Polytrauma RehabilitationSteven G. Scott, DO, Joel D. Scholten, MD, Gail A. LAtlief, DO, Faiza Humayun, MD, Heather G. Belanger, PhD, and Rodney D. Vanderploeg, PhD

SynonymsBlast injuryMultiple injuriesMultiple trauma

ICD-9 Codes344.0Quadriplegia and quadriparesis344.1 Paraplegia451.1 Phlebitis andthrombophlebitis of deep wessels of lower extremities784.0 Headache850 Concussion854.0 Intracranial injury of other and unspecified nature without mention of open intracranial wound854.1 Intracranial injury of other and unspecified nature with open intracranial wound886 Traumatic amputation of other finger(s) (complete) (partial)887 Traumatic amputation of arm and hand (complete) (partial)895 Traumatic amputation of toe(s) (complete) (partial)896 Traumatic amputation of foot (complete) (partial)897 Traumatic amputation of leg(s) (complete) (partial)905.0 Late effect of trauma amputation906.5 Late effect of burn of eye, face, head, and neck906.6 Late effect of burn of wrist and hand906.7 Late effect of burn other extremities906.8 Late effect of burn of unspecified site907.0 Late effect of intracranial injury without mention of skull fracture997.63 Infection (chronic)V52 Fitting and adjustment of prosthetic device and implant

DEFINITONPolytrauma literally means injury to multiple parts secondary to trauma. Because injury of multiple body parts or systems most typically includes traumatic brain injury, polytrauma can be defined in practice as injury to the brain in addition to other body parts or systems, resulting in physical, cognitive, psychological, or psychosocial impairments and functional disability. Injury to the brain is the impairment that typically guides the course of rehabilitation.1,2 Other common disabling conditions include traumatic amputation, auditory and visual impairments, spinal cord injury, post-traumatic stress disorder, and other mental health disorders.Because of recent military conflicts in the world (e.g.,Iraq) as well as increasing terrorist and associated violence, the likelihood of polytraumatic injury is increasing for both military personnel and civilians. Polytrauma is frequently caused by exposure to high-energy blasts or explosions.3 Currently, more than half of all combat injuries are the result of explosive munitions.4 Blast-related injuries are divided into four categories: primary, secondary, tertiary, and quaternary of miscellaneous injuries. Individuals may sustain multiple injuries from one more of these mechanism. Primary blast injuries are caused by barotraumaoverpressurization from the blast wave followed by underpressurization; organ systems affected contain gas or have a gas-fluid interface (e.g., ears, lungs, bowel). Secondary blast injury occur by fragments and other penetrating metal projectiles, which can cause soft tissue trauma and head injuries. Contamination from these fragments can also caused additional damage or infections. Tertiary blast injuries result from displacement of the whole body by combined pressure loads. Finally, there are miscellaneous blast-related injuries, such as burns and crush injuries from collapsed structures and displaced heavy objects.5 Although explosions are a common military or terrorist cause of polytrauma, serious accidents like train derailments, severe motor accidents, and plane crashes can also result in polytrauma.Polytrauma war-related injuries as well as civilian-based injuries occur more frequently in the younger population and predominantly in males. In noncombat conditions, active-duty men are 2.5 times more likely to have a traumatic brain injury. Statistics of the frequency of polytrauma injuries are not available at this time.5,6

SYMPTOMSMost polytrauma patients present with obvious physical traumas or injuries from blast with symptoms related to soft tissue or orthopedic injuries. Some symptoms related to traumatic brain injury, the signature wound of polytrauma, are immediately recognized; others are more subtle and may go unrecognized.7 symptoms related to damaged sensory organs, nervous system, and internal structures may be readily apparent or may be difficult to diagnose. Symptoms related to traumatic brain injury include cognitive, emotional, and physical symptoms.Cognitive or mental symptoms may include difficulties with speech, thinking, memory, concentration, and judgment. Irritability, anxiety, depression, and emotional lability are common emotional sequelae. Physical symptoms include obvious issues, such as motor and sensory deficits, and more subtle symptoms, such as headache, dizziness, and fatigue. Balance and loss of equilibrium are common and may be overlooked.8 There is frequently weakness and motor incoordination. Spasticity can also occur. Pain is common and arises from multiple causes, complicating pain management. Hearing loss with tinnitus is a hallmark symptom of blast-related polytrauma injuries. Vision is frequently impaired with visual field loss or unilateral blindness as a result of shrapnel or other penetrating injuries to the eye or brain. Almost half of polytrauma patients have communication problems, such as dysarthria and aphasia. Bladder and bowel dysfunction can affect a significant number of patients.

PHYSICAL EXAMINATIONA thorough physical examination is essential in the evaluation of a patient who has sustained polytrauma. A mechanism of injury-directed review of systems is suggested.5 If the mechanism of injury is blast related, the examination emphasizes testing for typical sequelae. A thorough neurologic examination including assessment of cranial nerves, motor strength, sensation, and coordination and neuropsychological evaluation is mandatory. Multiple specialty consultants are frequently needed to help in the assessment. Neuro-ophthalmologist, audiologists, and otolaryngologists are consulted to document functioning of specific senses. Wound specialists and plastic surgeons are also often needed to assist in evaluation of open wounds, burns, and skin grafts. In addition, special attention is paid to the assessment of skin and soft tissue for retained shrapnel.

FUNCTIONAL LIMITATIONSPolytrauma patients have multiple functional limitations based on the severity and number of physical and cognitive impairments. Hearing and visual field deficits affect everyday life functions and can make educational and vocational goals difficult to achieve. Lower extremity muscle weakness often impairs ambulation and creates a safety risk from falls. Upper extremity weakness and spasticity impair the patients ability to do everyday activities such as dressing, hygiene, and handwriting. Cognitive deficits affect the ability to work and to perform roles related to parenting and living independently. Particularly in the early phase of recovery, some patients may require continuous surveillance to prevent wandering; chronologically later, driving can be achieved in some patients, but with modifications. Many will have social and relational problems. Traumatic brain injury, stress, and mental health-related issues predispose patients to depression, anger, and mood swings. Those with head injuries may experience significant personality changes, affecting their relationships.

