Author(s): Diane Schretzman Mortimer, MD, Kathy Guo, MD
Originally published: July 30, 2012 Last updated: December 28, 2021
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Disease/ Disorder

Definition

Polytrauma: traumatic injuries that affect two or more body systems or organs, with at least one of the injuries being potentially life-threatening in severity. They typically include traumatic brain injury (TBI), along with traumatic amputations, burns, orthopedic trauma, and damage to internal organs. These injuries can lead to impairments in physical, cognitive, psychological, or psychosocial functioning.1, 2, 3

Debility: a state of decline in abilities that can include physical frailty, decreased muscle mass, and impaired mobility. This condition is characterized by loss of strength and functional limitations. It can occur gradually over time during aging. It can also occur acutely, as a consequence of acute illness. Decreased mobility often both contributes to and accompanies muscle loss. Sarcopenia is a state of low muscle mass.4

Burns: extensive burn injuries are often seen in the setting of trauma, brain injury, or spinal cord injury. Burn wounds are classified as superficial, partial-thickness, and full-thickness depending on the extent and depth of the injury. Superficial burns involve only the epidermal layer, and are typically dry, red, and blanchable. Partial-thickness burns can be further subdivided into superficial partial-thickness and deep partial thickness burns, and involves injury through the epidermis, and the upper portion of the dermis. Full-thickness burns extend deeper into the subcutaneous tissue.5

Etiology

Polytrauma: Common injury mechanisms include crashes involving motor vehicles, motorcycles, and bicycles. Assault and other blunt injuries, if associated with sufficient force, can also result in polytrauma. Falls, blunt trauma, and penetrating injuries, particularly from gunshot or stab wounds, are other possible etiologies.1

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 that quickly dissipates, followed by a prolonged blast pressure wave. 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

Debility: Patients who require prolonged hospitalizations or those who are critically ill in the ICU often suffer from significant deconditioning, malnutrition in the setting of critical illness, as well as psychological needs. Intensive care unit acquired weakness (ICUAW) typically affects proximal and respiratory muscles and may require extensive rehabilitation. ICUAW is associated with prolonged hospitalization and increased mortality, and risk factors for developing ICUAW include sepsis, shock, multi-organ failure, and hyperglycemia.7, 8

Burns: Causes of burn injuries include thermal, chemical, radiation, friction and electrical. Thermal burns can be from either excessive heat or cold causing skin injury, these can include open flames/fires, hot/cold objects, or hot/cold liquids. Chemical burns result from contact with caustic agents, and can have a direct effect on metabolic process, disrupt cellular membranes, and can cause life-threatening systemic issues if absorbed into the body. Ionizing radiation can cause burns ranging from sunburns to those seen after therapeutic radiation therapy, and they can ultimately cause deep burns due to the damage on DNA from ionizing radiation. Friction burns occur as a result of heat generated by the friction between the skin and another surface, while electrical burns can disrupt membrane potential.5, 9

Epidemiology including risk factors and primary prevention

Polytrauma: In the United States, trauma accounts for more than 40 million emergency department visits and more than 2 million hospital admissions every year. Trauma was a causative factor in more than 170,000 deaths in 2019.10 It is the leading cause of death for Americans aged 1 to 45, the third most common cause of death overall.11 Worldwide, approximately 16,000 people die from trauma-related death daily. The economic burden of trauma is upwards of $600 billion annually.12, 13

Debility: Estimated prevalence of debility varies widely among reports and studies. A recent systematic review posits that ICU-acquired weakness, including muscle loss of at least 10% of prior total mass, occurs in at least 40% of patients who require more than one week of critical care.8

Burns: According to the American Burn Association, over 400,000 people a year are treated for burn related injuries, including 40,000 hospitalizations, and it is the fourth leading cause of trauma worldwide.14 In the US, treating burns can cost upwards of over $1 billion annually.15 Burn injuries are more prevalent in males (68%), with the leading sources of burns being fire or flame (43%) and scald (34%).14 Fire safety and education is key to preventing burns.

