Cardiopulmonary Physiotherapy Trauma Ahb: Cardiopulmonary Physiotherapy in Trauma: an Evidence-Based Approach

Trauma is a serious public health problem worldwide and is the leading cause of death among adults and children. Physiotherapists play a key role in the interdisciplinary team caring for patients with physical injury after a traumatic event. The aim of Cardiopulmonary Physiotherapy in Trauma: An Evidence-based Approach is to encourage quality evidence-based physiotherapy management of adult and paediatric survivors of trauma in an acute care setting on a global level.The first edition of the book was written by South African physiotherapy academics and clinical physiotherapists with expertise in trauma care. This new edition involves the South African writers from the first edition as well as a team of international experts in trauma care across health care disciplines (including surgeons, nurses, occupational therapists, dieticians, pain experts, and social workers). The information shared in the first edition has therefore been updated with more clinical expertise and the latest available evidence. The new content in this latest edition aims to make physiotherapists more aware of the importance of considering how pain influences patients' participation in therapy sessions, and of a team approach to patient care (e.g. managing pain and planning of care) to ensure the best possible outcomes for adult and paediatric patients with traumatic injury, at hospital discharge. Contents Foreword Preface About the Editors List of Contributors Acknowledgement Chapter 1 Physiological Response to Trauma 1.1. Human Immunity and its Response to Injury and Inflammation 1.1.1. Haemostasis 1.1.2. Fibrinolysis 1.1.3. Non-specific defence systems 1.1.4. Specific defence systems 1.1.5. Activation of the body’s defence systems 1.1.5.1. Cytokines 1.1.5.2. Systemic inflammatory response syndrome and sepsis 1.1.6. Musculoskeletal changes associated with inflammation 1.1.6.1. Muscle protein breakdown and atrophy 1.1.6.2. Muscle weakness 1.2. Shock and its Effects on the Human Body 1.2.1. What is shock? 1.2.2. Organ responses to blood loss 1.2.2.1. Cardiovascular system 1.2.2.2. Central nervous system 1.2.2.3. Pulmonary system 1.2.2.4. Peripheries 1.2.2.5. Renal system 1.2.2.6. Skeletal and splanchnic systems 1.2.3. Types of shock 1.2.3.1. Hypovolaemic shock 1.2.3.2. Obstructive shock 1.2.3.3. Distributive shock 1.2.3.3.1. Neurogenic shock 1.2.3.3.2. Anaphylactic shock 1.2.3.3.3. Septic shock 1.2.3.4. Cardiogenic shock 1.2.3.5. Refractory shock 1.2.4. Management of shock 1.3. Factors that Influence Blood Oxygen Content 1.4. Effect of Trauma on Blood Glucose Levels 1.5. Clinical Case Scenario 1.5.1. Adult case 1.5.2. Paediatric case 1.6. Classification of Patients with Traumatic Injuries 1.6.1. Severity of illness scoring systems 1.6.1.1. APACHE II and SAPS III 1.6.1.2. Anatomic and physiologic scores 1.6.1.3. TRISS and ASCOT scores 1.6.2. Morbidity scoring systems 1.6.2.1. SOFA score 1.6.3. Paediatric scoring systems 1.7. Additional Resources Bibliography Chapter 2 Not Just ‘Small Adults’: Paediatric Anatomy and Physiology in Relation to Trauma 2.1. Introduction 2.2. Anatomical and Physiological Differences between the Adult and Child 2.2.1. General 2.2.2. The airway 2.2.3. The chest, lungs and breathing 2.2.3.1. Signs of paediatric respiratory distress 2.2.3.2. Signs of inadequate respiratory effort 2.2.4. The heart and circulation 2.2.5. Head, neck and central nervous system 2.2.6. The abdomen 2.2.7. Musculoskeletal system 2.2.8. Temperature regulation 2.3. Psychosocial dependence and vulnerability 2.4. Conclusion Bibliography Chapter 3 Trauma and Chronic Diseases 3.1. Chronic Pulmonary Diseases 3.1.1. Asthma 3.1.1.1. Prevalence, pathophysiology and presenting symptoms 3.1.2. Bronchiectasis 