DIAGNOSTIC STUDIESImaging StudiesBecause of the complex nature of injuries, several different imaging modalities are used to assess the polytrauma patient. In general, central nervous system injury is assessed by a combination of computed tomography and magnetic resonance imaging. Because of retained ferrous shrapnel, magnetic resonance imaging may not be possible. Post-traumatic encephalomalacia, hydrocephalus, intracranial hemorrhage, diffuse axonal injury, cerebral contusions, mass effect, and degree of atrophy can be assessed by routine magnetic resonance or computed tomographic imaging of the brain. The same diagnostic studies can be applied to the spinal cord to determine an anatomic level of injury versus compression myelopathy.Routine radiographs are often sufficient to assess for skeletal injuries and intra-thoracic and intra-abdominal disease. However, computed tomography can be used when more detailed examination is necessary. Bone scan is particularly useful for assessment of heterotopic ossification or recent injury or infection that is not readily apparent on radiographic examination.

Electrodiagnostics Patients with multiple trauma often sustain damage to the peripheral nervous system. A review of 33 activeduty patients admitted to the Tampa Polytrauma Rehabilitation Center revealed multiple cases of plexopathies, single-nerve injuries, and multiple-nerve injuries related to blasts, penetrating wounds, crush injuries, and motor vehicle collisions.9 Electromyography and nerve conduction studies should be used whenever a peripheral nerve injury is suspected.In addition, electroencephalography is a useful tool in diagnosis of post-traumatic epilepsy or encephalopathy.Vascular StudiesThromboembolic disease is an unfortunate consequence of polytrauma and subsequent immobility after a blast injury. Venous Doppler ultrasonography is frequently employed to detect deep venous thrombosis in the extremities. More proximal testing can be done by computed tomographic angiography.Arterial dissection has also been documented to occur secondary to blast. Traditional angiography and magnetic resonance angiography are both useful to explore the extent of dissection and superimposed thrombus after traumatic dissection.

Functional TestingQuantitative gait analysis is useful in objective documentation of walking ability as well as in the identification of the underlying causes of walking abnormalities. It is helpful in determining the best course of treatment in patients with brain injury or neuromuscular injury.

Neuropsychological and Psychological EvaluationsA comprehensive battery of neuropsychological and psychological test is necessary to determine the full spectrum of cognitive and psychological sequelae from polytrauma injuries. This is typically completed once the person is medically stable, in an acute rehabilitation program, and out of any postinjury confusional state such as post-traumatic amnesia. Evaluations may be repeated to address different clinical questions during the course of recovery. Initially, assessment helps identify cognitive and emotional impairments that should be a focus of treatment. Repeated evaluations may be useful in making decisions about additional treatment needs, residential placement independence capacity, and future vocational or educational endeavors.Differential DiagnosisConversion disorderSomatoform disorderMalingeringSome potential diagnoses are actually the traumas or injuries of polytrauma:Dementia or cognitive disorder NOSNormal pressure hydrocephalusToxic exposureFibromyalgiaMycobacterial infectionMycoplasmal infectionInfectious diseaseDrug and alcohol abuseMedication side effectsOthers are potential differential diagnoses:Progressive dementiasSleep apneaMultiple sclerosisNeoplasmsAutoimmune disease (e.g., rheumatoid, lupus, vasculitis)Other infectious disease (Lyme disease, syphilis, poliomyelitis, human immunodeficiency virus infection, Epstein-Barr virus infection)Differential diagnosis for patients sustaining polytrauma injuries is complex for seemingly simple problems. Even the cause of the injury is frequently debated. For example, brain injury can be cause by primary, secondary, and tertiary, blast injuries or a combination of the three. A broad differential should be included when any problem with polytrauma patients is considered. The clinician must maintain a high index of suspicion for possible central nervous system infection when patients with a history of penetrating head injury present with such vague complaints as confusion, fatigue, and functional decline. Likewise, patients with a history of penetrating abdominal wounds may present with vague abdominal complaints, and an aggressive evaluation may be required for retained shrapnel and possible abscess. Musculoskeletal complaints may also be challenging, and evaluation for retained shrapnel and possible abscess. Musculoskeletal complaints may also be challenging, and evaluation for retained shrapnel causing impingementor nerve injury should be explored. Any complaint that does not respond to treatment as expected should be explored and the differential diagnosis widened in an effort to treat this challenging population of patients. In this regard, the potential for development of chronic pain or somatoform disorders, post-traumatic stress disorder, depression, or other psychological conditions should be considered.

evaluation for retained shrapnel and possible abscess. Musculoskeletal complaints may also be challenging, and evaluation for retained shrapnel causing impingement or nerve injury should be explored. Any complaint that does not respond to treatment as expected should be explored and the differential diagnosis widened in an effort to treat this challenging population of patients. In this regard, the potential for development of chronic pain or somatoform disorders, post-traumatic stress disorder, depression, or other psychological conditions should be considered.