Patho-anatomy/physiology

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.13, 16

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. 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.13, 17

Severe catabolism in response to stress can be seen in prolonged critically ill individuals, therefore it is important to ensure that patients receive adequate nutrition to meet the energy demand. Undernutrition can be associated with multiple complications, such as increased length of stay, infections, and mortality.7, 8

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Polytrauma: In the field, care focuses on life-saving measures. The airway is established and managed. Bleeding is controlled, at least temporarily, with mechanical and chemical measures. In the emergency setting, serious injuries are identified. Initial medical and surgical treatment plans are implemented. In the intensive care unit and acute care phase, surgeries are completed, and hemodynamic stability is achieved. The extent of injuries and their likely sequelae are assessed. Throughout the course, the risk for secondary problems like pulmonary embolism, cardiac events, pulmonary dysfunction and infection are addressed.16, 17, 18

Rehabilitation of patients with multi-organ injuries is complex. Over 40% of those with moderate to severe TBI will suffer from long term TBI-related sequelae, which can include cognitive deficits, motor and sensory impairments, headaches, visual/perceptual dysfunction, vestibular dysfunction, sleep disturbances, and psychiatric issues. Patients recovering from musculoskeletal injuries, who may require multiple additional surgeries to optimize bone healing, often require multimodal pain management and have impaired mobility. Injuries to other organ systems, and the additive effects of the injuries, can all significantly affect current and subsequent function.19

Debility: Critical illness is a catabolic state, and immobilization leads to muscle unloading and denervation. Loss of muscle mass results. With less muscle mass, mobility is even more difficult later, and subsequent weakness can complicate recovery.8

Burns: Extensive burns can lead to hypertrophic scarring within the first few weeks after injury, which can subsequently cause contractures which ultimately limit one’s range of motion and can result in pain as well. Contributing factors include a family history of hypertrophic scarring. Non-invasive mechanisms of managing scar formation include the use of compression garments, scar massage, and silicone gel. Pressure garment therapy is thought to aid in recovery by decreasing the blood flow and oxygen, as well as nutrients, to the area of the scar, therefore inhibiting the growth of hypertrophic scars. In addition to scars and contractures, burn injuries can cause the body to go into a hypermetabolic state which can cause muscle atrophy/muscle loss and fatigue, so careful nutrition and fluid management is needed. Patients may also have decreased pulmonary function from muscle weakness or due to inhalation injury.5, 9

Specific secondary or associated conditions and complications

Polytrauma: Addressing psychosocial issues are a crucial component of polytrauma rehabilitation, as emotional and behavioral changes are often seen following TBI. Agitation, depression, and PTSD are often present after injury. Thus, in the polytrauma rehabilitation setting, it is important to have rehab psychologists and psychiatrists as part of the team, providing effective assessment and treatments for psychological sequelae of TBI and other severe injuries.19

Debility: Leads to lower functional ability status. This is associated with decreased independence and lower quality of life. Individuals may require assistance with ADLs and IADLs as they slowly recover.4

Burns: Burns can affect and change the physical appearance of a person. It is important to consider the psychological effects of the injury. Patients can often be affected by PTSD, which has been found to be present in 45% of burn survivors within the first year of injury, and/or depression. Providers should actively monitor patients and offer psychiatric and psychological interventions or support groups if indicated.9

Essentials of Assessment

History

Polytrauma: Assessment 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 TBI severity.20

The Injury Severity Score (ISS) provides quantifiable information about an injury’s anatomic scope and severity. It is particularly useful for characterizing patients with damage to multiple organs or systems because it allows for objective description and comparison of patients with multiple traumatic injuries. ISS is also an independent predictor of functional outcome so it can play an important role in prognostication, both acutely and later in course.17, 21