3.1.2.1. Prevalence, pathophysiology and presenting symptoms 3.1.3. Chronic bronchitis and emphysema 3.1.3.1. Prevalence, pathophysiology and presenting symptoms 3.1.4. Idiopathic pulmonary fibrosis 3.1.4.1. Prevalence, pathophysiology and presenting symptoms 3.1.5. Factors that influence recovery from trauma 3.1.6. Implications for physiotherapy 3.2. Congestive Cardiac Failure 3.2.1. Prevalence, pathophysiology and presenting symptoms 3.2.2. Factors that influence recovery from trauma 3.2.3. Implications for physiotherapy 3.3. Diabetes Mellitus 3.3.1. Prevalence, pathophysiology and presenting symptoms 3.3.2. Factors that influence recovery from trauma 3.3.3. Implications for physiotherapy 3.4. Human Immunodeficiency Virus 3.4.1. Prevalence, pathophysiology and presenting symptoms 3.4.2. Factors that influence recovery from trauma 3.4.3. Implications for physiotherapy 3.5. Tuberculosis 3.5.1. Prevalence, pathophysiology and presenting symptoms 3.5.2. Implications for physiotherapy 3.6. Conclusion References Chapter 4 Interdisciplinary Team Members in Trauma Care 4.1. Patient-Centred Care 4.2. Shared Decision-Making 4.3. Principles of Communication 4.4. Interdisciplinary Team Members 4.4.1. Trauma surgeon 4.4.1.1. Primary survey and resuscitation of vital functions 4.4.1.2. Secondary survey as adjunct to primary survey 4.4.1.3. Definitive care 4.4.2. Trauma emergency nurse 4.4.2.1. Triage 4.4.2.2. Standard approach to the patient 4.4.2.3. Communication 4.4.3. Physiotherapist 4.4.3.1. Principles of physiotherapy in patient care 4.4.3.2. General considerations to physiotherapy in intensive care 4.4.3.3. Tracheostomy care 4.4.3.3.1. Indications for tracheostomy 4.4.3.3.2. Positioning of the tracheostomy tube 4.4.3.3.3. Tracheostomy chart 4.4.3.3.4. Red flags 4.4.3.3.5. Interdisciplinary team responsibilities in tracheostomy care 4.4.4. Occupational therapist 4.4.5. Dietitian 4.4.6. Social worker 4.4.6.1. Psychosocial support 4.4.6.2. Liaison, networking and referral 4.4.6.3. Safety of the patient 4.4.6.3.1. Non-accidental injury 4.4.6.3.2. Abuse of an adult patient 4.4.6.3.3. Trauma-informed patient care 4.4.7. Trauma psychologist 4.5. Injury Prevention and Control 4.6. Understanding the Impact of Trauma 4.6.1. Patient 4.6.2. Family or caregivers 4.6.3. Provider 4.6.3.1. Understanding one’s personal risk for experiencing these conditions 4.6.3.2. Have a personal plan 4.7. Conclusion References Chapter 5 Pain in Trauma 5.1. What Is Pain? 5.1.1. Time-based classification of pain 5.1.2. Mechanism-based classifications of pain 5.2. Pain Physiology in Trauma 5.2.1. Peripheral nervous system 5.2.2. Spinal cord 5.2.2.1. A special note about neuropathic pain and spinal cord mechanisms 5.2.3. The brain 5.2.4. Synergistic systems 5.3. Assessment of Pain in a Person Who Has Suffered Traumatic Injury 5.3.1. Assessing pain in paediatric patients who have had a traumatic injury 5.4. Treating Pain in the Person Who Has Suffered Trauma 5.4.1. Pharmacological management of pain 5.4.2. Physiotherapy management of acute pain 5.4.3. Physiotherapy management of sub-acute and chronic pain 5.4.3.1. Physiotherapy treatments for pain which target activity in the brain 5.4.3.2. Physiotherapy treatments for pain that target activity in the spinal cord 5.4.3.3. Physiotherapy treatments for pain which target activity in the peripheral nervous system 5.4.4. Physiotherapy treatments — Special considerations and techniques for children 5.4.5. Non-physiotherapy modalities for pain 5.5. Conclusion References Chapter 6 Physiotherapy Modalities, Markers and Outcome Measures 6.1. Early Mobilisation and Graded Exercise Therapy 6.1.1. Early mobilisation 6.1.2. Exercise therapy 6.1.2.1. Mental health benefits 6.1.2.2. Physical health benefits 6.1.2.3. Exercise prescription 6.2. Cardiopulmonary Physiotherapy