Trauma is a major cause of disability and death for individuals in the United States. In fact, trauma from unintentional injuries, homicide, and suicide is the leading cause of death for Americans aged 1 to 44 years. Injuries associated with trauma account for approximately one third of all emergency department visits and 8% of all hospital stays in trauma care systems. The top four mechanisms of traumatic injuries involve falls, motor vehicle accidents (struck by or against another individual), and other transportation accidents. The mechanism of injury varies in different age groups. For those younger than 7 years or 75 and older, falls account for 40% of traumatic injuries; but in those aged 15–33 years, motor vehicle injuries account for 27% of the injuries, peaking around age 19.

Based on these numbers and the burden on the U.S. health care system, one can understand the need for integrated trauma care programs. In the U.S. civilian health care system, there has been and continues to be a growth of trauma care systems. A trauma center is a hospital that has the resources and equipment to help care for severely injured patients. The American College of Surgeons (ACS) Committee on Trauma classifies levels of trauma centers from 1 to 4, with a level 1 trauma center providing the highest level of trauma care. The designation of trauma facilities is a geopolitical process that only the government is empowered to delegate; however, the ACS verifies the presence of the resources listed in the Resources for Optimal Care of the Injured Patient. ACS certification is a voluntarily process undertaken by participating hospitals. Having access to specialized resources and equipment is critical for severely injured patients. Research supported by the Centers for Disease Control and Prevention shows that there is a 25% reduction in the death rate for severely injured patients who received care at a level 1 trauma center rather than a nontrauma center.

With more people today surviving severe traumatic injuries, it is essential that rehabilitative services be made available throughout the acute and postacute hospital care system. The rehabilitation process for acute trauma patients should be initiated as early as possible in the hospital setting. Many of these patients have specific medical and rehabilitative needs that can benefit from the expertise of rehabilitation physicians in an acute care hospital setting.

The role of rehabilitation physicians in an acute care hospital can differ somewhat from their role in an inpatient rehabilitation facility. In the inpatient facility, the rehabilitation physician serves as the team leader; in the acute hospital setting, the rehabilitation physician is a valuable team member whose importance and input may vary based on the patient’s specific injury, time since injury, and clinical course. For patients with recent multitrauma injury who are being treated in an intensive care unit, the primary role of the rehabilitation physician may consist of an initial evaluation, documentation of the patient’s injury, and deciding what, if any, therapy can be initiated based on the patient’s status (Tables 32–1 and 32–2). This information is useful for future rehabilitation planning, prognosis, and care.

In the acute care hospital, the team of rehabilitation providers may consist of members who spend variable amounts of treatment time with each patient. Physical, occupational, and speech therapists, social workers, and psychologists also may have varying degrees of expertise with certain types of injuries. It is important that the rehabilitation physician recognize and understand these team variables and potential limitations as certain therapists may require greater instruction on specific care precautions than others. The initial team focus is often preventive in nature, centered on preventing morbidity associated with immobility, positioning, nutrition, or other specific diagnostic issues. Monitoring of a patient’s changing status is essential, as adjustment of therapy orders and medical intervention may be required.

Often the rehabilitation physician serves to educate patients, their families, and other team members about the patient’s injury and future functional course. At discharge from the acute care hospital, the most important role of the rehabilitation physician may be to assist with discharge placement, whether in a postacute care facility or the home setting. This requires matching the patient’s medical and functional needs with available patient and community resources (see later discussion).

The initial evaluation of the trauma patient focuses on rapidly assessing key systems and organs necessary for sustaining life and maintaining function. Once the patient’s condition is stabilized, ongoing evaluation seeks to clarify the extent of an individual’s injuries, as well as their current and future functional status.

Spinal Clearance

If there is concern that a patient may have spinal trauma, a process for documenting spinal clearance is implemented. At many centers this is protocol driven, and patients undergo a spinal series with review and clearance by a specified physician. The spinal clearance protocol usually begins with plain radiographs to identify fractures by looking at the alignment of the bones and at adjacent soft tissue outlines. When indicated, computed tomography (CT) scanning may also be used. CT provides better imaging of bones when evaluating for fractures and is more sensitive than plain radiographs. Magnetic resonance imaging (MRI) scanning can be used for evaluation of soft tissues and potential ligament injuries. Although the task of giving final spinal clearance usually rests with the primary team, it is important that the rehabilitation physician understand which films have been completed. If there are questions or concerns about spinal stability, the physician should communicate directly with the primary team. Spinal clearance must be obtained before initiating patient mobilization or therapy services.

Head

Cerebral imaging results for the acute patient should be reviewed initially and followed over time. Ongoing studies may assist in tracking patient status, presence of edema or blood, or other intracranial processes. Care providers may need to be reminded that a negative cerebral imaging study does not rule out an underlying head injury. (See Chapter 13 for further details.)

Pulmonary Function

Many trauma patients have some injury that affects their respiratory system either directly or indirectly. These patients may require mechanical ventilation as a result of severe head trauma, high cervical injuries, or multiple other injuries requiring medical management. Patients with multiple rib fractures or other direct trauma often require insertion of chest tubes. Once the chest tube is in place, negative pressure is maintained either by wall unit suction or by placing the tube into a water seal. The negative-pressure suction system draws fluid out of the pleural space. The chest tube and its water seal container are a closed system and allow for one-way movement of air and liquid out of the chest. Proper functioning of the latter system relies on having the appropriate amount of fluid in the water base chamber and keeping the chamber below the level of the tube insertion site. If the container tips over or is placed above the level of the tube (eg, during patient care or mobilization therapy), the negative-pressure system can be disrupted, which may cause backflow into the pleural space. Clamping of the tube can also disrupt the negative pressure and should be avoided when possible. Therapists need to be aware of this precaution when mobilization is initiated.

Gastrointestinal Function & Nutritional Status

Patients with severe trauma develop hypermetabolic rates. For example, individuals with spinal cord or head injuries have marked increased nutritional needs in the acute phase of their recovery. Often complicating this increased nutritional requirement is the fact that patients have difficulties with oral intake owing to reduced level of consciousness, medications, mechanical ventilation, direct facial and neck injury, or other problems. This issue must be addressed early in the patient’s care to ensure that nutritional needs are met. Consequently, the rehabilitation team should be familiar with the different options for nutritional delivery, as well as any treatment-related precautions. Special caution must be taken with patients who receive non-oral feedings, as they may still be at risk for aspiration. Patients should be positioned with the head of the bed elevated during feedings to reduce this risk.

Genitourinary Function

Intravenous fluids and indwelling Foley catheters are often required during the acute phase of trauma care. Whenever medically possible these catheters should be discontinued; however, prior to catheter removal, the clinician must understand why the catheter was inserted. In patients with penetrating or urethral injuries, it is often appropriate to insert either a urethral or a suprapubic catheter and leave it in place during the acute recovery phase. The Foley catheter is often maintained in patients with spinal cord or head injuries during their acute hospitalization. After catheter discontinuation, the patient is monitored for any problems with urgency, dysuria, or voiding. Urinalysis, postvoid residuals, or urologic evaluation may be required for bladder management. These principles can be applied to trauma patients with prolonged hospital stays.