Physiotherapy Trauma Talks
In Physiotherapy Trauma Talks we discuss the key roles that physiotherapists and other healthcare practitioners play in the management and rehabilitation of patients with traumatic injury. Experts in trauma care offer their insights about in-hospital patient care and post-discharge follow up service delivery. New research in the field of trauma care and rehabilitation is shared to provide answers to your questions.
Physiotherapy Trauma Talks
Trunk Trauma Part 3: Abdominal Injuries: Physiotherapy Interventions for Optimal Recovery
In this final episode of our three-part trunk trauma series, we explore the management of patients with abdominal trauma and the challenges it poses to rehabilitation. Whether you're a new graduate or experienced practitioner, this episode equips you with the knowledge to confidently and effectively treat these complex cases. Subscribe to Physiotherapy Trauma Talks for more insights into specialized trauma care. Podcast website: https://physiotherapytraumatalks.buzzsprout.com
Book: Cardiopulmonary Physiotherapy in Trauma: An Evidence-based Approach’ published by World Scientific: https://doi.org/10.1142/13509
Hi there, fellow physiotherapists. I am Helene van Asvegen, your host for Physiotherapy Trauma Talks, where we discuss everything related to trauma care. So if you are passionate to learn more about physiotherapy in the field of trauma to ensure that you provide the best possible care for your patients, then this is the right podcast series for you. Welcome to the last of our three-part series about trunk trauma, and in this episode we're going to talk about abdominal injury. Abdominal trauma occurs in less than 10% of all trauma cases, and I'm sure you're wondering why are we spending time discussing this topic today? Well, the incidence of abdominal trauma is definitely affected by the setting in which you work and the socioeconomic status of the population that you're dealing with. Certainly, in South Africa, we commonly see abdominal trauma, and this is often the result of blunt injury to the trunk in the form of physical assault or in the form of compression in a motor vehicle crash, where the patient's trunk is compressed between the steering wheel and the back of the seat. And you also sometimes see abdominal trauma in patients who fall from a height. In addition to this, we see abdominal trauma in patients who have been involved in penetrating injuries, so either self-inflicted with a gun or where a person has been assaulted with a foreign object like a knife. So abdominal trauma is definitely a condition that we commonly encounter in the South African public and private healthcare setting. Like other forms of trauma, the incidence of abdominal trauma in males is much higher than in females, with a ratio of 4 to 1, because of the risk-taking behavior of males in general. In blunt abdominal trauma, the organs that we find are mostly affected are the liver and the spleen and the small intestine, although some cases of large bowel perforation do occur as a result of these organ injuries. Abdominal trauma has a significant mortality rate, particularly in cases involving severe injuries to these organs, and mortality can be as high as 20% in some cases. In penetrating abdominal trauma, the organs that are injured are those that are typically in the pathway of the penetrating object, and most commonly these organs would include the small intestines, the colon and also the liver, and these injuries can lead to severe complications such as shock and infection. Lead to severe complications, such as shock and infection.
Speaker 1:So when patients with abdominal trauma are admitted to the emergency department, they would be managed again according to the advanced trauma life support sequence of primary survey, secondary survey and definitive care. So part of the diagnosis process for abdominal trauma to see which organs have been injured includes imaging technology such as ultrasound imaging and CT scanning from the emergency department. So within minutes the medical team would know which organs are injured. So we have an increase in diagnosis of abdominal injuries and this, of course, aids in the decision-making process as to whether the patient should be managed conservatively through admission to the trauma wards or the ICU and monitoring of the patient's condition, or whether they should undergo immediate surgical management. Conservative management is more commonly used nowadays if the patient's injuries are not immediately life-threatening and if the patient is hemodynamically stable. However, if bowel injury is suspected, then surgical repair will be done as soon as possible to avoid contamination of the abdominal compartment with bowel matter. Apart from the presence of bowel injury, rapid surgery will also be done if there's a high-grade solid organ injury or vascular injury, and immediate surgery in these cases is known to improve the patient's survival rate.