Techniques 6.2.1. Breathing exercises 6.2.1.1. Active cycle of breathing technique 6.2.1.1.1. How to perform the technique 6.2.1.1.2. Contraindications and precautions 6.2.1.2. Breath-stacking 6.2.1.2.1. How to perform the technique 6.2.1.2.2. Contraindications and precautions 6.2.1.3. Glossopharyngeal breathing 6.2.1.3.1. How to perform the technique 6.2.1.3.2. Contraindications and precautions 6.2.1.4. Respiratory muscle training 6.2.1.4.1. How to perform the technique 6.2.1.4.2. Contraindications and precautions 6.2.2. Devices 6.2.2.1. Incentive spirometry 6.2.2.1.1. How to perform the technique 6.2.2.1.2. Contraindications and precautions 6.2.2.2. Intermittent positive pressure breathing 6.2.2.2.1. How to perform the technique 6.2.2.2.2. Contraindications and precautions 6.2.2.3. Mechanical insufflation-exsufflation 6.2.2.3.1. How to perform the technique 6.2.2.3.2. Contraindications and precautions 6.2.2.4. Positive expiratory pressure therapy 6.2.2.4.1. How to perform the technique 6.2.2.4.2. Contraindications and precautions 6.2.2.5. Intrapulmonary percussive ventilation 6.2.2.5.1. How to perform the technique 6.2.2.5.2. Contraindications and precautions (Vargas et al., 2005; UTMB Respiratory Care Services, 2018) 6.2.3. Positioning 6.2.3.1. Body positioning for ventilation/perfusion matching 6.2.3.1.1. How to perform the technique 6.2.3.1.2. Contraindications and precautions 6.2.3.2. Body positioning to enhance clearance of pulmonary secretions 6.2.3.2.1. Contraindications and precautions 6.2.4. Manual chest therapy techniques 6.2.4.1. Percussion 6.2.4.1.1. How to perform the technique 6.2.4.2. Vibration 6.2.4.2.1. How to perform the technique 6.2.4.3. Shaking 6.2.4.3.1. How to perform the technique 6.2.4.4. Sustained expiratory manoeuvre 6.2.4.4.1. How to perform the technique 6.2.4.5. Contraindications and precautions for the use of manual chest therapy techniques 6.2.5. Assisted and supported coughing 6.2.5.1. Manually assisted cough 6.2.5.1.1. How to perform the technique 6.2.5.1.2. Contraindications and precautions 6.2.5.2. Supported cough 6.2.5.2.1. How to perform the technique 6.2.5.2.2. Contraindications and precautions 6.2.6. Hyperinflation techniques 6.2.6.1. Manual hyperinflation 6.2.6.1.1. How to perform the technique 6.2.6.1.2. Contraindications and precautions 6.2.6.1.3. Safety and efficacy of MHI in adults 6.2.6.1.4. Safety and efficacy of MHI in the paediatric population 6.2.6.2. Ventilator hyperinflation 6.2.6.2.1. How to perform the technique 6.2.6.2.2. Contraindications and precautions 6.2.7. Airway suctioning 6.2.7.1. Suction of artificial airways 6.2.7.1.1. How to perform the technique 6.2.7.2. Nasotracheal and orotracheal suctioning 6.2.7.2.1. Nasopharyngeal and nasotracheal suction 6.2.7.2.2. Oropharyngeal suction 6.2.7.3. Contraindications and precautions for suction 6.2.7.4. Complications associated with suction (ACPC, 2015; Blakeman et al., 2022) 6.3. Markers and Outcome Measures 6.4. Conclusion Bibliography Chapter 7 Blunt and Penetrating Injuries to the Trunk 7.1. Causes and Mechanisms of Injury 7.1.1. Penetrating injuries 7.1.1.1. Low energy injuries 7.1.1.2. High energy injuries 7.1.2. Blunt injury 7.1.3. Relevant truncal anatomy 7.1.4. Thoracic injury 7.1.4.1. Thoracic injury in adults 7.1.4.2. Thoracic injury in paediatrics 7.1.5. Abdominal injury 7.1.5.1. Abdominal injury in adults 7.1.5.2. Abdominal injury in paediatrics 7.2. Causes of Fatality after Thoracic or Abdominal Injuries 7.3. Medical and Surgical Management of Survivors of Thoracic or Abdominal Trauma 7.3.1. Primary survey and resuscitation of vital functions 7.3.1.1. The lethal six injuries as a result of thoracic trauma — ATOMFC 7.3.1.1.1. Airway obstruction 7.3.1.1.2. Tension pneumothorax 7.3.1.1.3. Open pneumothorax (“sucking chest wound”) 7.3.1.1.4. Massive haemothorax 