TREATMENTInitialThe initial treatment of soldiers wounded in war or of civilians injured in serious accidents is predominantly surgical. In the case of both civilian and war-related injuries, dramatic improvement in life expectancy has been attained by highly skilled emergency and surgical intervention; in the war-related injuries, this includes forward military surgical teams and then rapid evacuation to the continental United States. Massive quantities of blood products are often required during resuscitation of patients sustaining polytrauma in a combat situation. The concept of hypotensive resuscitation has now regained favor in the field. The combat wounded receive blood and blood products at a rate to keep a palpable distal radial pulse and systolic blood pressure at approximately 90 mmHg.10 This is thought to improve outcomes by preserving intravascular volume and diminishing risk of clot disruption, reducing dilutional coagulopathy, and minimizing hypothermia.11 Serial abdominal closure is frequently used to treat patients with abdominal wounds in theater. Gore-Tex mesh is implanted and the abdomen is closed in several separate procedures, allowing the abdomen to remain decompressed and to protect the intra-abdominal components. This in turn allows earlier rehabilitation.12Patients who may have sustained crush injuries in war and elsewhere may require fasciotomies because of impending compartment syndrome. Many patients who have sustained severe head trauma will require partial craniectomy both for removal of blood accumulation and for control of cerebral edema. The removed portion of the skull is frequently not able to be salvaged because of fragmentation injuries. If the skull plate is salvageable, it is either frozen or implanted into the abdominal wall for reimplantation at a later date.Multiple surgeries are frequently required during the acute hospitalization phase. Multiple revisions of amputated limbs may be required as well as multiple interventions for burned patients, such as repeated skin grafting.Infection control can also be a problem for returning wounded soldiers. Most casualties are initially placed in isolation status until surveillance cultures can be obtained, clearing them from isolation status.

RehabilitationThe rehabilitation process begins in acute medical settings, such as military treatment facilities, with the initiation of individual physical, occupational, and speech therapy. Collaboration by video teleconferences has allowed earlier physiatric input into the care of these complex patients and helped coordinate a smooth transition from acute care facilities to rehabilitation units.Successful rehabilitation of polytrauma patients requires both multidisciplinary medical care and interdisciplinary rehabilitation care. In addition to the physiatrist, the multidisciplinary team frequently includes specialists in medicine, surgery, infectious disease, neurology, psychiatry, burns, spinal cord injury, and others. The interdisciplinary rehabilitation team consisting of speech therapists, physical therapists, occupational therapists, nurses, blind rehabilitation specialists or certified low vision therapists, audiologists, recreational therapists, psychologists, social workers, rehabilitation counselors, and other work together to minimize disability, to maximize independence, and to support the family. There are also specialized rehabilitation teams to meet the needs of the ventilator-dependent, burn, and amputee polytrauma patients. The polytrauma patients, with their multiple impairments and disabilities, will need to be observed with a rehabilitation model of care consisting of transitional day programs and long-term rehabilitation care.

ProceduresDuring the rehabilitation process, various interventions may be used to augment the efforts of the multidisciplinary team. Botulinum toxin injection can help reduce spasticity and improve overall mobility, hygiene, pain, and function. Serial casting is often used to help slowly reduce contracture and to improve range of motion. Negative-pressure wound therapy with vacuum-assisted closure may be used for large or slowly healing traumatic or postsurgical wounds.

SurgeryBecause of the complex nature of polytrauma patients, multiple surgical interventions may be required during the initial acute rehabilitation stay. Patients may also require frequent readmission to the hospital for more surgeries, and an additional stay in the rehabilitation unit may allow the attainment of further independence goals. Those patients with skull defects will eventually require cranioplasty for correction of the defect. Most surgeons recommend a wait of at least 3 to 6 months since the last major infection before cranioplasty is performed. Patients with hydrocephalus may require placement of a ventriculoperitoneal shunt. The patients cognitive and functional status is carefully monitored; patients with penetrating head injuries with retained fragments appear to be at a higher risk for intracranial infections. Finally, reconstructive procedures for facial deformities, revision of skin grafts and scars, and resection of heterotopic of ossification may be required in the late post-acute rehabilitation stage.

POTENTIAL DISEASE COMPLICATIONSExplosions have the potential to inflict multiple and severe trauma that few U.S. health care providers outside the military and the Veterans Administration have experience treating. The acute complications vary according to the mechanism and pattern of trauma. Such complications can include air embolism, compartment syndrome, rhabdomyolysis, renal failure, seizures, hemorrhage, increased intracranial pressure, infections, meningitis, and encephalopathy. Early complications that follow major burns include bacterial infections, septicemia, deep venous thrombosis, pulmonary embolism, renal failure, hypovolemic shock, jaundice, glottic edema, and ileus.From October 2001 through December 2005, 188 war injured service members were treated at one of the four polytrauma rehabilitation centers.13 Complications before admission to a polytrauma rehabilitation center and complications that occurred during the polytrauma rehabilitation program are listed in Table 136-1. During the acute rehabilitation stage of care, there is certainly overlap of potential complications; but some variable patterns emerge, depending on whether the major injury is traumatic brain injury, spinal cord injury, burn, or limb amputation. Complications in traumatic brain injury include seizures, meningitis, spasticity, contractures, heterotopic ossification, headache, and agitation. In the spinal cord-injured population, complications include urinary retention, decubitus ulcers, spasticity, heterotopic ossification, deep venous thrombosis, pulmonary embolism, osteopenia, fracture, and urinary tract infections. Complications in burns can include microstomia, contractures, heterotopic ossification, anemia, pain, and skin graft failure. Limb amputation complications include phantom pain, stump pain, contractures, sinus formation, heterotopic ossification, wound dehiscence, tissue necrosis, falls, fractures, wound infections, edema, and hematoma.Table 136-1Frequency and Percentage of Complications before and during PRC treatment (N=188)

