Multi Trauma

General Information
Case no.	12.A Multi Trauma
Authors	Rachel Pata, PT, DPT, CHSE, Board Certified Clinical Specialist in Cardiovascular & Pulmonary Physical Therapy Tracy Wall, PT, PhD Erin Lampron, PT, DPT, Board Certified Clinical Specialist in Neurologic Physical Therapy
Diagnosis	Multitrauma status post (s/p) 50-foot fall, multiple right rib fractures, moderate right pneumothorax, open right tibial/fibular fracture with internal fixation.
Setting	Emergency Department to Trauma Intensive Care Unit (ICU).
Learner expectations	☑ Initial evaluation ☐ Re-evaluation ☐ Treatment session
Learner objectives	1. Describe the pathophysiology of the patient’s history in progress. 2. Discuss the impact of patient comorbidities on activity tolerance and healing. 3. Interpret examination components for this patient. 4. Formulate a safe and evidence-based plan of care.

Medical
Chief complaint	Right lower extremity (RLE) pain and difficulty breathing
History of present illness	The patient is a 62-year-old man brought to hospital by ambulance. The patient is s/p a work-related trauma in which he fell 50 feet from a scaffold. He presented to the Emergency Department with acute shortness of breath, hypoxemia, and laceration of the RLE. He was diagnosed with multiple right-sided rib fractures, a moderate right pneumothorax and open right distal tibial/fibular fracture. He was stabilized with right chest tube placement and then underwent open reduction internal fixation (ORIF) of his RLE.
Past medical history	Chronic obstructive pulmonary disease (COPD), obesity, non–insulin-dependent diabetes mellitus, hypertension, anxiety
Past surgical history	s/p appendectomy 30 years ago
Allergies	None
Medications	Ambien, Lisinopril, Xanax, Albuterol, Metformin
Precautions/orders	Activity as tolerated Non–weight bearing (NWB) RLE No range of motion (ROM) of right ankle/Controlled Ankle Motion (CAM) boot at all times Fig. 12.1

Fig. 12.1 An example of a CAM boot.

Social history
Home setup	Lives alone in a ranch-style home. Four steps to enter from the front door; two steps to enter from the garage. Flight of steps to basement, where laundry is located.
Occupation	Works full time as a commercial painter.
Prior level of function	Independent in all functional mobility and activities of daily living (ADLs) without supplemental O₂. Fatigue with prolonged community ambulation. (+) Driving
Recreational activities	Primarily sedentary during his time off, watches TV. Meets up with friends at the bar twice a week. Walks his dog around the block daily.

Hospital day 0: Emergency Department
Vital signs	Presentation	Corrected
Blood pressure (mmHg)	150/92	132/84
Heart rate (beats/min)	110	95
Respiratory rate (breaths/min)	36	23
Pulse oximetry (SpO₂)	82% 4 L nasal cannula (NC)	91% 2 L NC
Temperature (°F)	98.7	98.6

Imaging/diagnostic tests	Hospital day 0: Emergency Department	Hospital day 1: ICU
Chest X-ray	1. Impression: fracture to right ribs 3 to 5 at the costal angle, moderate right pneumothorax.	1. Impression: chest tube in place with small right pneumothorax, improved from last study.
RLE X-ray	1. Impression: comminuted open fracture of the distal right tibia and fibula	1. Impression: ORIF in place with good alignment of tibia and fibula Fig. 12.2

Fig. 12.2 (a,b) Radiologic evaluation of lower leg, ankle, and foot fracture fixation hardware. (Adapted from Mar W, Schilling J, Lomasney L et al. Radiologic evaluation of lower leg, ankle, and foot fracture fixation hardware. Semin Musculoskelet Radiol 2019;23(02):36–55.)