7.3.1.1.5. Flail chest 7.3.1.1.6. Cardiac tamponade 7.3.1.2. The hidden six injuries that result from thoracic trauma 7.3.1.2.1. Pulmonary contusion 7.3.1.2.2. Blunt cardiac injury 7.3.1.2.3. Traumatic disruption of the aorta 7.3.1.2.4. Traumatic diaphragmatic rupture 7.3.1.2.5. Tracheobronchial injury 7.3.1.2.6. Oesophageal trauma 7.3.1.3. Abdominal trauma — Initial management 7.3.2. Secondary survey assessment of the abdomen 7.3.3. Definitive care 7.3.3.1. Thoracic injury 7.3.3.1.1. Pneumothorax or haemothorax 7.3.3.1.2. Post-traumatic empyema 7.3.3.1.3. Cardiac, airway or great vessel injuries 7.3.3.1.4. Soft tissue injuries of the chest wall 7.3.3.1.5. Pulmonary contusion 7.3.3.1.6. Diaphragmatic injury 7.3.3.1.7. Skeletal injuries of the chest wall 7.3.3.2. Abdominal injury 7.3.3.2.1. Damage control surgery 7.4. Physiotherapy Aims of Management 7.4.1. Paediatric considerations 7.4.2. Functional assessment prior to discharge 7.5. Precautions and Contraindications Related to Physiotherapy Management 7.5.1. Precautions and contraindications related to thoracic injuries 7.5.1.1. Adult and paediatric patients 7.5.1.2. Paediatric-specific considerations 7.5.2. Precautions and contraindications related to abdominal injuries 7.5.2.1. Adult patients 7.5.2.2. Paediatric patients 7.6. Physiotherapy Interventions 7.6.1. Respiratory system management 7.6.1.1. Oxygenation 7.6.1.1.1. Sedated and intubated patient 7.6.1.1.2. Awake and alert intubated patient 7.6.1.1.3. Spontaneously breathing patient 7.6.1.2. Humidification 7.6.1.2.1. Intubated patient 7.6.1.2.2. Spontaneously breathing patient 7.6.1.3. Management of pulmonary secretions 7.6.1.3.1. Intubated patient 7.6.1.3.2. Spontaneously breathing patient 7.6.1.4. Lung capacity and volumes 7.6.1.4.1. Sedated and intubated patient 7.6.1.4.2. Awake and alert intubated patient 7.6.1.4.3. Spontaneously breathing patient 7.6.1.5. Respiratory muscle training 7.6.1.6. Paediatric considerations 7.6.1.6.1. Sedated and intubated child 7.6.1.6.2. Spontaneously breathing child 7.6.2. Neuromusculoskeletal system management 7.6.2.1. Pain 7.6.2.2. Joint range of motion 7.6.2.2.1. Sedated and intubated patient 7.6.2.2.2. Awake and alert patient 7.6.2.3. Muscle strength 7.6.2.3.1. Sedated and intubated patient 7.6.2.3.2. Awake and alert intubated patient 7.6.2.3.3. Spontaneously breathing patient 7.6.2.4. Functional activities and mobilisation 7.6.2.5. Exercise endurance 7.6.2.6. Paediatric considerations 7.6.3. Patient response to treatment 7.7. Clinical Case Scenarios 7.7.1. Adult clinical case scenarios 7.7.1.1. Case 1 7.7.1.1.1. Discussion of case 1 7.7.1.2. Case 2 7.7.1.2.1. Discussion of case 2 7.7.2. Paediatric case scenario 7.7.2.1. Discussion 7.7.2.1.1. Medication 7.7.2.1.2. Treatment modalities 7.7.2.1.3. Contra-indications or precautions to treatment 7.8. On-Going Rehabilitation after Discharge 7.9. Additional Resources 7.10. Conclusion References Chapter 8 Burn Injuries 8.1. Causes and Mechanisms of Burn Injury 8.1.1. Injury in adults 8.1.2. Injury in paediatrics 8.2. Types of Burn Injuries 8.2.1. Chemical burns 8.2.2. Electrical burns 8.2.3. Inhalation burns 8.2.3.1. Upper airway injury 8.2.3.2. Lower airway injury 8.2.3.3. Lung parenchymal injury 8.2.3.4. Systemic toxicity 8.2.4. Thermal burns 8.3. Systemic Effects of a Burn Injury 8.3.1. Burn shock 8.3.2. Immune system responses 8.3.3. Metabolic responses 8.3.4. Thermoregulatory system 8.4. Classification of Burn Injuries 8.4.1. Depth of tissue injury 8.4.1.1. Superficial burns 8.4.1.2. Partial thickness burns 8.4.1.2.1. Superficial partial thickness burns 8.4.1.2.2. Deep partial thickness burns 8.4.1.3. Full thickness burns 8.4.2. Extent of burn wounds 8.5. Medical and Surgical Management 8.5.1. Primary survey and resuscitation of vital functions 8.5.2. Secondary survey as adjunct to