Prior medical and surgical history are also relevant. Co-morbidities can affect the treatment and rehabilitation of the new injuries. Prior psychosocial history is also important to obtain, since mental health issues can affect and can be affected by acute stress.20

Debility: In addition to a thorough strength and neurologic exam, electromyography and nerve conduction studies can allow for the diagnosis of critical illness polyneuropathy and critical illness myopathy.7, 8

Burns: On initial exam of burn patients, it is always important to assess airway, circulation, and breathing (ABCs), and knowing the mechanism of burn can be important for management as well. The Modified Brooke and Parkland formulas can be used to assess fluid status and guide fluid resuscitation. Assessment of burns include determining the extent of the burn as well as the depth of the burn and estimating the injured areas as a total percentage of body surface area (TBSA). Lund-Browder’s chart and the “Rule of 9s”, to determine the TBSA affected by burns. Of note, due to infants and children having proportionally larger heads in relation to body, the Lund-Browder charts can offer a more accurate estimate.22

Functional assessment

Polytrauma: 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. Post traumatic headaches, other pain types, 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.1

The FIM (Functional Independence Measure) score quantifies abilities regarding activities of daily living and overall function. After being a stalwart assessment tool for more than 25 years, FIM is currently being replaced. The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 required that standardized patient data elements (SPADE) be reported for acute rehabilitation patients. The elements comprise standardized quality and clinical assessment measures. SPADE touches on more than 40 topics, including cognition, pain, mood, hearing, speech, vision, sleep, and medical complications. Domains include skin integrity, functional status, cognitive function, medication reconciliation, incidence of major falls, resource usage, and rate of discharge to community.  In addition to documenting progress in rehabilitation, these measures can serve as the basis for quality indicators.23, 24

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 in the long term. MPAI-4 includes a Participation Index subscale, the M2PI, which evaluates and quantifies psychosocial consequences of TBI.25

Debility: Patients require assessment of function. Their ability to complete ADLs and IADLs is especially important. When debility complicates recovery from an illness or injury, the effects of both need to be assessed.8

Burns: Similar to polytrauma, functional assessments vary depending on the site of injury. FIM score can assist in quantifying one’s ability in performing ADLs and IADLs. For burn injuries, it is important to measure a patient’s strength, range of motion (ROM) using a goniometer, pain, and sensation after an injury. Oftentimes specific positioning and splinting is needed to prevent the formation of contractures that can limit future ROM or to prevent pressure injuries.9, 26

Laboratory studies

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 dysuria. 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 and burns. 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.27

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. 27

In COVID-19 patients who often have debility, oxygen saturation, diastolic blood pressure, D-dimer, C-reactive protein, ferritin, WBC, and IL-6 may help to predict clinical severity and hospital course. It is thought that COVID-19 results in an acquired prothrombotic state, therefore elevated D-dimers may help guide empiric anticoagulation use, though research is still ongoing.28, 29

Imaging

Polytrauma: Early in the course, when polytrauma patients have altered level of consciousness or impaired ability to communicate, imaging is needed. CT scans of head, abdomen, chest and pelvis, CT angiograms of potentially affected blood vessels, ultrasounds, and plain radiographs can help with rapid diagnosis of traumatic injuries.30

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. Functional MRI (fMRI) can offer a glimpse into early recovery of consciousness for those with disorders of consciousness.31 Venous ultrasounds assess for deep venous thrombosis in patients with limb tenderness, edema, or related symptoms.