PRC, polytrauma rehabilitation center

Pain, ranging from traumatic, postsurgical, neuropathic, and burn-related headaches to chronic pain syndromes, is common in the polytrauma patient. Ninety-six percent of polytrauma rehabilitation center admissions experienced at least one pain problem.14An often overlooked complication for almost all patients in rehabilitation is mental health status. Some of the more common challenges include depression, post-traumatic stress disorder and anxiety disorders, body image issues, and behavioral or emotional dysregulation. Any or all of these can have an impact on medication or treatment compliance and general recovery.POTENTIAL TREATMENT COMPLICATIONSThe various pieces of exercise equipment, orthotics, prosthetics, ceiling lifts, and other medical adaptive devices can sometimes result in complications, whether they are used correctly or incorrectly. For example, resting splints used in burn cases to prevent joint contractures can result in pressure ulcers. Compartment syndrome, nerve injury, and infections can develop under casts that are sometimes used to treat contractures in the polytrauma population. An amputate may develop skin irritation, abrasions, ulcerations, or other skin changes from the prosthetic liner or socket. The polytrauma patient is at high risk for falls and injury during the rehabilitation treatment phase from multiple factors, including polypharmacy, deconditioning, altered cognition, impulsivity, agitation, limb loss, impaired balance, spasticity, bracing, weakness, and urinary incontinence.With complex polytrauma often comes significant pain at one or more sites; 50% or more of these patients require opioids or nonsteroidal anti-inflammatories.14 Complications of opioids have been well described and can include constipation, altered cognition, somnolence, nausea, vomiting, convulsions, hypothalamic effect, neuroendocrine effect, respiratory depression, tolerance, dependence, and addiction.15 the principal side effects of nonsteroidal anti-inflammatory drugs are dyspepsia, peptic ulcer disease, renal dysfunction, altered liver function, gastrointestinal bleed, and impaired cartilage repair in osteoarthritis.

References1. Brown A, Leibson C, Malec J, et al. Long-term survival after traumatic brain injury: a population-based analysis. Neurorehabilitation 2004; 19: 37-43.2. Nolan S. Traumatic brain injury: a review. Crit Care Nurs Q 2005; 28: 188-194.3. DePalma RG, Burris DG, Champion HR, Hodgson MJ. Blast injuries N Engi J Med 2005; 1335-1342.4. Fox CJ, Gillespie DL, ODonnell SD, et al. Contemporary management of wartime vascular trauma. J Vasc Surg 2005; 41: 638-644.5. Belanger HG, Scott S, Scholten S, et al. Utility of mechanism-of-injury-based assessment and traetment: blast injury program case illustration. J Rehabil Res Dev 2005; 42: 403-412.6. Scott SG, Vanderploeg RD, Belanger HG, Scholten J. Blast injuries: evaluating and treating the postacute sequelae. Fed Pract 2005; 22: 67-75.7. Vanderploeg RD, ed. Traumatic Brain Injury. Birmingham, Ala bama, Department of Veterans Affairs, Employee Education Resource Center, 2004.8. Newton RA. Balance abilities in individuals with moderate and severe traumatic brain injury. Brain Injury 1995; 9: 445-451.9. Merritt B, Humayun F, Tran H. Patterns of peripheral nerve injuries sustained by polytrauma active duty service members. Poster presented at the annual assembly of the American Academy of Physical Medicine and Rehabilitation, September 2007.10. Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma 2007; 62: 307-310.11. Covey DC. Combat orthopeadics: a view from the trenches. J Am Arcad Orthop Surg 2006; 14: S10-S17.12. Vertrees A, Kellicut D, Ottman S, et al. Early definitive abdominal closure using serial closure technique on injured soldiers returning of Afghanistan and Iraq. J Am Coll Surg 2006; 202: 762-771.13. Sayer N, Chiros C, Sigford B, et al. Characteristics and rehabilitation outcomes among patients with blast and other injuries sustained during the global war on terror. Arch Phys Med Rehabil 2008; 89: 163-170.14. Clark ME, Bair MJ, Buckenmaier CC III, et al. Pain and combat injuries in soldiers returning from Operations Enduring Freedom and Iraqi Freedom: implications for research and practice. J Rehabil Res Dev 2007; 44: 179-194.15. Ballantyne JC, ed. The Massachusetts General Hospital Handbook of Pain Management, 3rd ed. Philadelphia, Lippincott Williams & Wilkins, 2005.

Rehabilitasi PolitraumaSteven G. Scott, DO, Joel D. Scholten, MD, Gail A. LAtlief, DO, Faiza Humayun, MD, Heather G. Belanger, PhD, and Rodney D. Vanderploeg, PhD

SynonymsBlast injuryMultiple injuriesMultiple trauma

ICD-9 Codes344.0Quadriplegia and quadriparesis344.1 Paraplegia451.1 Phlebitis andthrombophlebitis of deep wessels of lower extremities784.0 Headache850 Concussion854.0 Intracranial injury of other and unspecified nature without mention of open intracranial wound854.1 Intracranial injury of other and unspecified nature with open intracranial wound886 Traumatic amputation of other finger(s) (complete) (partial)887 Traumatic amputation of arm and hand (complete) (partial)895 Traumatic amputation of toe(s) (complete) (partial)896 Traumatic amputation of foot (complete) (partial)897 Traumatic amputation of leg(s) (complete) (partial)905.0 Late effect of trauma amputation906.5 Late effect of burn of eye, face, head, and neck906.6 Late effect of burn of wrist and hand906.7 Late effect of burn other extremities906.8 Late effect of burn of unspecified site907.0 Late effect of intracranial injury without mention of skull fracture997.63 Infection (chronic)V52 Fitting and adjustment of prosthetic device and implant

