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

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

3. Case History  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

4. Trauma CT

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

9. Follow up CT

11. Gastric appearances

12. Angiogram

13. What Happened next?

14. 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

15. 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

16. Benign Paraoxysmal Positional Vertigo

17. Orthostatic Hypotension

18. 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.

19. 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

20. Epley’s Manouvre

21. 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

22. 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

23. 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….)

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

25. 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

26. 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

27. Limitations of current processes ‘We’ve had no help at all since being at home” Comment from Mrs Willis 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

29. 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

30. Thank you!