Debility: CT and MRI can be employed to evaluate skeletal muscle mass. As well, ultrasound is a fast method of examining muscles at bedside and can be used to evaluate muscle mass and quality.32

Burns: Currently the gold standard of assessing burn wounds is visual assessment, measuring the length and depth of the injury. However, with advancements in technology, there is emerging technology that can assist in further assessments. Harmonic and doppler ultrasound imaging are a quick and relatively inexpensive means of assessing depth of burn injury that can be done at bedside.33 Ankle brachial index (ABI), transcutaneous oxygen measurements, fluorescent vascular angiography, and hyperspectral imaging can all be used to assess tissue oxygenation in an area of injury. More recently, the use of high-resolution digital photography on devices such as smart phones are on the rise, and can aid in assessing wound size, and may be able to recognize healthy versus necrotic tissue.34

Supplemental assessment tools

Polytrauma: 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. Full neuropsychological testing is typically completed months after a moderate to severe TBI, but brief testing can be done in the acute inpatient rehabilitation setting and used as prognostic indicators of functional outcomes. This comprehensive evaluation of cognition, executive functioning, and mental health issues can be useful for establishing a diagnosis and planning rehabilitation treatments.35

Driving ability, which is often affected by polytrauma, is an important aspect of a patient’s community reintegration and overall independence. Driving simulators and formal driving evaluations can help assess where patients are in terms of complex visual, motor, and cognitive activities that are needed for safe driving. Driver evaluations also assess for possible vehicle adaptations that may be helpful.36

Debility: The Medical Research Council sum score gives a quantified estimation of motor function, including diaphragm muscles, while the patient is still in the ICU. The 6 Minute Walk Test provides information about functional capacity when ambulation is possible again.8

Burns: Functional recovery from burn injuries vary depending on the site of injury, and there are various assessments such as the “Life Impact Burn Recovery Assessment-Profile,” that measure community reintegration in burn patients. Although there are various scales and assessments that aim to measure factors such as pain, sleep, cognition, and contractures after burn injuries, there is no consensus on a standard means of assessing at this time.9, 26

Early predictions of outcomes

Polytrauma: Predictors of outcome include injury severity as measured by Injury Severity Scale (ISS), the Revised Trauma Score, and the Glasgow Coma Score (GCS) scores, both soon after injury and at admission to rehabilitation, and functional status on admission to rehabilitation.16

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.

Debility: The underlying reason for the ICU stay, including necessary treatments and interventions, is the primary driver of debility severity. In addition, patients seem to do better when they do not have hyperglycemia in the ICU, if they receive adequate nutrition early in their course, and if they are mobilized earlier.7,8

Burns: With burn injuries, scars often lead to the development of contractures, which can result in significant interference with ADLs, ROM, and independence, and cause neuropathic pain and pruritis. The Vancouver Scar Scale is one assessment tool for examining scars. There is a correlation between healing time and the development of hypertrophic scars, with 30% incidence of hypertrophic scars for burn injuries that heal in 2-3 weeks, and 78% for those that take greater than 3 weeks to heal. Deep burn injuries may require grafting, which can ultimately take several months to greater than a year to heal.37

Environmental

Throughout the patient’s course, rehabilitation clinicians promote environments that are friendly to healing, patient and caregiver empowerment, and functional recovery.

As patients transition back to home, some basic interventions can help facilitate safety. Home evaluations can be performed to evaluate for tripping hazards, like throw rugs and clutter. Installation of grab bars can make bathrooms safer. It is also crucial to ensure that patients have proper equipment and training and that pathways in the home can be navigated safely by patients who are still using assistive devices.

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.

Professional Issues

Effective polytrauma, burn, and debility rehabilitation involves close collaboration with providers across multiple disciplines. 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.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.38, 39  For patients with TBI, the Guidelines for the Treatment of Severe TBI can also be useful.40

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. 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.21 When these injuries are recognized in the rehabilitation setting, physiatrists collaborate with trauma specialists to develop and implement appropriate treatment plans.

