Northern Trauma System Regional Conference 2014

1. Northern Trauma System Regional Conference 2014 High quality trauma care from ‘Roadside to Recovery’

2. The Role of Specialist Rehabilitation in Polytrauma Management Dr James Graham (Consultant Radiologist) Dr Rachel Reaveley (SPR in Neurological Rehabilitation)

3. Objectives 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 Assessing the psychological impact of poly-trauma in the context of concurrent head injury Reflect together on potential gaps in the service

4. Case History • 50 year old driving instructor • High speed head on collision 10/10/12 • Brought to MTC

5. Trauma CT

6. Trauma CT

7. Trauma CT

8. Trauma CT

9. Case History - summary • 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

10. A few days later… • Gradual clinical deterioration • Lactate 1.3 • Amylase 439 • WCC 20 • CRP 116 • Bilirubin 63 • ALP 335 • ALT 282

11. Follow up CT

12. Follow up CT

13. Gastric appearances

14. Angiogram

15. Endoscopy

16. What Happened next?

17. Rehabilitation Assessment & Planning • First seen by Rehabilitation Consultant on General Surgery Ward 21/11/12 • Referred by Head Injury Sister – small frontal contusion • Dizziness • Nausea • Back pain • ? Change in personality

18. Dizziness and nausea • 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

19. Benign Paraoxysmal Positional Vertigo

20. Orthostatic Hypotension

21. 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.

22. Rehabilitation Medicine Review as Outpatient May 2013 • 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

23. Epley’s Manouvre

24. People involved/pending procedures • 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

25. Out patient Review: May 2013 • 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

26. Rehabilitation Actions & further Progress • 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….)

27. In Patient Admission to WGP Cognitive Assessment Bed February 2014 Increasing concern about ongoing depressive episodes with psychological trauma- type symptoms post RTA

28. 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 under-performance • Cognitive assessment noted only very mild problems in verbal abstract reasoning. Working memory unimpaired

29. Other Therapies • 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 • 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

30. Limitations of current processes ‘We’ve had no help at all since being at home” Comment from patient’s wife at first rehab OP review • 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

32. Summary • Interesting case of patient with multi-trauma and complications • Long period of rehabilitation including inpatient stay required • Illustrates that not all changes in behavior following head injury are related to injury

33. Thank you!

34. Northern Trauma System Regional Conference 2014 High quality trauma care from ‘Roadside to Recovery’

35. Transforming Trauma Rehabilitation Recommendations for the North East Region Sharon Smith Paula Dimarco 35 NHS | Presentation to [XXXX Company] | [Type Date]

36. Overview of talk • Purpose of project • Background of project • Best practice pathway • Key findings • Recommendations

37. Purpose of project • On behalf of NE SHA • Provide information and recommendations • Develop a best practice pathway • Support commissioning for development of rehabilitation services following major or serious trauma

38. The Project • Regional steering group • Two work streams, JCUH and RVI • Review of MSK and neurological rehabilitation • Map of current pathway • Data collection and analysis • Stakeholder consultations • Identify models of best practice • Gap analysis

39. Best practice pathway

40. Key findings

41. No consultants in Rehabilitation Medicine in MSK and insufficient within neurotrauma National Standards Recommend: • 6 WTE per million population • No single handed consultants Current Regional Provision: • 3.8 WTE in level 1 Services • 3 WTE in level 2 services all working single handed There is a 2/3 Shortfall on the national standards.

42. Lack of communication, co-ordination and leadership across the pathway leading to disjointed care and inadequate management of patients • RVI has head injury nurse specialist • JCUH has acquired brain injury coordinator • No formal coordinated MDT rehab specifically for TBI at either MTC • No coordinator for MSK at either MTC • Rehabilitation needs to be well planned across the whole pathway, including TUs and community services

43. No specialist inpatient beds for MSK rehabilitation resulting in longer lengths of stay in acute beds or transfer to inappropriate settings • Case example: • 55 year old male – MSK polytrauma including ITU stay • MTC also patient’s local hospital • NWB for 6 months, remained on an acute ortho ward • Transferred to intermediate care at 7 months – little experience of younger patients and ortho rehab

44. No specialist community MDT for MSK rehabilitation leading to sub-optimal outcomes and longer lengths of rehabilitation • If there were community MSK trauma rehab teams, the outcome of the previous example may have been somewhat different

45. Insufficient level 1 and 2 inpatient rehabilitation facilities for neurotrauma patients • BSRM guidelines recommend 60 level 2 beds per million population • Currently 47 in the North East and Cumbria • Level 1 facility is Walkgate Park = 35 beds

46. Insufficient specialist community teams for neurotrauma patients • Only available in 3 areas: • Northumberland (3 therapies in one team) • Gateshead (no physiotherapy) • Cumbria • Different models at each locality • All teams work across health and social care

47. No robust system for data collection to indicate the number of patients requiring specialist and non-specialist Recovery, Rehabilitation and Reablement • TARN can provide a list of injuries and ISS, but these don’t tell us what the patient’s rehabilitation needs are and are retrospective • UKROC not used by all aspects of the pathway • Rehabilitation prescription yet to function as a data recording tool

48. Lack of vocational rehabilitation resulting in no focus on reablement, return to work and social integration • No vocational rehab for MSK trauma • Limited for neurotrauma • All have access to statutory services – not always appropriate • Momentum for neuro patients

49. No standardised or consistent approach to the use of outcome measures which makes it difficult to evaluate rehabilitation • Different emphasis at each stage of rehab, therefore a variety of outcome measures are used • No standardised approach • Work is being undertaken to determine best outcome measures to use

50. Recommendations