primary survey 8.5.3. Definitive care 8.5.3.1. Care provided over the first 24 hours 8.5.3.1.1. Fluid replacement 8.5.3.1.2. Calorie intake 8.5.3.1.3. Routine interventions 8.5.3.1.4. Laboratory tests 8.5.3.1.5. Impaired respiration and inhalation injury 8.5.3.1.6. Pain management 8.5.3.2. Surgery 8.5.3.2.1. Debridement 8.5.3.2.2. Escharotomy 8.5.3.2.3. Fasciotomy 8.5.3.3. Wound management 8.5.3.3.1. Autograft 8.5.3.3.2. Cultured epithelial grafts 8.5.3.3.3. Dermal substitutes (prosthetic grafts) 8.5.3.3.4. Allografts 8.5.3.3.5. Xenograft 8.5.3.3.6. Wound dressings 8.6. Physiotherapy Aims of Management 8.6.1. Paediatric considerations 8.6.2. Functional assessment prior to discharge 8.7. Precautions and Contraindications Related to Physiotherapy Management 8.7.1. General precautions to physiotherapy in intensive care 8.7.2. Specific precautions and contraindications to physiotherapy in patients with burn injuries 8.7.2.1. Adult patient with burn injury 8.7.2.2. Paediatric patient with burn injury 8.8. Physiotherapy Interventions 8.8.1. Education 8.8.2. Pain 8.8.2.1. Paediatric considerations 8.8.3. Respiratory system management 8.8.3.1. Oxygenation 8.8.3.1.1. Intubated patient 8.8.3.1.2. Spontaneously breathing patient 8.8.3.2. Humidification 8.8.3.2.1. Intubated patient 8.8.3.2.2. Spontaneously breathing patient 8.8.3.3. Management of pulmonary secretions 8.8.3.3.1. Intubated patient 8.8.3.3.2. Spontaneously breathing patient 8.8.3.4. Lung capacity and volumes 8.8.3.4.1. Intubated patients 8.8.3.4.2. Spontaneously breathing patient 8.8.3.5. Respiratory muscle training 8.8.3.6. Paediatric considerations 8.8.4. Neuromusculoskeletal system 8.8.4.1. Joint range of motion 8.8.4.1.1. Intubated patients 8.8.4.1.2. Spontaneously breathing patients 8.8.4.2. Splinting 8.8.4.3. Muscle strength 8.8.4.4. Functional activities and mobilisation 8.8.4.4.1. Intubated patient 8.8.4.4.2. Spontaneously breathing patients 8.8.4.5. Exercise endurance 8.8.4.6. Paediatric considerations 8.8.5. Rehabilitation strategies for the management of complications associated with burn injuries 8.8.5.1. Exposed tendons 8.8.5.2. Heterotopic ossification 8.8.5.3. Hypertrophic scars 8.8.6. Patient response to treatment 8.9. Clinical Case Scenarios 8.9.1. Case scenario of an adult patient 8.9.1.1. Discussion 8.9.1.1.1. Precautions and contraindications 8.9.1.1.2. Physiotherapy interventions in the ICU 8.9.2. Case scenario of a paediatric patient 8.9.2.1. Discussion 8.10. Additional Resources 8.11. Conclusion Bibliography Chapter 9 Multiple Orthopaedic Injuries 9.1. Causes and Mechanisms of Injury 9.1.1. Causes of injury in adults 9.1.2. Causes of injury in paediatrics 9.1.3. Mechanism of injury in adults 9.1.4. Mechanism of injury in paediatrics 9.2. Types of Fractures 9.3. Orthopaedic Injuries Commonly Encountered in the Polytrauma Patient 9.3.1. Shoulder girdle 9.3.2. Humerus 9.3.3. Radius and ulna 9.3.4. Hand and wrist 9.3.5. Pelvis 9.3.6. Acetabulum 9.3.7. Hip dislocation 9.3.8. Femur 9.3.9. Knee dislocation 9.3.10. Patella injury 9.3.11. Floating knee injury 9.3.12. Tibial plateau 9.3.13. Tibia and fibula 9.3.14. Foot 9.4. Classification of Fractures 9.4.1. Long bones 9.4.2. Pelvis 9.4.3. Acetabulum 9.4.4. Floating knee 9.4.5. Tibial plateau 9.4.6. Physeal fractures in children 9.4.7. Open fractures 9.5. Complications Associated with Orthopaedic Injuries 9.5.1. Avascular necrosis 9.5.2. Myositis ossificans 9.5.3. Fat embolism 9.6. Mechanism of Bone Healing 9.6.1. Phases of bone repair 9.6.1.1. Reactive phase 9.6.1.2. Reparative phase 9.6.1.3. Remodelling phase 9.6.2. Abnormal bone healing 9.6.2.1. Malunion 9.6.2.2. Delayed union 9.6.2.3. Non-union 9.7. Medical and Surgical Management 9.7.1. Primary survey and resuscitation of vital functions 9.7.2. Secondary survey as adjunct to primary survey 9.7.3. Definitive