Debility: In the past, muscle loss in aging and critical illness were considered fairly inevitable but are now considered at least partially preventable and treatable. Clinicians from critical care, rehabilitation and geriatrics fields have been instrumental at changing the paradigm of care for these patients.4, 41

Burns: In the acute phase of burn injuries, it is crucial to assess the ABCs (airway, breathing, and circulation), fluid status, nutritional status, and the extent of burn injuries in order to stabilize the patient. In burn injuries, it is important to assess for inhalation injuries as well. Areas of injury can be quantified by using the Rule of 9s and Lund and Browder method. Depending on the extent of injuries, grafting may be required. Throughout the rehabilitation course, proper wound care, ROM, and preventing contractures through splinting and positioning should be encouraged to prevent further complications.5

At different disease stages

New onset/acute care
Rehabilitation occurs in the many stages and sites along the care continuum. 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.4, 8, 41

Debility: Patients may 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. It is particularly to focus on oxygenation, nutrition, mobility, and minimizing effects of sedating medications when possible.4, 8

Burns: Rehabilitation should begin as soon as possible, after the patient has been stabilized in the acute phase of hospitalization. Prolonged immobility in the ICU can lead to muscle atrophy, loss of strength, pressure injuries, infections, delayed wound healing, and cardiopulmonary issues. Early mobilization, use of compression garments, and splinting to prevent contractures can help in providing maximal functional outcome after injuries.9

Acute rehabilitation
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.

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.41

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.

During acute rehabilitation, patients, family and team members plan for post-discharge needs. Targeted adaptations can often help optimize safety in the setting of impairments affecting cognition, vision, mobility, and other aspects of function.

Community re-entry and longer-term issues can be addressed in residential programs. For example, Polytrauma Transitional Rehabilitation Programs (PTRP), which are part of the VA’s Polytrauma System of Care, is a residential rehabilitation program that focuses on community reintegration. An interdisciplinary team that helps patients address skill necessary to reintegrate into the community in the least restrictive setting.1, 42

Chronic/stable

Polytrauma: 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.42

Debility: patients should continue with exercise programs that help with progressive recovery of strength and function. They may still require assistive devices and adaptive strategies aimed at optimizing function. This may include at least some follow up with physical and occupational therapy.41

Burns: After patients transition to the community-based setting, patients should continue to follow up regularly with physiatrists and other providers to continue ongoing management of medical problems such as pain and ROM limitations. Patients should also continue with therapies and continue to perform resistance and/or aerobic exercises. Burn scar contractures can be a large barrier preventing return to work, affecting quality of life and independence. Workplace accommodations is one means of assisting patients returning to work. There is also evidence to suggest a correlation between burn injury contractures and return to work, strongest at 6 months after injury.9

Coordination of care

Optimal outcomes in polytrauma, debility, and burn 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.1

Emerging/unique interventions

The VHA Polytrauma System of Care (PSC), was designed to meet the complex rehabilitation needs of service members who sustain polytraumatic injuries. This national 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 polytrauma points of contact at all other VA clinics. The PSC model includes proactive case management, coordinated caregiver resources, use of telehealth, and guidelines for long-term follow-up. The overarching goal of this system is to provide individuals with holistic, effective care for as long as needed.3, 44, 45

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.

Telehealth has been in use since the 1950s. During the COVID-19 pandemic, it has become more readily used across disciplines. Telehealth and telerehabilitation allows patients to connect with polytrauma rehabilitation specialists. Telehealth increases accessibility to polytrauma rehabilitation specialists, especially for those in remote or underserved areas. Its use can improve caregiver burden, with decreased transportation needed as well. Patient compliance with programs and satisfaction in using tele rehabilitation have also been shown to be high, and it allows a decrease in travel time and reduced indirect cost of care.45, 46

Cutting Edge/ Emerging and Unique Concepts and Practice

The use of assistive technology (AT) can help optimize recovery, rehabilitation, subsequent quality of life, independence, overall functional status, and decrease caregiver burden. AT include power wheelchairs and vehicle conversion that allow for greater mobility and independence, speech generating devices and voice recognition software for communication, or cognitive aids which include pillboxes with alarms or wearable technology such as smartwatches. The Human Activity Assistive Technology (HAAT) model can be used to guide the selection of AT to meet a patient’s individualized needs. Rehabilitation engineers and assistive technology experts design and provide patient-centered interventions to meet an individual’s goals.47