Speaker 1:Typically, an exploratory laparotomy incision is made so that the surgeon has got good visual access to the abdominal compartment and the ability to explore with their hands to see which organs have been injured and where repairs need to be done. The vertical abdominal incision that is made for an exploratory laparotomy extends from the tip of the sternum all the way down to the pubic ramus, so it's a long abdominal incision. During the surgery the intra-abdominal organs would be surgically repaired. Any points of bleeding will be managed and contamination will be contained by removing any bowel matter from the abdominal compartment and, where possible, all dead and contaminated tissues are removed or excised to leave healthy tissue behind before the laparotomy wound is closed.
Speaker 1:In cases where a patient is exceedingly unstable from a hemodynamic point of view, damage control surgery is done. So this means that there is a staged approach to repair of damaged abdominal organs. So initially the surgeon would aim to only stop the internal bleeding and to control bowel urine and pancreatic contamination within the abdominal compartment compartment. If they are happy that they've stopped the bleeding, the visceral cavity is then packed with swabs to control capillary oozing and the solid organs are either resected or packed with swabs as well to stop the bleeding, while the abdominal wall is left open and only temporarily covered with wound dressings and drainage tubes, and the patient is then taken to the ICU to be stabilized and then, only 24 to 48 hours after the initial injury, the patient will be taken back to theatre for formal repair to the bowel and any organs that are injured, to ensure that any dead tissue is further removed and any further contamination is managed.
Speaker 1:The damage control surgery often involves repeated procedures in theatre. So we would often see a patient lying in the intensive care unit with an open abdomen that is only temporarily covered and the drainage tubes that facilitate drainage of contaminated fluid from the abdominal compartment for several days to weeks until the surgeons are satisfied that with the repeated trips to theatre, all of the injuries have been dealt with effectively. At that stage the abdominal wall is then closed, but it cannot be closed when there is excessive swelling of the intra-abdominal organs, so it may need a staged approach to closure. So when there is increased intra-abdominal swelling or intra-abdominal pressure, the surgeons may delay the closure of the wound completely, and in severe cases a skin graft would need to be done to eventually close the abdominal wound, and this is usually done several months after the initial surgery took place. An important challenge associated with abdominal trauma is delayed diagnosis. Inj injuries may not manifest immediately, leading to delayed diagnosis and increased risk of complications such as sepsis and peritonitis.
Speaker 1:Unplanned laparotomy becomes necessary in the presence of intra-abdominal sepsis, intra-abdominal bleeding, missed injuries, small bowel obstruction and fluid leaks at anastomosis sites. Patients who need an unplanned laparotomy have a higher mortality rate than those who don't need further surgery and therefore these patients would need priority care from a physiotherapy point of view to try and curb respiratory complications around the unplanned surgery as much as possible. In patients who need to undergo repeated laparotomy procedures, part of wound care may include negative pressure wound therapy and the aim is to remove infectious material from the wound site, to promote the formulation of granulation tissue and to draw the wound edges closer together. So these patients would typically have a black colored sponge that is packed into the abdominal wound. It has got a drainage tube that sits in the middle of the sponge and the sponge is secured in the abdominal region through clear wound dressing. So these patients are usually attached to a vacuum suction bottle that helps to extract the infectious material from the abdominal compartment. So from a physiotherapy point of view, when we mobilize these patients, we need to just make sure that there's no pulling on these wound drains during activity.
Speaker 1:Wound drains during activity so patients who sustained abdominal trauma often present with hypotension, especially in severe cases of trauma where there was a lot of internal bleeding. So it is important to monitor your patient's blood pressure and to see whether it is safe from a hemodynamic point of view to mobilize the patient out of bed. It's also important to look out for signs of postural hypotension, so in other words the signs that the patient is at risk of fainting when coming up from a supine position into a sitting or a standing position. So careful monitoring of the patient's blood pressure, their response to activity, is very important to reduce their risk of falls.