care 9.7.3.1. Care provided in the ICU 9.7.3.2. Non-surgical interventions 9.7.3.2.1. Splints, braces or casts 9.7.3.2.2. Traction 9.7.3.3. Surgical interventions 9.7.3.3.1. External fixation 9.7.3.3.2. Internal fixation 9.7.3.3.3. Amputation 9.8. Physiotherapy Aims of Management 9.8.1. Paediatric considerations 9.8.2. Functional assessment prior to discharge 9.9. Precautions and Contraindications Related to Physiotherapy Management 9.9.1. General precautions related to physiotherapy in intensive care 9.9.2. Specific precautions related to physiotherapy in patients with multiple orthopaedic injuries 9.9.2.1. Adult patients 9.9.2.2. Paediatric patients 9.10. Physiotherapy Intervention 9.10.1. Respiratory system 9.10.2. Neuromusculoskeletal system 9.10.2.1. Pain 9.10.2.2. Joint range of motion 9.10.2.2.1. Sedated patient in the ICU 9.10.2.2.2. Cooperative intubated or spontaneously breathing patient 9.10.2.3. Muscle strength 9.10.2.4. Functional activity, mobilisation and exercise endurance 9.10.2.5. Paediatric considerations 9.10.3. Patient response to treatment 9.11. Clinical Case Scenarios 9.11.1. Case scenario of an adult patient 9.11.1.1. Discussion 9.11.1.1.1. Precautions and contraindications to physiotherapy intervention 9.11.1.1.2. Limitations related to activity and participation 9.11.2. Case scenario of a paediatric patient 9.11.2.1. Discussion 9.12. Ongoing Rehabilitation after Discharge 9.13. Additional Resources 9.14. Conclusion Bibliography Chapter 10 Spinal Cord Injury 10.1. Causes and Mechanisms of Injury 10.1.1. Causes of injury in adults 10.1.2. Mechanisms of injury in adults 10.1.2.1. Primary mechanisms of injury to the spinal cord 10.1.2.1.1. Dislocation of vertebral bodies 10.1.2.1.2. Fracture of vertebrae 10.1.2.1.3. Spinal epidural haematoma 10.1.2.1.4. Spinal subdural haematoma 10.1.2.1.5. Indirect trauma of the spinal cord 10.1.2.1.6. Laceration of the spinal cord 10.1.2.1.7. Haematomyelia 10.1.2.2. Secondary mechanisms of injury to the spinal cord 10.1.2.2.1. Neurogenic shock 10.1.2.2.2. Spinal shock 10.1.2.2.3. Autonomic dysreflexia 10.1.3. Causes and mechanisms of injury in paediatrics 10.2. Spinal Cord Lesions and Classification of the Level of Injury 10.2.1. Types of spinal cord lesions 10.2.1.1. Complete lesion of the spinal cord 10.2.1.2. Incomplete lesion of the spinal cord 10.2.1.2.1. Anterior cord syndrome 10.2.1.2.2. Central cord syndrome 10.2.1.2.3. Posterior cord syndrome 10.2.1.2.4. Brown Sequard syndrome 10.2.1.2.5. Compression of the conus medullaris and cauda equina 10.2.2. Location of injury 10.2.2.1. Paraplegia 10.2.2.2. Tetraplegia 10.2.3. Classification of the level of injury 10.3. Respiratory System Complications following Spinal Cord Injury and Changes in Respiratory Muscle Function 10.3.1. Spinal cord injury and respiratory muscle function 10.3.2. Respiratory complications following spinal cord injury 10.3.2.1. Complications encountered in the early phase after spinal cord injury 10.3.2.1.1. Overproduction of pulmonary secretions 10.3.2.1.2. Bronchospasm 10.3.2.1.3. Atelectasis 10.3.2.1.4. Respiratory failure 10.3.2.1.5. Ventilator-associated pneumonia 10.3.2.1.6. Pulmonary oedema 10.3.2.2. Complications encountered in the later stages following spinal cord injury 10.3.2.2.1. Changes in respiratory pattern 10.3.2.2.2. Changes in compliance 10.3.2.2.3. Changes in lung capacity and lung volumes 10.3.2.2.4. Aspiration pneumonia 10.3.2.2.5. Pulmonary thromboembolism and deep venous thrombosis 10.3.3. Recovery of respiratory function following spinal cord injury 10.3.4. Spinal cord injury not associated with respiratory compromise 10.4. Complications Related to Other Bodily Systems following Spinal Cord Injury 10.5. Medical and Surgical Management 10.5.1. Primary survey and resuscitation of vital functions 10.5.2. Secondary