DEFINISIPolitrauma sebenarnya berarti cedera pada beberapa bagian sekunder terhadap trauma. Karena cedera dari beberapa bagian tubuh atau sistem biasanya termasuk cedera otak, politrauma dapat dikatakan sebagai cedera otak dengan tambahan cedera bagian tubuh lainnya atau sistem organ dengan dampak gangguan pada fisik, kognitif, psikologis atau psikososial serta cacat fungsional. Cedera pada otak merupakan gangguan yang biasanya dapat menentukan jenis dari rehabilitasi.1,2 Kondisi cacat lain biasanya seperti amputasi terhadap cedera, gangguan pendengaran dan penglihatan, cedera saraf tulang belakang, stress pasca trauma, dan gangguan mental lainnya.Karena konflik militer di dunia belakangan ini (seperti Irak) disertai dengan peningkatan jumlah teroris dan yang berhubungan dengan kejahatan, cedera politrauma cenderung meningkat baik bagi tim militer maupun bagi penduduk. Politrauma sering disebabkan oleh paparan ledakan energi tinggi atau ledakan.3 Saat ini , lebih dari setengah dari semua cedera tempur adalah hasil dari ledakan amunisi.4 Luka yang terkait dengan ledakan dibagi menjadi empat kategori: primer, sekunder, tertier dan kuartener atau luka yang bervariasi. Seorang individu dapat mengalami cedera multiple satu atau lebih dari mekanisme ini. Luka ledakan primer disebabkan oleh barotraumas tekanan udara yang berlebihan dari gelombang ledakan diikuti oleh tekanan udara yang rendah; sistem organ mengandung gas atau gas-cairan antar ruang (seperti telinga. Paru-paru, perut). Luka ledakan sekunder terjadi karena segmen atau bahan logam proyektil yang dapat menyebabkan trauma pada jaringan halus dan cedera kepala. Kontaminasi dari segmen-segmen ini dapat menyebabkan kerusakan atau infeksi tambahan. Luka ledakan tertier merupakan dampak dari perubahan dari seluruh tubuh akibat beban tekanan gabungan. Selanjutnya, terdapat luka ledakan yang bervariasi seperti luka bakar dan luka yang hancur akibat dari runtuhan struktur dan benda yang berat.5 Walaupun ledakan merupakan penyebab umum pada politrauma militer atau teroris, kecelakaan serius seperti kereta api yang tergelincir, kecelakaan kendaraan bermotor yang parah, dan tabrakan pesawat terbang dapat juga mengakibatkan politrauma.Luka yang berhubungan dengan perang biasanya sering dialami oleh populasi yang lebih muda dan lebih banyak pada laki-laki. Pada kondisi yang tidak sedang berperang, laki-laki yang aktif biasanya 2,5 kali lebih rentan mengalami cedera kepala. Statistik dari cedera politrauma saat ini tidak tersedia.5,6

GEJALAKebanyakan pasien politrauma mengalami trauma dan cedera fisik yang jelas dari ledakan dengan gejala yang berhubungan dengan cedera pada jaringan lunak dan cedera tulang. Beberapa gejala yang berhubungan dengan cedera otak, luka khas dari politrauma dapat segera dikenali.7 Gejala yang berhubungan dengan kerusakan organ sensori, sistem saraf, dan struktur internal mungkin akan muncul atau mungkin juga sulit didiagnosa. Gejala yang berhubungan dengan trauma otak termasuk gejala kognitif, emosional, dan fisik.Gejala kognitif atau mental termasuk kesulitan berbicara, berpikir, ingatan, memori, konsentrasi, dan kemampuan mempertimbangkan. Iritabilitas, ansietas, depresi, dan emosional merupakan gejala sekuele yang umum. Gejala fisik termasuk jaringan yang jelas seperti defisit saraf motorik dan sensorik, dan gejala lainnya yaitu sakit kepala, pusing dan lelah. Seimbang dan hilangnya keseimbangan sangat umum dan sangat terlihat.8 Terdapat inkoordinasi motorik dan kelemahan yang sering. Kekakuan bisa juga terjadi. Nyeri sangat umum terjadi dan berasal dari multi faktor, mengakibatkan komplikasi dari manajemen nyeri tersebut. Kehilangan pendengaran disertai tinnitus merupakan gejala yang khas dari luka politrauma terkait dengan ledakan. Penglihatan sering terganggu dengan kehilangan lapang pandang atau kebutaan unilateral sebagai hasil dari logam atau luka penetrasi lainnya yang masuk ke mata atau otak. Hampir sebagian pasien politrauma memiliki masalah komunikasi, seperti disartria dan afasia. Disfungsi kandung kemih dan perut dapat mempengaruhi beberapa pasien.

PEMERIKSAAN FISIKPemeriksaan fisik yang lengkap sangat penting dalam evaluasi pasien yang mengalami politrauma. Mekanisme luka- pengkajian sistem yang langsung disarankan.5 Apabila mekanisme luka tersebut terkait dengan ledakan, pemeriksaan menekankan pada sekuele yang tipikal. Pemeriksaan saraf yang lengkap termasuk assesmen saraf kranial, kekuatan motorik, sensasi, dan koordinasi serta evaluasi neuropsikologi sangatlah wajib.Konsultan yang memiliki beberapa spesialistik sering diperlukan untuk membantu dalam asesmen ini. Neuroopthalmologis, audiologis, dan otolaringologis dikonsultasikan mengenai fungsi-fungsi dari indera yang spesifik. Spesialis luka dan ahli bedah plastik sering juga diperlukan untuk mengevaluasi luka terbuka, luka bakar, dan pencangkokan kulit. Sebagai tambahan, perhatian khusus harus diberikan terhadap asesmen kulit dan jaringan lunak untuk kepingan logam yang masuk.

BATASAN FUNGSIONALPasien politrauma memiliki beberapa batasan fungsional tergantung dari tingkat keparahan dan jumlah dari gangguan fisik dan kognitif. Defisit pendengaran dan lapangan pandang mempengaruhi aktivitas hidup sehari-hari dan dapat membuat tujuan dari edukasi dan pekerjaan seseorang sulit dicapai. Kelemahan otot ekstremitas bawah sering mengganggu ambulasi dan mengakibatkan resiko jatuh. Kelemahan ekstremitas atas dan kekakuan mengganggu kemampuan pasien untuk melakukan aktivitas sehari-hari seperti berpakaian, higinitas, dan menulis. Defisit kognitif mempengaruhi kemampuan bekerja dan peran dalam mengasuh serta hidup secara mandiri. Biasanya pada fase penyembuhan awal, beberapa pasien diwajibkan untuk menghindari berjalan jauh, kronologisnya nanti, menyetir bisa dilakukan oleh beebrapa pasien, tapi dengan modifikasi. Banyak pasien yang akan memiliki masalah sosial dan relasi. Cedera trauma kepala, stress, dan maslaah mental- predisposisi yang berhubungan dengan depresi, kemarahan, dan mood swing. Pasien dengan cedera kepala tersebut mungkin akan mengalami perubahan kepribadian, yang dapat mempengaruhi hubungan mereka.