Speaker 1:Patients who sustained abdominal injuries often present with swelling, especially when surgery was done. So there is increased intra-abdominal pressure and this has got a negative effect on the function of the lungs because it causes compression of the basal lung regions and prevents the normal excursion of the diaphragm during breathing. So these patients often develop decreased lung compliance, they have a more shallow breathing pattern and their respiratory rate would be higher. In severe cases patients may even be at risk of respiratory failure and the need for intubation and mechanical ventilation. So because the lung compliance is decreased and the depth of breathing is affected, these patients present with decreased oxygen saturation because of these factors, as well as the potential loss of lung volume within the anterior, posterior and lateral basal lung segments. So there is a risk of atelectasis developing as a result of intra-abdominal swelling.
Speaker 1:One of the main causes of complications developing in patients with abdominal injury and those that needed abdominal surgery is the pain associated with the injury and the operative procedures. Pain would lead to patients having a poor cough effort and retention of secretions and therefore the risk of developing pneumonia is much higher. It also leads to altered gas exchange and poor oxygenation. The increased intra-abdominal pressure may put patients at risk of poor perfusion of the kidneys and subsequent renal failure, especially if the intra-abdominal pressure is sustained over several days or weeks. So it's important to look at your patient's fluid balance to see whether there are any signs of renal failure or not and, if there are, to become more vigilant in screening the patient for the presence of pulmonary edema, which we've discussed in previous episodes and which we know is often a contraindication to physiotherapy. Because of the increased removal of surfactant from the lungs and the risk of atelectasis developing.
Speaker 1:Patients with these types of injuries often require several days of bed rest, and those who are undergoing damage control surgery will often have a prolonged stay within the ICU. So they will present typically with generalized muscle weakness weakness of the respiratory muscles if they were on prolonged mechanical ventilation and therefore the risk of developing ICU-acquired weakness, particularly for those who have gone through episodes of abdominal sepsis. So it's important to think about muscle strengthening for the peripheral muscles, but particularly for the respiratory muscles, so that we can aid in successful weaning of patients from mechanical ventilation when they are ready and able to breathe on their own sustain. These type of injuries will have some emotional impairments because of the fact that they were involved in a traumatic event. They may also have some cognitive dysfunction because of the prolonged stay within the hospital and both of these will impact on their recovery, will impact on their recovery. So what can we do as physiotherapists to assist these patients through their journey to recovery While they are in the intensive care unit, the high care unit or the trauma ward?
Speaker 1:It is really important to prioritize screening for respiratory complications and to try and reduce the risk of these complications as much as possible. So if you have a patient with retained secretions that they're struggling to cough and clear on their own, consider introducing humidification therapy and nebulizer therapy to facilitate with mobilization of the secretions. So putting into your nebulizer therapy to facilitate with mobilization of the secretions. So putting into your nebulizer device a normal saline, the 0.9% sodium chloride, and administering this before the start of your physiotherapy treatment session. And if you find that the normal saline is not effective enough, it is worth discussing with the trauma team to prescribe another type of mucolytic like mesna that we can also administer via nebulizer.
Speaker 1:Your patient how to do active huffing and coughing, but of course always with support to the laparotomy incision site if your patient had surgery, and also support to the abdominal compartment, even if the patient is managed conservatively, because there would be bruising and discomfort and swelling of the abdominal organs anyway. So to get a proper and strong cough effort from the patient, it is important to educate them about wound support. Deep breathing exercises should form part of your physiotherapy management on a daily basis, encouraging deep breathing into the basal lung segments and doing this in a seated position, over the side of the bed or in standing if sitting for a longer period of time is too uncomfortable for the patient. At that point you can also consider using strategies such as incentive spirometry to facilitate deep inspiratory breaths and oscillating positive expiratory pressure therapy to encourage opening of the airways at the end of expiration to improve lung capacity and volumes If your patient is on mechanical ventilation and you found through your assessment that they have got a loss of lung volume in the lower segments of the lung.
Speaker 1:Consider using manual hyperinflation or ventilator hyperinflation as part of your physiotherapy intervention to try and re-expand those areas of the lung and to facilitate with clearance of secretions from those lower parts of the lung, because these patients do not have a strong cough effort. There are always sputum plugs that are mobilized out of the lungs with manual hyperinflation, to the surprise of physiotherapists when they include this in their patient management. So it's an important strategy to consider to include in your management, and you can discuss the appropriateness of including these two hyperinflation techniques in your patient management with the trauma surgeon beforehand. And then various strategies for respiratory muscle strength training exist, so any of these can be used to encourage the patient to strengthen their inspiratory muscles as they breathe against resistance applied to the chest wall. But this should only be started after the abdominal wound has been closed.