survey as adjunct to primary survey 10.5.3. Definitive care 10.5.3.1. Surgical interventions 10.5.3.1.1. Early stage after spinal cord injury 10.5.3.1.2. Surgical management approaches in the later stages after spinal cord injury 10.5.3.1.3. Nonsurgical management approaches in the later stages after spinal cord injury 10.5.3.2. Conservative management 10.5.3.2.1. Skeletal skull traction 10.5.3.2.2. Halo vest immobilisation 10.5.3.2.3. Cervical braces 10.5.3.3. Care provided in the ICU or the spinal unit 10.5.3.3.1. Pain control 10.5.3.3.2. Management of hypoxaemia 10.5.3.3.3. Respiratory failure 10.5.3.3.4. Haemodynamic support 10.5.3.3.5. Regulation of body temperature 10.5.3.3.6. Genitourinary care 10.5.3.3.7. Corticosteroids 10.5.3.3.8. Prophylaxis for deep venous thrombosis 10.5.3.3.9. Gastro-intestinal care 10.5.3.3.10. Nutrition 10.5.3.3.11. Spasticity 10.6. Physiotherapy Aims of Management 10.6.1. Paediatric considerations 10.6.2. Ongoing assessment 10.7. Precautions and Contraindications Related to Physiotherapy Management 10.7.1. General precautions related to physiotherapy in intensive care 10.7.2. Specific precautions and contraindications related to physiotherapy in patients with spinal trauma 10.7.2.1. Adult patient 10.7.2.2. Paediatric patient 10.8. Physiotherapy Interventions 10.8.1. Respiratory system 10.8.1.1. Oxygenation 10.8.1.2. Humidification 10.8.1.3. Management of pulmonary secretions 10.8.1.3.1. Intubated patient 10.8.1.3.2. Spontaneously breathing patient 10.8.1.4. Lung capacity and volumes 10.8.1.4.1. Intubated patient 10.8.1.4.2. Spontaneously breathing patient 10.8.1.5. Respiratory muscle training 10.8.1.6. Paediatric considerations 10.8.2. Neuromusculoskeletal system 10.8.2.1. Pain 10.8.2.2. Joint range of motion 10.8.2.2.1. Awake and alert intubated or spontaneously breathing patient 10.8.2.3. Muscle strength 10.8.2.4. Functional activity, mobilisation and exercise endurance 10.8.2.5. Paediatric considerations 10.8.3. Patient response to treatment 10.9. Clinical Case Scenarios 10.9.1. Case scenario of an adult patient 10.9.1.1. Discussion 10.9.1.1.1. Treatment goals 10.9.1.1.2. Precautions or contraindications to treatment interventions in the ICU 10.9.2. Case scenario of a paediatric patient 10.9.2.1. Discussion 10.9.2.1.1. Treatment during the acute stage after injury (ventilator dependent) 10.9.2.1.2. Treatment options after six weeks 10.10. Ongoing Rehabilitation after Discharge 10.11. Additional Resources 10.12. Conclusion Bibliography Chapter 11 Traumatic Brain Injury 11.1. Causes and Mechanisms of Injury 11.1.1. Injury in adults 11.1.2. Injury in paediatrics 11.1.3. Forces related to traumatic brain injury 11.2. Types of Traumatic Brain Injury 11.2.1. Open or closed injury 11.2.2. Focal or diffuse injury 11.2.2.1. Focal injury 11.2.2.1.1. Epidural haematoma 11.2.2.1.2. Subdural haematoma 11.2.2.1.3. Subarachnoid haematoma 11.2.2.1.4. Intracerebral haematoma 11.2.2.2. Diffuse injury 11.3. Primary and Secondary Injury Associated with Traumatic Brain Injury 11.3.1. Intracranial pressure 11.3.2. Cerebral perfusion pressure 11.4. Severity of Injury 11.5. Medical and Surgical Management 11.5.1. Primary survey and resuscitation of vital functions 11.5.2. Secondary survey as adjunct to primary survey 11.5.3. Definitive care 11.5.3.1. Care provided in the ICU 11.5.3.1.1. Pupil size and reactivity 11.5.3.1.2. Neurogenic pulmonary oedema 11.5.3.2. Surgical interventions 11.5.3.2.1. Craniotomy 11.5.3.2.2. Decompressive craniectomy 11.5.3.3. Brain stem death 11.6. Physiotherapy Aims of Management 11.6.1. Functional assessment prior to discharge 11.7. Precautions and Contraindications Related to Physiotherapy Management 11.7.1. General precautions related to physiotherapy in the intensive care unit 11.7.2. Specific precautions related to physiotherapy