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



No Image Available!




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



No Image Available!




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?





































































































































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


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.






























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?

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Dec 11, 2021 | Posted by in MANUAL THERAPIST | Comments Off on Multi Trauma

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