-morbidities with current injuries. Psychological history and current pain levels are also important.5
Once patients are medically stable, even prior to coming to a rehabilitation setting, the functional implications of injuries and treatment need to be assessed and addressed. Specific assessments vary by primary injury.
Aphasia, focal weakness and neglect present potential safety issues. Dysphagia can lead to pneumonia and additional problems. Burns, wounds, contractures and spasticity can cause pain and impede mobility. Post traumatic headaches and seizures can cause further debility. Neuroendocrine and sexual dysfunction, neurogenic bowel and bladder and visual abnormalities can pose threats to optimal health. Psychological issues, including depression, anxiety, PTSD and substance misuse disorders, can ensue. These conditions, alone and in combination, can interfere with an individual’s independence and quality of life.5
In acute rehabilitation, the FIM (previously called Functional Independence Measure) score is commonly utilized. FIM scores quantify abilities regarding activities of daily living and overall function.5 Polytrauma patients who have TBI can also be evaluated using The Mayo-Portland Adaptability Inventory-4 (MPAI-4). This instrument can assess progress in rehabilitation and then over the long term. MPAI-4 includes a Participation Index subscale, the M2PI, which evaluates and quantifies psychosocial consequences of TBI.16
The rehabilitation clinician follows any ongoing medical or surgical issues. If relevant, tests like blood counts, coagulation times and inflammatory markers are monitored. Urinalysis and urine culture can be checked to evaluate dysruria. Nutritional status, as reflected by tests like prealbumin and vitamin D, is monitored. Metabolic function can be tracked via electrolytes, blood urea nitrogen, creatinine, and liver function tests.
If rhabdomyolysis is or has been suspected, creatine kinase (CK) and myoglobin need to be monitored closely. This potentially life-threatening condition, which results from the rapid breakdown of skeletal muscle fibers, can occur with musculoskeletal trauma. As myoglobin, CK, and other muscle cellular contents leak into the blood, CK levels can increase to over 10 times the upper limit of normal and myoglobin is also elevated. Renal function, which can be damaged when CK and myoglobin blockages cause acute tubular necrosis, needs to be aggressively monitored.17
Monitoring myoglobin carefully is also important in situations involving prolonged immobilization and compartment syndrome. Detecting and addressing increases in myoglobin can avert secondary complications, including renal failure, in those conditions as well.17
Early in the course, when polytrauma patients have altered level of consciousness or impaired ability to communicate, CT scans and ultrasound tests are used to diagnose traumatic injuries rapidly. X-rays of non-life-threatening injuries are obtained after initial stabilization.8,18
In rehabilitation settings, imaging is useful for following up on the status of previously treated injuries, like fractures. Imaging is also used to evaluate problems that develop in the rehabilitation setting. For example, head CT can assess structural changes in patients with TBI who demonstrate seizures or other acute changes. Venous ultrasounds assess for deep venous thrombosis in patients with limb tenderness, edema, or related symptoms.
Supplemental assessment tools
Patients who sustain injury to the brain, either in the form of a TBI or secondary injury in the setting of polytrauma, undergo formal neuropsychological testing. This comprehensive evaluation of cognition, executive functioning, and mental health issues can be useful for establishing a diagnosis and planning rehabilitation treatments.5
Patients with cognitive impairment, visual impairment, mobility limitations, or related problems are commonly sent for driving assessment. The therapist assesses abilities and provides recommendations for adaptations.
Early predictions of outcomes
Predictors of outcome include injury severity as measured by Injury Severity Scale (ISS) and the Glasgow Coma Score (GCS) scores, both soon after injury and at admission to rehabilitation, and FIM scores on admission to rehabilitation.16,19
In cases of TBI, spinal cord injuries, burns and traumatic limb loss, and other conditions, physiatrists can lend instrumental expertise to discussions about likely prognosis and rehabilitation needs both in the immediate future and over the long-term.
Throughout the patient’s course, rehabilitation clinicians promote environments that are friendly to healing, patient and caregiver empowerment, and functional recovery.