in patients with traumatic brain injury 11.7.2.1. Adult patients 11.7.2.2. Paediatric patients 11.8. Physiotherapy Interventions 11.8.1. Respiratory system 11.8.1.1. Oxygenation 11.8.1.2. Humidification 11.8.1.3. Management of pulmonary secretions 11.8.1.3.1. Intubated patient 11.8.1.3.2. Spontaneously breathing patient with a tracheostomy 11.8.1.3.3. Spontaneously breathing patient without an artificial airway 11.8.1.4. Lung capacity and volumes 11.8.1.4.1. Intubated patient 11.8.1.4.2. Spontaneously breathing patient 11.8.1.5. Respiratory muscle training 11.8.1.6. Paediatric considerations 11.8.2. Neuromusculoskeletal system 11.8.2.1. Patient orientation 11.8.2.2. Altered muscle tone 11.8.2.3. Joint range of motion 11.8.2.3.1. Intubated unresponsive patient 11.8.2.3.2. Responsive and cooperative patient 11.8.2.4. Muscle strength 11.8.2.5. Functional ability, mobilisation and exercise endurance 11.8.2.6. Paediatric considerations 11.8.3. Patient response to treatment 11.9. Clinical Case Scenarios 11.9.1. Adult case scenario 11.9.1.1. Discussion 11.9.1.1.1. Cerebral perfusion pressure 11.9.1.1.2. Physiotherapy-related impairments 11.9.1.1.3. Physiotherapy intervention 11.9.1.1.4. Precautions to physiotherapy intervention 11.9.2. Paediatric case scenario 11.9.2.1. Discussion 11.9.2.1.1. Risks and benefits of treatment (Table 11.1) 11.9.2.1.2. Treatment modalities 11.10. Additional Resources for Ongoing Rehabilitation after Discharge 11.11. Conclusion Bibliography Chapter 12 Quality of Life of Survivors of Trauma 12.1. Definition of Quality of Life and Health-related Quality of Life 12.2. Assessment of Quality of Life and Health-related Quality of Life 12.3. Health-related Quality of Life of Survivors of Trauma and Critical Illness 12.3.1. Physical function-related components of health-related quality of life 12.3.1.1. Survivors of blunt or penetrating trauma 12.3.1.1.1. Paediatric patients who suffered blunt or penetrating trauma 12.3.1.2. Survivors of burn injury 12.3.1.2.1. Paediatric patients with burn injury 12.3.1.3. Survivors of multiple orthopaedic injuries 12.3.1.3.1. Paediatric patients after multiple orthopaedic injuries 12.3.1.4. Survivors of spinal cord injury 12.3.1.4.1. Paediatric patients with spinal cord injury 12.3.1.5. Survivors of traumatic brain injury 12.3.1.5.1. Paediatric patients with traumatic brain injury 12.3.2. Mental health-related components of quality of life 12.3.2.1. Survivors of blunt or penetrating trauma 12.3.2.2. Survivors of burn injury 12.3.2.2.1. Paediatric patients with burn injury 12.3.2.3. Survivors of multiple orthopaedic injuries 12.3.2.3.1. Paediatric patients with multiple orthopaedic injuries 12.3.2.4. Survivors of spinal cord injury 12.3.2.4.1. Paediatric patients with spinal cord injury 12.3.2.5. Survivors of traumatic brain injury 12.3.2.5.1. Paediatric patients with traumatic brain injury 12.4. Post-intensive Care Syndrome 12.4.1. Adult population 12.4.2. Paediatric population 12.5. Posttraumatic Stress Disorder 12.5.1. Adult population 12.5.2. Paediatric population 12.6. Rehabilitation of Survivors of Critical Illness 12.7. Suggestions for Exercise Rehabilitation for Survivors of Trauma and Critical Illness 12.7.1. Exercise prescription for children and adolescents who suffered trauma 12.8. Potential Challenges Associated with Exercise Rehabilitation of Survivors of Trauma 12.9. Conclusion Bibliography Appendix I Trauma and Injury Severity Score Appendix II Appendix IIa: Sofa Scoring System for Adults Appendix IIb: Sofa Scoring System for Children Appendix III Paediatric Trauma Score Appendix IV Normal Values for Paediatrics Appendix V Appendix Va: Behavioural Pain Scale (BPS) Appendix Vb: Critical Care Pain Observation Tool Appendix VI Bedside Measures to Establish the Oxygenation Status of Critically Ill Patients Index