Gaps in the Evidence-Based Knowledge

Polytrauma: More knowledge is needed to optimize polytrauma rehabilitation for both civilians and military personnel. Recent military-based work on use of whole blood transfusion during acute trauma has demonstrated that this intervention can have significant benefits. However, it is not yet widely available in civilian centers.16

There are likely ways to more effectively transition between care facilities, and particularly from a specialized rehabilitation center to a patient’s hometown and primary care physician. Ensuring continuous and safe care can be especially difficult after polytrauma. During the often-prolonged course, patients and families often have to negotiate a fragmented system of health care providers and services across multiple health care settings.

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.1, 3

Debility: The COVID-19 pandemic has demonstrated the potentially disastrous effects of prolonged ICU stays. Patients who require weeks (and longer) of sedating medications, mechanical ventilation, prone positioning, and other interventions, have emerged from the critical illness with nerve injuries, muscle loss, overriding weakness and fatigue. They also report cognitive and mental health challenges. Better methods of tracking these symptoms, finding ways to prevent them, and then to address them when they do occur, are needed.29

Burns: Although many assessment tools are available in assessing burn injuries and outcomes, more research needs to be done to establish consensus guidelines. As well, the use of technology to assess burns is increasing and offers exciting opportunities to examine injuries that may be missed on visual exam, but more development and research needs to be done to ensure consistency and accuracy in the technology.