Medical management	Hospital day 0: Emergency Department	Hospital day 1: ICU
Procedure	1. Right chest tube placed	1. Chest tube remains in place
Additional medications	1. Percocet 5 mg/325 mg every 12 hours 2. Lovenox 40 mg subcutaneous daily 3. Intravenous (IV) fluids	1. Continue per medical orders
Respiratory	1. Oxygen: 4 L O₂ by NC in ambulance, reduced to 2 L after chest tube placement and stabilization of hypoxic respiratory failure.	1. Continue 2 L O₂ by NC to keep O₂ saturation ≥ 90% 2. Duonebs q.i.d.
Surgery	—————————————–	1. s/p ORIF right distal tibial/fibular fracture in the operating room

Lab		Reference range	Hospital day 0: Emergency Department	Hospital day 1: ICU	Hospital day 2: ICU
Complete blood count	White blood cell (WBC)	5.0–10.0 × 10⁹/L	6.4	8.7	12.2
	Red blood cell (RBC)	4.1–5.3 million/mm³	4.2	4.0	3.8
	Hemoglobin (Hgb)	14–17.4 g/dL	15	13	11
	Hematocrit	42–52%	47%	40%	35%
	Platelets	140,000–400,000/μL	250	255	260
Arterial blood gas	PaO₂	80–95 mmHg	65	75	90
	PaCO₂	37–43 mmHg	47	50	45
	PH	7.35–7.45	7.4	7.32	7.36
	HCO₃	20–30 mmol/L	32	32	33
Basic metabolic panel	Glucose (fasting)	70–100 mg/dL	150	172	156
	Hgb A1C	< 5.7%	6.7%	–	–
	Cholesterol	< 200 mg/dL	210	–	–
	Low-density lipoprotein (LDL)	< 70 mg/dL	130	–	–
	High-density lipoprotein (HDL)	> 60 mg/dL	80	–	–
	Blood urea nitrogen (BUN)	6–25 mg/dL	25	28	30
	Creatinine	0.7–1.3 mg/dL	1.2	1.4	1.7
	Potassium	3.7–5.1 mEq/L	4	4.2	4.1
	Sodium	134–142 mEq/L	136	140	142
	Chloride	98–108 mEq/L	100	100	102
	Calcium	8.6–10.3 mg/dL	8.4	8.5	8.4
	Magnesium	1.2–1.9 mEq/L	1.4	1.3	1.4

Pause points
Based on the above information, what are the: Precautions for physical therapy? Examination priorities? Patient monitoring priorities? Potential reasons for abnormal laboratory values?

Pause points

Based on the above information, what are the:

Precautions for physical therapy?
Examination priorities?
Patient monitoring priorities?
Potential reasons for abnormal laboratory values?