Social role and social support system
Family members and caregivers play a vital role in recovery. They may learn to provide or manage physical care following injury. Caregivers may also take on financial, familial, and household responsibilities while the patient is unable.
Rehabilitation clinicians connect patients and caregivers with available community resources. Formal support groups and assistance programs are sponsored by counties, states, and local organizations. For example, The Brain Injury Association of America, and its affiliates around the country, provides patients and families with information and support services. Veterans can access services provided by the VA in addition to county and regional service groups.
Effective polytrauma rehabilitation involves close collaboration with multiple other providers. These include practitioners of orthopedics, general surgery, cardiothoracic surgery, urology, otolaryngology, neurosurgery, general medicine, pulmonary, cardiology, neurology, endocrinology, infectious disease and others. The team develops and implements a plan to treat and follow-up on polytraumatic injuries. Rehabilitation interventions intertwine smoothly and safely with this underlying plan.20
3. REHABILITATION MANAGEMENT AND TREATMENTS
Available or current treatment guidelines
Polytrauma patients’ multiple injuries and sequelae require adept and skillful treatment. The American College of Surgeons Advanced Trauma Life Support protocols provide an evidence-based roadmap for some of this care.21 For patients with TBI, the Guidelines for the Treatment of Severe TBI can also be useful.22
Clinically significant missed injuries or delayed diagnoses, which can occur in more than 20% of trauma patients and can lead to increased morbidity and mortality, are a significant issue in patients with polytrauma.23 Patients with TBI, GCS of 8 or less, multiple traumatic injuries, and higher severity as measured by ISS are most likely to have injuries that are not diagnosed in the critical or acute care phases.23,24 When these injuries are recognized in the rehabilitation setting, physiatrists collaborate with trauma specialists to develop and implement appropriate treatment plans.
At different disease stages
New onset/acute care
Rehabilitation occurs in the many stages and sites along the continuum of recovery for polytrauma patients. Rehabilitation should begin as soon as possible. In the intensive care or acute care unit, interventions can include passive and then active range of motion or isometric exercises, early mobilization, and optimal nutrition. These are geared at minimizing muscle loss and deconditioning despite presence of critical injury or illness.25
Some polytrauma patients require a stay at a long term acute care facility or skilled nursing facility at some point during their course. Focused rehabilitation interventions at those facilities can help optimize function even though the patient is facing protracted medical issues.
In acute rehabilitation settings, patients experience individualized, interdisciplinary, multifaceted and intensive rehabilitation programs. Team members include experts in speech-language pathology, occupational therapy, physical therapy, rehabilitation psychology, recreation therapy, rehabilitation nursing, nutrition, rehabilitation social work, rehabilitation engineering, and vocational rehabilitation. Therapies can be delivered in individual or group format. Effective communication and collaboration among team members optimizes the work.26
Complex medical issues can challenge rehabilitation clinicians. Polytrauma patients often experience prolonged immobilization, leading to deconditioning, muscle atrophy, and depleted functional reserve. They require careful management of risk for venous thromboemboli while they are not fully ambulatory or have healing fractures that can predispose them to clots. These patients are also at risk for skin breakdown, wound problems, and pressure ulcers, which need to be addressed and treated.27
Rehabilitation clinicians optimize fluid status and nutrition because these are crucial for healing. Patients may still have catheters, tubes, drains, and lines, which require vigilant and thoughtful care. Physiatrists collaborate with surgeons and other acute care teams to ensure that these devices are managed appropriately and removed as soon as possible. Patients also require attentive pain management assessments and interventions while undergoing rehabilitation from polytraumatic injuries.27
During acute rehabilitation, patients, family and team members plan for post-discharge needs. Home safety evaluation, generally performed by occupational therapists, can provide important information about the patient’s home environment. Targeted adaptations can often help optimize safety in the setting of impairments affecting cognition, vision, mobility, and other aspects of function.5
Patients generally transition to community-based settings. Options include living with family, group homes or another supported environment, or independent living. Community participation and re-entry activities can be optimized by visits to school or work settings by team members. Patients continue to follow with rehabilitation professionals on an outpatient basis until their functional goals are attained. When there are chronic, ongoing issues, patients continue to follow with the physiatrist and rehabilitation team over time.20
Coordination of care
Optimal outcomes in polytrauma rehabilitation rely on the successful integration of biopsychosocial and therapy resources with medical and surgical treatments, programs and facilities. Case management interventions are invaluable for patients whose needs are complex, ongoing, and multifaceted.20
The US Department of Veterans Affairs (VA), Polytrauma System of Care (PSC), was designed to meet the complex rehabilitation needs of service members who sustain polytraumatic injuries. This national hub and spoke system includes five dedicated outpatient and subacute rehabilitation centers, more than 20 specialized outpatient and subacute rehabilitation programs, designated polytrauma teams at smaller facilities, and a polytrauma point of contact at all other VA clinics. The PSC model also includes proactive case management, use of telehealth, and guidelines for long-term follow-up.28 The overarching goal of this system is to provide individuals with holistic, effective care for as long as needed.26,28
Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills
If the VA’s Polytrauma System of Care proves to be an effective model long term, it could be generalized to other patients and systems.