References

  1. Armstrong M, Champagne J, Mortimer DS. Department of Veterans Affairs Polytrauma Rehabilitation Centers: Inpatient Rehabilitation Management of Combat-Related Polytrauma. Phys Med Rehabil Clin N Am. 2019; 30(1):13-27.
  2. Butcher N, Balogh ZJ. The definition of polytrauma: The need for international consensus. Injury. 2009; 40: S12-S22.
  3. Department of Veterans Affairs, Veterans Health Administration Directive. Polytrauma Rehabilitation Centers. Washington DC: Veterans Health Administration; 2019.
  4. Billot M, Calvani R, Urtamo A, et al. Preserving mobility in older adults with physical frailty and sarcopenia: Opportunities, challenges, and recommendations for physical activity interventions. Clinical Interventions in Aging. 2020; 15: 1675-1690.
  5. Greenhalgh DG. Management of Burns. N Engl J Med. 2019; 380(24):2349-2359. doi: 10.1056/NEJMra1807442. PMID: 31189038.
  6. Kinch K, Fullerton JL, Stewart W. One hundred years (and counting) of blast-associated traumatic brain injury. J R Army Med Corps. 2019 Jun;165(3):180-182.
  7. Batt J, Herridge M, Dos Santos C. Mechanism of ICU-acquired weakness: skeletal muscle loss in critical illness. Intensive Care Med. 2017; 43(12): 1844-1846. doi: 10.1007/s00134-017-4758-4. Epub 2017 Mar 10. PMID: 28283700.
  8. Vanhorebeek I, Latronico N, Van den Berghe G. ICU-acquired weakness. Intensive Care Med. 2020; 46: 637-653.
  9. Young AW, Dewey WS, King BT. Rehabilitation of burn injuries: An update. Phys Med Rehabil Clin N Am. 2019; 30(1): 111-132. doi: 10.1016/j.pmr.2018.08.004. Epub 2018 Oct 31. PMID: 30470416.
  10. Centers for Disease Control and Prevention. National Vital Statistics 2019: https://www.cdc.gov/nchs/fastats/accidental-injury.htm.  Accessed 8/3/21.
  11. Centers for Disease Control and Prevention. 10 leading causes of death 2019.  https://webappa.cdc.gov/cgi-bin/broker.exe (https://www.aast.org/resources/trauma-facts). Accessed 8/3/21.
  12. Centers for Disease Control and Prevention. (WISQARS) Web-based Injury Statistics Query and Reporting. 〈http://www.cdc.gov/injury/wisQars〉. Accessed 8/3/21.
  13. 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.
  14. American Burn Association. Burn incidence and treatment in the United States: 2016. https://ameriburn.org/who-we-are/media/burn-incidence-fact-sheet/. Accessed 10/30/21.
  15. Nielson CB, Duethman NC, Howard JM, et al. Burns: Pathophysiology of systemic complications and current management. J Burn Care Res. 2017; 38(1): e469-e481. doi: 10.1097/BCR.0000000000000355. PMID: 27183443; PMCID: PMC5214064.
  16. Malkin M, Nevo A, Brundage SI. Effectiveness and safety of whole blood compared to balanced blood components in resuscitation of hemorrhaging trauma patients: A systematic review. Injury. 2021; 52: 182-188.
  17. Le TD, Orman JA, Stockinger ZT et al. Military Injury Severity Score (mISS): A better predictor of combat mortality than Injury Severity Score (ISS). J Trauma Acute Care Surg. 2016; 81:114-121.
  18. Hussman B, Lendemans S. Pre-hospital and early in-hospital management of severe injuries: Changes and trends. Injury. 2014; 45S: S39-S42.
  19. Oberholzer M, Müri RM. Neurorehabilitation of traumatic brain injury (TBI): A clinical review. Med Sci. 2019. 7(3); 47.
  20. Capizzi A, Woo J, Verduzco-Gutierrez M. Traumatic brain injury: An overview of epidemiology, pathophysiology, and medical management. Med Clin North Am. 2020; 104(2):213-238.
  21. Galvagno SM Jr, Massey M, Bouzat P, et al. Correlation between the Revised Trauma Score and Injury Severity Score: Implications for prehospital trauma triage. Prehosp Emerg Care. 2019; 23(2): 263-270.
  22. Partain KP, Fabia R, Thakkar RK. Pediatric burn care: New techniques and outcomes. Curr Opin Pediatr. 2020; 32(3):405-410. doi: 10.1097/MOP.0000000000000902. PMID: 32371842.
  23. Centers for Medicare and Medicaid Services C. IMPACT Act of 2014: Data Standardization and Cross Setting Measures. CMS. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-of-2014-Data-Standardization-and-Cross-Setting-Measures. Published 2018. Accessed 8/3/21.
  24. Centers for Medicare and Medicaid Services C. IMPACT Act Standardized Patient Assessment Data Elements. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/-IMPACT-Act-Standardized-Patient-Assessment-Data-Elements. Published 2019. Accessed 8/3/21.
