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The Role of Specialist Rehabilitation in
Polytrauma Management
Dr James Graham (Consultant Radiologist)
Dr Rachel Reaveley (SPR in Neurological
Rehabilitation)
Objectives
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By the end of this case presentation we will
have covered…
Radiology of the case
Specialist Rehabilitation Interventions
 How the specialist rehabilitation process worked
from acute referral through to outpatient review and
inpatient admission
 Summary of causes of dizziness in the rehabilitation
setting
 Reflect together on potential gaps in the service
 Assessing the psychological impact of poly-trauma in
the context of concurrent head injury
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Case History
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50 year old driving instructor
High speed head on collision 10/10/12
Right haemo-pnuemothorax and lung
contusion with rib fractures – 7-12
Left pneumothorax
Jejunal perforation and terminal ileum
mesenteric injury- requiring laparotomy,
repair and end ileostomy
Complications – chest sepsis, need for high
inotropic support, abnormal kidney function,
LFTs & amylase – 19 days in ICU
Trauma CT
Trauma CT
Trauma CT
Trauma CT
A few days later…
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Gradual clinical deterioration
Lactate 1.3
 Amylase 439
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WCC 20
 CRP 116
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Bilirubin 63
 ALP 335
 ALT 282
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Follow up CT
Follow up CT
Gastric appearances
Angiogram
What Happened next?
Rehabilitation Assessment &
Planning
 First seen by Rehabilitation Consultant on
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General Surgery Ward 21/11/12
Referred by Head Injury Sister – small
frontal contusion
Dizziness
Nausea
Back pain
? Change in personality
Dizziness and nausea
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When moving from sitting to standing and from
lying to sitting
Documented drop in BP on standing
Contributory factors
Medications – opioids
Fluid depletion (nausea)
Coeliac axis injury – damage to autonomic
nerve supply to splanchnic bed
? BPPV
Benign Paraoxysmal Positional
Vertigo
Orthostatic Hypotension
Coeliac Plexus
Kambadakone A et al. CT-guided Celiac Plexus Neurolysis: A Review of Anatomy, Indications, Technique,
and Tips for Successful Treatment. RadioGraphics 2011; 31: 1599-1621
Sir Roger Bannister. Autonomic Failure. A Textbook of Clinical Disorders of the Autonomic Nervous System.
Second Edition.
Rehabilitation Medicine Review
as Outpatient May 2013
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Dizziness - diagnosed with BPPV – treated
with Epley’s manoeuvre
Nausea and vomiting improved - Awaiting
surgical reversal of ileostomy
Significant back pain – remained under
surgical review with plan for follow up
physiotherapy – referral made to health
psychology to support through this.
Low mood – body image issues
Character change
Epley’s Manouvre
People involved/pending
procedures
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Mr B Griffiths – General surgery – awaiting
ileostomy reversal
Mr G Wynne Jones – Orthopaedics
Mr Waldron – ENT Sunderland
Sister Hastie – Head Injury
GP – commenced sertraline for low mood
Dr J Lawson - Falls & Syncope Service
Mr Jenkins - Urologist UHND – admitted with
urinary sepsis shortly after discharge from RVI
– 4x unsuccessful TWOC as inpatient
Out patient Review: May 2013
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Assessment of frontal brain injury vs
mood disturbance: Subtle changes in character
 Loss of sense of humour
 Concrete thinking
 Short term memory impairment
 Easily provoked by loud noises and crowds
 Lack of initiation
Rehabilitation Actions & further
Progress
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Ileostomy reversal – health psychology at RVI
requested to provide peri-operative support
Complicated by further sepsis/leakage
requiring readmission via UHND
On-going back pain – waiting for orthopaedic
review and physiotherapy
Continued family concerns around change in
personality (short term memory and increased
irritability)
Referred to neuropsychology as outpatient (
long waiting list….)
In Patient Admission to WGP Cognitive
Assessment Bed February 2014
Increasing concern about ongoing depressive
episodes with psychological trauma- type
symptoms post RTA
Psychology and Psychiatry Input
Changes in cognition reported largely explained by
mood disorder
 Concrete thinking
 Slowness in mental speed both associated with
depression
 Anxiety also may have contributed to underperformance
 Cognitive assessment noted only very mild
problems in verbal abstract reasoning. Working
memory unimpaired
Other Therapies
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OT assessment:
 independent with route finding, money handling and
road safety.
 independent and safe at problem solving in the
kitchen. Written instructions for more complex tasks
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SALT assessment
 Cognitive communication skills largely intact,
however some reading comprehension difficulties
 With prompting to slow down his reading rate and
check his responses, accuracy improved
Limitations of current processes
‘We’ve had no help at all since being at home”
Comment from Mrs Willis at first rehab OP review
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Lack of co-ordinated follow up on discharge from
MTC unless head injury severe enough to require
ongoing inpatient follow up or community therapies
needed specific to TBI
Predictable problems – ongoing dizziness and need
for Dix Hallpike. Catheter issues – reassurance of
empty bladder/UTI prevention/onward referral
Mood disorder - psychological complications can be
significant following trauma. Services to address
these issues currently very limited – differences
between psychological trauma and brain injury effect
Summary
Interesting case of patient with multitrauma and complications
 Long period of rehabilitation including
inpatient stay required
 Illustrates that not all changes in behavior
following head injury are related to injury
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Thank you!