STUDI DIAGNOSTIKStudi PencitraanKarena luka yang kompleks, beberapa perbedaan dari modalitas pencitraan digunakan untuk menilai pasien politrauma. Secara umum, cedera pada sistem saraf pusat dinilai oleh kombinasi computed tomography dan MRI. Akibat dari elemen logam yang mengandung besi, MRI tidak mungkin dilakukan. Ensephalomalasia post-trauma, hidrocephalus, perdarahan intrakranial, cedera pada axon yang menyebar, kontusio serebral, efek massa, dan derajat atrofi bisa dinilai dengan MRI atau CT pada otak. Studi diagnostik yang sama bisa dilakukan pada saraf tulang belakang untuk menentukan tingkat cedera anatomis dibandingkan kompresi myelopati.Radiografi yang rutin dinilai cukup untuk menilai cedera skeletal dan penyakit intra torakal dan intra abdomen. Akan tetapi, computed tomography dapat digunakan apabila pemeriksaan lengkap lebih lanjut diperlukan. Pemeriksaan scan tulang biasanya berguna dalam menilai osifikasi heterotopik atau luka atau infeksi yang baru yang belum muncul pada pemeriksaan radiografi.

ElektrodiagnostikPasien dengan trauma multipel sering mengalami kerusakan pada sistem saraf tepi. Pemeriksaan pada 33 pasien aktif yang dibawa ke Pusat Rehabilitasi Politrauma Tampa menunjukkan kasus multipel dari plexopati, cedera saraf tunggal, dan cedera saraf multipel yang terkait ledakan, luka penetrasi, cedera tabrakan, dan tabrakan kendaraan bermotor.9 Elektromiografi dan studi konduksi saraf harus dilakukan ketika dicurigai terdapat cedera saraf tepi. Sebagai tambahan, elektroencephalografi berguna dalam diagnosis epilepsi post trauma atau ensephalopati.

Studi VaskularPenyakit tromboembolitik merupakan konsekuensi dari politrauma dan imobilitas setelah cedera dari ledakan. USG Venous Doppler sering digunakan untuk mendeteksi trombosis pada vena dalam di ekstremitas. Pemeriksaan proksimal lebih lanjut dapat dilakukan dengan CT angiography.Diseksi arteri juga didokumentasikan sebagai kejadian sekunder dari ledakan. Angiografi tradisional dan MRI, keduanya berguna dalam mengekspolrasi dari diseksi tersebut dan superimpose dari trombosis setelah diseksi trauma.

Uji FungsionalAnalisa gait kuantitatif berguna dalam dokumentasi yang objektif terhadap kemampuan berjalan sebagai identifikasi penyebab dari abnormalitas berjalan. Hal ini sangat membantu dalam menentukan perawatan yang terbaik untuk pasien dengan cedera kepala dan cedera neuromuskular.

Evaluasi Neuropsikologi dan PsikologiUji komprehensif dari neuropsikologi dan psikologi penting untuk menentukan spektrum kognitif dan sekuele psikologi dari cedera politrauma. Biasanya pemeriksaan ini dilengkapi ketika pasien sudah stabil dan berada pada program rehabilitasi akut, dan tidak berada pada keadaan kebingungan pasca trauma seperti anemsia post trauma. Penilaian diulangi untuk mendapatkan pertanyaan klinis yang berbeda selama fase penyembuhan. Asesmen membantu untuk mengidentifikasi gangguan kognitif dan emosional yang merupakan fokus penting dari perawatan. Penilaian yang berulang berguna dalam membuat keputusan terhadap perawatan tambahan, kapasitas tempat tinggal yang mandiri, mata pencaharian dan edukasi di kemudian harinya.

Diagnosis BandingConversion disorderSomatoform disorderMalingeringBeberapa diagnosis yang sebenarnya adalah trauma atau poitrauma:Demensia atau gangguan kognitif NOSHidrosefalus tekanan normalPaparan racunFibromyalgiaInfeksi mikobaterialInfeksi mikoplasmaPenyakit infeksiPenyalahgunaan obatobatan dan alkoholEfek samping pengobatanDiagnosis banding potensial yang lain:Demensia progresifSleep apneaMultiple sclerosisNeoplasmaPenyakit autoimun (contoh: rheumatoid, lupus, vasculitis)Penyakit infeksi yang lain (Lyme disease, sifilis, poliomyelitis, infeksi HIV, infeksi virus Epstein-Barr)Diagnosis banding untuk pasien yg mengalami cedera politrauma cukup kompleks untuk masalah yang tampaknya sederhana. Bahkan penyebab dari cedera sering diperdebatkan. Misalnya, cedera otak bisa disebabkan oleh cedera primer, sekunder, tertier, luka ledakan atau kombinasi ketiganya. Diagnosis banding yang luas harus tetap dimasukkan ketika dianggap ada masalah dengan pasien politrauma. Ahli klinis harus tetap curiga dengan adanya kemungkinan infeksi sistem saraf pusat terhadap pasien yang memiliki riwayat cedera penetrasi kepala disertai keluhan seperti kebingungan, lelah, dan penurunan fungsional. Seperti pasien yang memiliki riwayat luka penetrasi pada abdomen memiliki keluhan pada abdomen, dan evaluasi progresif lebih lanjut sangat diperlukan. Keluhan pada muskuloskeletal juga mungkin menantang, dan evaluasi untuk mempertahankan pecahan peluru yg menyebabkan kerusakan cedera saraf harus dieksplorasi. Setiap keluhan yang tidak berespons terhadap pengobatan harus dieksplorasi dan memperluas diagnosis banding dalam upaya mengobati populasi dari pasien-pasien tersebut.Dalam hal ini, potensi dari perkembangan nyeri kronik atau kelainan somatoform, gangguan stres pasca-trauma, depresi, atau kondisi psikologis lainnya yang harus dioertimbangkan.

pecahan peluru yang menyebabkan kerusakan cedera saraf harus dieksplorasi. Setiap keluhan yang tidak berespons terhadap pengobatan harus dieksplorasi dan memperluas diagnosis banding dalam upaya mengobati populasi dari pasien-pasien tersebut.Dalam hal ini, potensi dari perkembangan nyeri kronik atau kelainan somatoform, gangguan stres pasca-trauma, depresi, atau kondisi psikologis lainnya yang harus dipertimbangkan.