  25. 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. J Head Trauma Rehabil. 2015; 30: 38-46.
  26. Ryan CM, Parry I, Richard R. Functional outcomes following burn injury. J Burn Care & Res. 2017; 38 (3); e614–e617. https:// doi-org.ezp2. lib.umn.edu/10.1097/ BCR. 0000000000000537
  27. Zutt R, Van der Kooi AJ, Linthorst GE, Wanders RJA, De Visser M. Rhabdomyolysis: Review of the literature. Neuromusc Disorders. 2014; 24: 651-659.
  28. Bennett TD, Moffitt RA, Hajagos JG, et al. Clinical characterization and prediction of clinical severity of SARS-CoV-2 infection among US adults using data from the US National COVID Cohort Collaborative. JAMA Netw Open. 2021; 4(7):e2116901.
  29. Naymagon L, Zubizarreta N, Feld J, et al. Admission D-dimer levels, D-dimer trends, and outcomes in COVID-19. Thromb Res. 2020; 196: 99-105.
  30. Thippeswamy PB, Rajasekaran RB. Imaging in polytrauma – Principles and current concepts. J Clin Orthop Trauma. 2020; 5 (16): 106-113.
  31. Smith LGF, Milliron E, Ho ML, et al. Advanced neuroimaging in traumatic brain injury: an overview. Neurosurg Focus. 2019; 47(6):E17-E22.
  32. Formenti P, Umbrello M, Coppola S, Froio S, Chiumello D. Clinical review: Peripheral muscular ultrasound in the ICU. Ann Intensive Care. 2019; 9:57.
  33. Lee, Rahul YH, Chittajallu D, et al. Real-time burn classification using ultrasound imaging. Sci Rep. 2020; 10 (1):5829. doi: 10.1038/s41598-020-62674-9. PMID: 32242131; PMCID: PMC7118155.
  34. Sen CK, Ghatak S, Gnyawali SC, et al. Cutaneous imaging technologies in acute burn and chronic wound Care. Plast Reconstr Surg. 2016;138 (3 Suppl):119S-128S. doi: 10.1097/PRS.0000000000002654. PMID: 27556752; PMCID: PMC5207795.
  35. Soble JR, Critchfield EA, O’Rourke JJ. Neuropsychological evaluation in traumatic brain injury. Phys Med Rehabil Clin N Am. 2017; 28 (2):339-350.
  36. Caffò AO, Tinella L, Lopez A, et al. The Drives for Driving Simulation: A scientometric analysis and a selective review of reviews on simulated driving research. Front Psychol. 2020; 11:917.
  37. Sharp P, Pan B, Yakuboff, et al. Development of a best evidence statement for the use of pressure therapy for management of hypertrophic scarring. J Burn Care Res.2016; 37: 255-264.
  38. American College of Surgeons. Advanced Trauma Life Support. 2018; Chicago: ACS.
  39. Galvagno SM Jr, Nahmias JT, Young DA. Advanced Trauma Life Support® Update 2019: Management and Applications for Adults and Special Populations. Anesthesiol Clin. 2019; 37 (1):13-32.
  40. Carney N, Totten AM, O’Reilly C, et al. Guidelines for the management of severe traumatic brain injury. Neurosurgery. 2017; 1; 80(1):6-15.
  41. Nydahl P, Sricharoenchai T, Chandra S, et al. Safety of patient mobilization and rehabilitation in the Intensive Care Unit. Systematic review with meta-analysis. Ann Am Thorac Soc. 2017; 14 (5): 766-777.
  42. Critchfield E, Bain KM, Goudeau C, et al. A model of care for community reintegration: The Polytrauma Transitional Rehabilitation Program. Phys Med Rehabil Clin N Am. 2019; 30 (1):43-54.
  43. 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 Phys Med Rehabil. 2008; 89: 160-162.
  44. Wehman P, Avellone L, Pecharka F, et al. Reintegrating Veterans with polytrauma into the community and workplace. Phys Med Rehabil Clin N Am. 2019; 30 (1):275-288.
  45. Subbarao BS, Stokke J, Martin SJ. Telerehabilitation in acquired brain injury. Phys Med Rehabil Clin N Am. 2021; 32 (2):223-238.
  46. Tenforde AS, Borgstrom H, Polich G, et al. Outpatient physical, occupational, and speech therapy synchronous telemedicine: A survey study of patient satisfaction with virtual visits during the COVID-19 pandemic. Am J Phys Med Rehabil. 2020; 99 (11):977-981.
  47. Oliver M. Assistive technology in polytrauma rehabilitation. Phys Med Rehabil Clin N Am. 2019; 30 (1): 217-259.

Original Version of the Topic

Carl Granger, MD, Andrew Hall, MD. Polytrauma. 7/30/2012

Previous Revision(s) of the Topic

Diane Schretzman Mortimer, MD. Polytrauma, Debility and Burns. 9/13/2016

Author Disclosure

Diane Schretzman Mortimer, MD
Nothing to Disclose

Kathy Guo, MD
Nothing to Disclose