Major Trauma

We should be able to understand the underlying pathophysiology of MSK trauma, head & spinal cord trauma and burn trauma, the medical management of these conditions and PT management of cardiopulmonary problems that may arise.

Multiple Trauma
Can include: DVT occurs in 20-40% of patients in absence of prophylaxis
 * Chest wall injuries
 * Lung contusions
 * Pleural space disorders
 * Diaphragm injuries
 * multiple fractures
 * Head injuries
 * Internal injuries
 * Heart contusion

Shock and Acute Respiratory Distress Syndrome (ARDS) often follow initial insult, the risk of ARDS can be lowered through early intervention of body positioning (compared to later intervention).

The clinical picture of patients with multiple traumas is compounded by the mobilization and positioning restrictions.

Factors and signs and contribute to cardiopulmonary failure after multiple trauma:
 * Airway obstruction - respiratory distress & impaired blood gases
 * Inadequate ventilation - reduced thoracic movement/ paradoxical movement
 * Tension pneumothorax - cyanosis, unilateral absent breath sounds, distended neck veins, subcutaneous emphysema
 * Cardiac tamponade (pericardial effusion) - distended neck veins, muffled heart sounds, narrowed pulse pressure, paradoxical pulse
 * Open pneumothorax - decreased breath sounds, penetration of thoracic wall
 * Myocardial contusion - dysrhythmia
 * Flail chest - loose segment, mutiple palpalbe fractured ribs, decreased breath sounds, hemoptysis

Musculoskeletal trauma
Crushing and penetrating injuries are often seen in the ICU, many problems arising in the list above. Fractures of the long bones and pelvis are associated with fat emboli (threat of pulmonary embolism). Pain from severe injuries may also reduce alveolar ventilation, airway closure and inefficient breathing patterns.

Post traumatic injuries often have blood gases with hypoxemia and hypercapnia, acidemia (metabolic and respiratory components). Patients with severe injuries have better outcomes if hemodynamic status can be optimized.

Rib Fractures
Pathophysiology

Diagnosed by tenderness and crackles on physical examination + x-rays. Simple, uncomplicated rib fractures have no specific treatment (maybe treat the pain with nerve blocks and analgesia).

Flail chest = >2 ribs fractured at 2 or more sites, which results in paradoxical breathing motions from the instability of the chest wall, these injuries can be very painful

Medical Management 

Internal stabilization of the chest via positive pressure ventilation, via ventilator (stabilized by internal expansion of the lungs). The patient is often stable by 2 weeks (if not, may consider surgical option).

Patient will be weaned off of ventilator once they can maintain a reasonable tidal volume and normal arteriale blood gases for 12-24 hours - extubated.

Pneumothorax and Hemothorax
Pathophysiology 

Blood or air in the pleural space promotes retention of secretions and intereferes with clearance, limiting lung expansion (ventilation) and cardiac contraction.

Tension pneumothorax - when air collects in the space under tension, causes lung to collapse (atelectasis) on ipsilateral and contralateral sides = respiratory failure

Diaphragmatic injuries have two effects - 1) lung action is compromised 2) abdomincal contents herniate into the thoracic cavity

Medical Treatment 

Air/ blood removed through a chest tube (usually sutured and tape, not easily dislodged):

mobilizing and frequent position changing promotes drainage and re-expansion of alveoli.
 * Pneumothorax - 2nd or 3rd intercostal space at the mid-clavicular line
 * Hemothorax - 6th intercostal space at the posterior axillary line

Physical Therapy Treatment 

Goals of treatment:
 * 1) Optimize alveolar ventilation
 * 2) Optimize V/Q mismatching
 * 3) Optimize mucociliary transport
 * 4) Improve cough effectiveness