TATA LAKSANAInisialPenatalaksanaan inisial bagi prajurit yang terluka dalam perang atau penduduk yang terluka dalam kecelakaan serius kebanyakan adalah operasi. Baik dari kasus cedera pada penduduk ataupun cedera dari akibat perang, angka harapan hidup didapatkan dari kemampuan emergensi yang tinggi dan intervensi bedah; pada cedera yang terkait dengan perang, termasuk tim bedah militer dan evakuasi yang meluas ke U.S. Jumlah unit kantong darah yang masif sering diperluan selama resusitasi terhadap pasien politrauma dalam situasi perang. Konsep dari resusitasi hipotensif sekarang diperlukan dalam kondisi seperti itu. Pasien yang terluka menerima darah dan unit darah dengan tujuan menjaga nadi radialis distal tetap teraba dan tekanan darah sistolik kira-kira 90 mmHg.10 Hal ini dianggap untuk meningkatkan outcome dengan menjaga volume intravaskular dan mengurangi resiko gangguan pada pembekuan, menurunkan koagulopati dilusional, dan menimimalisir hipotermia.11 Penutupan perut sering dilakukan untuk mengatasi pasien dengan luka perut di area perang. Gore-Tex mesh dilakukan dan abdomen ditutup dengan beberapa prosedur yang terpisah, memungkinkan abdomen agar tetap kempes dan melindungi komponen komponen intra abdomen. Inilah yang dimaksudkan dengan rehabilitasi dini.12Pasien yang mengalami luka pada saat perang atau dimanapun membutuhkan fasciotomi karena impending sindrom kompartemen. Banyak pasien yang mengalami cedera kepala berat membutuhkan craniectomi parsial baik untuk menghilangkan akumulasi darah atau untuk kontrol edema serebral. Bagian bagian tengkorak yang dibuang biasanya tidak bisa diselamatkan karena terjadi cedera fragmen-fragmen. Apabila bagian bagian tengkorak tersebut masih bisa diselamatkan, itu berarti dibekukan atau dimasukkan kedalam dinding abdomen untuk reimplantasi di kemudian hari.Beberapa operasi sering dibutuhkan selama fase rawat inap akut. Perubahan multipel dari ekstremitas yang diamputasi juga membutuhkan intervensi yang banyak seperti pada pasien dengan luka bakar, seperti pencangkokan kulit yang berulang.Kontrol infeksi juga merupakan masalah bagi prajurit yang terluka dan kembali ke perawatan. Kebanyakan korban awalnya ditempatkan di ruang isolasi sampai kultur dapat diperiksa, terbebas dari status isolasi.

RehabilitasiProses rehabilitasi dimulai pada keadaan medis akut, seperti fasilitas perawatan militer, dengan terapi permulaan terhadap fisik individu, okupasi, dan berbicara. Kolaborasi telekonferensi video mengizinkan psiatrik-psiatrik yang awalnya menangani pasien-pasien tersebut dari fasilitas akut ke unit rehabilitasi.Tingkat kesuksesan rehabilitasi dari pasien politrauma membutuhkan baik dari perawatan multidisiplin medis maupun perawatan interdisiplin rehabilitasi. Sebagai tambahan bagi psiatrik, tim multidisiplin sering memasukkan ahli-ahli obat, bedah, penyakit infeksi, neurologi, psikiatri, luka bakar, cedera tulang belakang, dan lain-lain. Tim interdisiplin rehabilitasi terdiri dari ahli terapi bicara, fisik, okupasi, perawat, ahli rehablitasi kebutaan, terapi penglihatan, pendengaran, rekreasi, psikologi, pekerja sosial, konsulen rehabilitasi, dan lainnya yang dapat bekerja bersama untuk meminimalisir cacat, memaksimakan kemandirian, dan untuk mensupport keluarga. Terdapat juga tim ahli rehabilitasi yang mengatasi kebutuhan seperti ketergantungan ventilator, luka bakar, dan pasien politrauma yang diamputasi. Pasien politrauma, dengan gangguan multipel dan cacat, penting untuk diobservasi dengan model rehabilitasi yang terdiri dari program transisi dan perawatan rehabilitasi jangka panjang.

ProsedurSelama proses rehabilitasi, berbagai macam intervensi dilakukan untuk meningkatkan upaya dari tim multidisiplin. Injeksi toksin botulinum dapat mengurangi kekakuan dan meningkatkan mobilitas, higinitas, nyeri dan beberapa fungsi. Serial casting sering digunakan untuk membantu untuk secara perlahan mengurangi kontraktur dan meningkatkan ROM. Terapi luka menggunakan tekanan negatif dengan vakum digunakan untuk penyembuhan trauma dengan lambat atau untuk luka pasca operasi.