4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE
Cutting edge concepts and practice
Telehealth and similar technologies that allow providers to see patients at remote locations can have a significant positive impact on polytrauma rehabilitation. Specialists and sub-specialists can provide treatment recommendations, and partner with local providers to implement interventions, without the patient needing to travel long distances.29
Assistive technological advances can optimize recovery, rehabilitation, subsequent quality of life, and overall functional status. Specialized wheelchairs or prosthetic devices can facilitate mobility and independence. Electronic tape recorders and calendar organizers are among the many available cognitive orthotic devices. Rehabilitation engineers and assistive technology experts design and provide patient-centered interventions an individual’s goals.
5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE
More knowledge is needed to optimize polytrauma rehabilitation for both civilians and military personnel. There are likely ways to more effectively transition care from a specialized rehabilitation center to a patient’s hometown and primary care physician. There are also potentially ways to expand and improve the use of telemedicine and assistive technology to optimize care and access to it.30
The most effective methods of tracking and caring for polytrauma patients over time are not yet known. This issue is quite pressing, since polytraumatic injuries, which most commonly affect young people, lead to complicated sequelae that often require long-term management.
- Charters E, Gillett L, Simpson GK. Efficacy of electronic portable assistive devices for people with acquired brain injury: A systematic review. Neuropsychology Rehabilitation. 2015; 25: 82-121.
- Department of Veterans Affairs, Veterans Health Administration Directive. Polytrauma Rehabilitation Centers. Washington DC: Veterans Health Administration; 2005; p.2.
- Gironda RJ, Clark ME, Ruff RL, et al. Traumatic brain injury, polytrauma, and pain: Challenges and treatment strategies for the polytrauma rehabilitation. Rehabilitation Psychology. 2009; 54: 247-258.1
- Paffrath T. How to define severely injured patients? An Injury Severity Score (ISS) based approach alone is not sufficient. Injury. 2014; 45S: S64-S69.
- Butcher N, Balogh ZJ. The definition of polytrauma: The need for international consensus. Injury. 2009; 40: S12-S22.
- Cifu DX, Lew HL. Handbook of Polytrauma Care and Rehabilitation. New York: Demos Medical Publishing; 2014.
- Sayer SA, Chiros CE, Sigford B, et al. Characteristics and rehabilitation outcomes among patients with blast and other injuries sustained during the Global War on Terror. Archives of Physical Medicine & Rehabilitation. 2008; 89: 163-170.
- Heron M. Deaths: Leading causes for 2013. Centers for Disease Control and Prevention (CDC) National Vital Statistics Reports. 2016; 65: 1-97.
- Gunn ML, Kool DR, Lehnert BE. Improving outcomes in the patient with polytrauma: A review of the role of whole body computed tomography. Radiology Clinics of North America. 2015; 53: 639-656.
- Baker MS. Casualties of the Global War on Terror and their future impact on health care and society: A looming public health crisis. Mil Med. 2014; 179 :348-355.