Hospital Day 2, ICU: Physical Therapy Examination
Subjective
“I can’t look at my leg. When I do, I can’t breathe.”
Objective
Vital signs	Pre-treatment			Post-treatment
Vital signs	Supine	Sitting	Standing	Sitting
Blood pressure (mmHg)	134/90	128/84	136/88	144/92
Heart rate (beats/min)	90	95	108	118
Respiratory rate (RR; breath/min)	24	28	32	34
Pulse oximetry on 2 L NC (SpO₂)	94%	93%	95%	92%
Borg scale	11/20	12/20	14/20	12/20
Pain	5/10 RLE 3/10 right side of thorax	5/10 RLE 3/10 right side of thorax	8/10 RLE 5/10 right side of thorax	6/10 RLE 5/10 right side of thorax
General	Patient found supine in bed with head of bed (HOB) elevated 45 degrees. RLE elevated with min serosanguineous drainage from incision. Appears to be anxious, as shown by elevated respiratory rate upon introduction to patient. Lines/equipment notable for telemetry, peripheral IV, right chest tube, 2 L O₂ by NC, CAM boot.
Cardiovascular and pulmonary	Inspection: shallow breathing, elevated RR, no accessory muscle use Palpation: reduced expansion right middle and lower lobe. 2 + pedal pulses bilateral lower extremity (BLE) Auscultation: diminished breath sounds bilateral lower lobes (BLL) R > L, occasional low-pitched expiratory wheeze right lower lobe (RLL), no crackles.
Gastrointestinal	Mild abdominal distention
Genitourinary	Voiding independently on bed pan, clear, yellow urine
Musculoskeletal	Range of motion (ROM)	Bilateral upper extremity (BUE): within functional limit (WFL), except right shoulder flexion and abduction: 120 degrees, limited by right-sided pain Left lower extremity (LLE): WFL Right hip flexion: 90 degrees, limited by pain Right knee flexion: 80 degrees, limited by pain Right ankle: not tested due to CAM boot and precautions for no ROM at ankle
	Strength	Left upper extremity (LUE): WFL Right shoulder flexion: 3/5 Right elbow flexion 4/5 Right elbow extension: 4/5 Right grip: 5/5 LLE: WFL Right hip flexion: 3-/5 Right knee flexion: 2/5 Right knee extension 2/5
	Aerobic	Unable to perform standardized assessment at this time. Refer to patient vital signs and signs and symptoms.
	Flexibility	Not assessed at this time
	Other	Not applicable
Neurological	Balance	Static sitting: fair, able to maintain sitting with support of LUE × 60 seconds, then needing additional support secondary to fatigue. Dynamic sitting: poor, requiring assistance to maintain sitting while reaching with either UE. Static standing: poor requiring moderate to maximum assistance to maintain standing plus the assist of a second person to maintain NWB RLE.
	Cognition	Alert and oriented (A&O) × 4
	Coordination	Finger to nose: intact BUE Toe tapping: LLE intact, unable to assess RLE
	Cranial nerves	II–XII: intact
	Reflexes	Not tested at this time
	Sensation	Right plantar surface: decreased sensation to light touch
	Tone	BUE: within normal limit (WNL) BLE: WNL
	Other	Not applicable
Functional status
Bed mobility	Scooting: moderate assistance × 1 Bridge: unable to perform at this time Left rolling: moderate assistance × 1, primarily to assist RLE Supine to/from sit: maximal assistance × 1
Transfers	Sit to/from stand: moderate to maximal assistance × 2 (1 person to assist at trunk, 1 person to assist RLE) with rolling walker (RW) Bed to/from chair: moderate to maximal assistance × 2 using stand pivot technique
Ambulation	Hopped two steps with moderate to maximal assistance and an RW, however becoming very anxious, with elevated RR and increased pain.
Stairs	Unsafe to trial at this time.

Assessment
☑ Physical therapist’s	Assessment left blank for learner to develop.
Goals
Patient’s	“I don’t want to be in pain anymore.”
Short term	1. Goals left blank for learner to develop. 2.
Long term	1. Goals left blank for learner to develop. 2.

Plan
☐ Physician’s ☑ Physical therapist’s ☐ Other’s	Patient will be seen for daily physical therapy including therapeutic exercise, bed mobility, transfer training, gait training and breathing exercises to improve strength, ROM, functional mobility, and endurance.

Plan

☐ Physician’s

☑ Physical therapist’s

☐ Other’s

Patient will be seen for daily physical therapy including therapeutic exercise, bed mobility, transfer training, gait training and breathing exercises to improve strength, ROM, functional mobility, and endurance.

Bloom’s Taxonomy Level	Case 12.A Questions
Create	1. Synthesizing the medical data and physical examination findings, develop an appropriate physical therapy assessment of the patient. 2. Develop two short-term physical therapy goals, including an appropriate timeframe. 3. Develop two long-term physical therapy goals, including an appropriate timeframe.
Evaluate	4. Discuss positive and negative prognostic indicators for this patient. 5. Describe how social history may impact discharge planning.
Analyze	6. Describe how this patient’s rib fractures may affect ventilation. 7. Describe how this patient’s weight-bearing status will affect endurance.
Apply	8. Discuss how to best perform gait training with this patient. 9. Implement strategies for energy conservation during gait training.
Understand	10. Interpret this patient’s day 0 vital signs. 11. Does this patient have restrictive or obstructive lung disease or both? 12. What are the potential causes for impaired sensation of the RLE? 13. What is the relationship between rib fractures and a pneumothorax? 14. How can timing of medication administration assist with patient performance in physical therapy?
Remember	15. How will this patient’s history of non–insulin-dependent diabetes mellitus (NIDDM) influence healing?