PembedahanKarena kompleksnya masalah dari pasien politrauma, intervensi bedah banyak diperlukan selama rehabilitasi akut. Pasien juga dibutuhkan untuk masuk kembali ke rumah sakit lebh sering untuk operasi lagi, dan rawat inap tambahan di rehabilitasi unit guna pencapaian kemandirian bagi pasien. Pasien-pasien dengan cacat pada tengkorak kepala pastinya membutuhkan cranioplasti. Kebanyakan ahli bedah menyarankan agar menunggu minimal 3-6 bulan sejak infeksi mayor terakhir sebelum cranioplasti dilakukan. Pasien dengan hidrosephalus membutuhkan dilakukannya ventriculoperitoneal shunt. Kognitif dan status fungsional pasien harus dimonitor secara hati-hati; pasien dengan luka penetrasi pada kepala beresiko lebih besar mengalami infeksi intrakranial. Selanjutnya, prosedur rekonstruksi untuk perubahan pada wajah, perubahan pada pencangkokan kulit dan luka, dan reseksi dari osifikasi heterotropik dibutuhkan pada fase rehabilitasi post-akut.

KOMPLIKASI DARI PENYAKITLedakan berpotensi mengakibatkan trauma yang multipel dan parah sebagaimana yang dirasakan oleh beberapa penyedia jasa kesehatan di Amerika diluar militer dan administrasi veteran. Komplikasi akut bervariasi tergantung dari mekanisme dan pola trauma. Komplikasi tersebut adalah seperti emboli udara, sindroma kompartemen, rhabdomyolisis, gagal ginjal, kejang, perdarahan, peningkatan TIK, infeksi, meningitis, dan ensephalopati. Komplikasi dini dari luka bakar termasuk infeksi bakteri, sepsticemia, trombosis vena dalam, emboli pulmonal, gagal ginjal, syok hipovolemik, jaundice, edema glotis, dan ileus. Dari Oktober 2001 sampai Desember 2005, 188 anggota perang yang terluka dirawat di salah satu dari 4 pusat rehabilitasi politrauma.13 Komplikasi sebelum pasien masuk ke rehabilitasi politrauma tedapat pada Tabel 136-1. Selama fase rehabilitasi akut, terdapat komplikasi yang potensial saling tumpang tindih; tetapi beberapa pola variabel muncul, tergantung apakah cedera utama nya adalah cedera otak, saraf tulang belakang, luka bakar, atau amputasi ekstremitas. Komplikasi pada cedera otak antara lain kejang, meningitis, kekakuan, kontraktur, osifikasi heterotropik, sakit kepala, dan agitasi. Komplikasi dari cedera saraf tulang belakang ialah retensi urin, ulkus dekubitus, spastisitas, osifikasi heterotropik, trombosis vena dalam, emboli paru, osteopenia, fraktur, dan infeksi saluran kencing. Komplikasi pada luka bakar termasuk mikrostomia, kontraktur, osifikasi heterotropik, anemia, nyeri, dan kegagalan pada pencangkokan kulit. Komplikasi pada amputasi adalah nyeri phantom, nyeri stump, kontraktur, pembentukan sinus, osfikasi heterotopik, nekrosis jaringan, jatuh, fraktur, infeksi luka, edema dan hematoma.Nyeri, berkisar dari trauma, setelah operasi, neuropati, dan sakit kepala yang berhubungan dengan terbakar, hingga sindrom nyeri kroni sudah biasa terjadi pada pasien-pasien politrauma. 96% dari data pusat rehabilitasi politrauma setidaknya terdapat satu masalah nyeri.14Komplikasi yang sering dilewatkan untuk hampir seluruh pasien rehabilitasi adalah status kesehatan mental. Beberapa yang sering, termasuk depresi, gangguan stres pasca trauma, dan gangguan cemas, gangguan penyesuaian, isu-isu bentuk tubuh disregulasi emosional atau tingkah laku. Banyak atau semua dari hal tersebut dapat berefek pada pengobatan atau pemenuhan perawatan dan perbaikan secara umum.Tabel 136-1Frekuensi dan Persentasi dari komplikasi sebelum dan selama terapi PRC (N=188)

PRC, polytrauma rehabilitation center

KOMPLIKASI DARI PENATALAKSANAANBermacammacam bagian dari peralatan latihan, ortotik, prostetik, alat pengangkat beban, dan alatalat medis dan adaptif lainnya terkadang dapat menimbulkan berbagai komplikasi, baik digunakan dengan cara yang benar maupun tidak. Sebagai contoh, bidai yang digunakan pada kasus kasus terbakar untuk mencegah kontraktur sendi yang dapat menimbulkan ulkus akibat tekanan. Sindrom kompartment, cedera saraf, dan infeksi dapat berkembang dari pemakaian gips yang terkadang digunakan untuk merawat kontraktur pada populasi politrauma. Seseorang yang diamputasi mungkin berkembang menjadi iritasi pada kulit, abrasi, ulserasi, atau perubahan-perubahan lain pada kulit dari pembatas prostetik atau penahan. Pasien politrauma berisiko tinggi untuk jatuh dan cedera selama fase perawatan rehabilitasi karena berbagai faktor, termasuk polifarmasi, pengkondisian ulang, perubahan kognisi, perubahan reaksi terhadap rangsangan, agitasi, kelemahan tungkai, ketidakseimbangan, spastisitas, menopang, kelemahan, dan inkontinensia urin.Dengan politrauma yang kompleks sering terjadi nyeri yang bermakna, pada satu atau lebih lokasi; 50% atau lebih dari pasien-pasien tersebut membutuhkan opioid atau anti-inflamasi nonsteroid.14 Komplikasi opioid telah dijelaskan dengan baik diantaranya yaitu konstipasi, perubahan kognisi, somnolen, mual, muntah, kejang, efek hipothalamus, efek neuroendokrin, depresi pernapasan, toleransi, ketergantungan, dan kecanduan.15 Efek samping utama dari obat-obat anti-inflamasi nonsteroid yaitu, dispepsia, penyakit ulkus peptikus, disfungsi ginjal, perubahan fungsi hepar, perdarahan saluran pencernaan, dan kegagalan perbaikan kartilago pada osteoartritis.

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