- Keel M, Trentz O. Pathophysiology of polytrauma. Injury. 2005; 36: 691-709.
- Arroyo W, Nelson KJ, Belmont PH, Bader JO, Schoenfeld AJ. Pelvic trauma: What are the predictors of mortality and cardiac, venous, thrombo-embolic and infectious complications following injury? Injury. 2013; 44: 1745-1749.
- Hussman B, Lendemans S. Pre-hospital and early in-hospital management of severe injuries: Changes and trends. Injury. 2014; 45S: S39-S42.
- Schoenfeld AJ, Dunn JC, Belmont PJ. Pelvic, spinal and extremity wounds among combat-specific personnel serving in Iraq and Afghanistan (2003-2011): A new paradigm in military musculoskeletal medicine. Injury. 2013; 44: 1866-1870.
- Brenner LA, Vanderploeg RD, Terrio H. Assessment and diagnosis of mild traumatic brain injury, posttraumatic stress disorder, and other polytrauma conditions: Burden of adversity hypothesis. Rehabilitation Psychology. 2009; 54: 239-246.
- Copes WS, Champion HR, Sacco WJ, Lawnick MM, KEast SL, Bain LW. The Injury Severity Score Revisited. J Trauma. 1988; 28: 69-77.
- McCulloch K, Pastorek NJ, Miller, BI et al. Clinician versus Veteran ratings on the Mayo-Portland Participation Index in Veterans with a history of mild traumatic brain injury. Journal of Head Trauma Rehabilitation. 2015; 30: 38-46.
- Zutt R, Van der Kooi AJ, Linthorst GE, Wanders RJA, De Visser M. Rhabdomyolysis: Review of the literature. Neuromuscular Disorders. 2014; 24: 651-659.
- Wongwaisayawan S, Suwannanon R, Prachanukool T, et al. Trauma ultrasound. Ultrasound Med Biol. 2015; 41: 2543-2561.
- Gehlback BK, Salamanca VR, Levitt JE et al. Patient-related factors associated with hospital discharge to a care facility after critical illness. American Journal of Critical Care. 2011: 20: 378-386.
- Strasser DC, Uomoto JM, Smits SJ. The interdisciplinary team and polytrauma rehabililitation: Prescription for partnership. Archives of Physical Medicine & Rehabilitation. 2008; 89: 179-181.
- American College of Surgeons. Advanced Trauma Life Support. 2014; Chicago: ACS.
- Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons. Guidelines for the management of severe TBI. Journal of Neurotrauma. 2007; 24: S1-S106.
- Pfeifer R, Pape HC. Missed injuries in trauma patients: A literature review. Patient Safety in Surgery. 2008; 2: 1-6.
- Lin YK, Lin CJ, Chan HM et al. Surgeon commitment to trauma care decreases missed injuries. Injury. 2014; 45: 83-87.
- Needham DM. Mobilizing patients in the intensive care unit: Improving neuromuscular weakness and physical function. JAMA. 2008; 300:1685-1690.
- Uomoto JM, William RM. Post-acute polytrauma rehabilitation and integrated care of returning veterans: Toward a holistic approach. Rehabilitation Psychology. 2009; 54: 259-269.
- Bell KR, Shenouda CN. Complications associated with immobility. In: Zasler ND, Katz DI, Zafonte RD, eds. Brain Injury Medicine, 2nd Edition. New York: Demos Medical Publishing; 2013.
- Sigford BJ. “To care for him who shall have borne the battle and for his widow and his orphan” (Abraham Lincoln): The Department of Veterans Affairs Polytrauma System of Care. Archives of Physical Medicine & Rehabilitation. 2008; 89: 160-162.
- Darkins A, Cruise C, Armstrong M, Peters J, Finn M. Enhancing access of combat-wounded veterans to specialist rehabilitation services: The VA Polytrauma Telehealth Network. Archives of Physical Medicine & Rehabilitation. 2008; 89: 182-187.
Original Version of the Topic:
Carl Granger, MD, Andrew Hall, MD. Polytrauma. Publication Date:2012/07/30.
Diane Schretzman Mortimer, MD
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