Speaker 1:So I mentioned earlier the importance of educating your patient on how to support their abdominal compartment or laparotomy incision sites when they cough or when they sneeze, and this can be done with manual support over the wound or on the sides of the wound, and also teaching your patient to use a rolled up towel or a pillow placed over the wound and then they wrap their arms around that in order to provide more support there when they cough or sneeze, and then also educate them on how to get out of bed in a way that places the least amount of strain on the laparotomy incision site, and this should be done through encouraging your patient to roll onto their side and then to get into a sitting position over the side of the bed by dropping their feet over the side of the bed and pushing up with their arms from side lying until they come into a seated position. This places less strain on the laparotomy than if you were to get your patient to just sit up directly from a supine position. It is important to engage in conversation with your patient, to set functional goals with them that are realistic and achievable, and maybe start with easier activities initially and progress accordingly with your patient as they get stronger and have less pain over the next few days. It is really important to discuss with them the importance of rehabilitation and exercise therapy while they are in the ward, and it is important to also discuss how to progress with these interventions after they leave the hospital. Early out-of-bed movement and mobilization away from the bedside should be prioritized, and this is important not just to improve pulmonary function and get better ventilation through the lungs, but it is also important to encourage bowel activity and to prevent the formation of paralytic ileus, so that your patient has a faster recovery and discharge planning.
Speaker 1:When treating these patients, it's very important that we collaborate with the trauma team. So have discussions with the surgeons, the nurses, the occupational therapists and dieticians about your plan for the patient, but also their plans for the management of the patient, to make sure that the patient receives comprehensive care of the patient, to make sure that the patient receives comprehensive care. So let's look a little bit closer at the precautions that we need to take with physiotherapy management of these types of patients, and the first one is to make sure that they receive adequate pain relief at least half an hour prior to your physiotherapy treatment session, and this is if they are not on continuous analgesia through IV administration at that stage. So assess the patient's level of pain before your treatment and also reassess the level of pain throughout the treatment and manage your patient accordingly. Acknowledge that what they are going through is painful, but also ensure that they understand why you are there and why your treatment interventions would help them to a faster recovery.
Speaker 1:We mentioned earlier the damage control surgery and the drainage tubes that normally are placed within the abdominal cavity. So as you move your patient, make sure that you know where those tubes are and that they don't accidentally pull out. So make sure that the patient carries whatever drainage bags they have with them if you mobilize them away from the bed and that those don't get stepped on or cause excessive pulling on the wound. So awareness about drainage tubes is very important. It's always important to screen your patient's hemodynamic stability over the previous 24 hours before you do exercise, therapy or out-of-beat mobilization. There are cases where patients develop a sudden drop in hemoglobin if they have got internal bleeding that suddenly started overnight or during the course of the day. So always monitor for hemodynamic stability and the patient's hemoglobin levels. We've mentioned already renal function. That could deteriorate and lead to the development of pulmonary edema. So make sure that you are vigilant in screening for that.
Speaker 1:And then, if the patient is nursed in ICU with an open abdomen due to damage control surgery or due to abdominal sepsis that developed and required laparotomy procedures in theater, again, obtain permission from the surgeon before you do any mobilisation activities with the patient, and these patients may not be allowed to mobilise for several days because of the amount of swelling within the abdominal cavity. So then just discuss positioning the patient in a head-up tilt of around 20 to 25 degrees to at least prevent aspiration into the lungs. And then, in cases where the patient has had an open abdomen for several weeks, the surgeons may request that you start mobilizing the patient out of bed before the abdominal wall was closed surgically, out of bed before the abdominal wall was closed surgically. In these cases, it always helps to speak to the orthotist and to get an abdominal binder for the patient so that it can keep all the abdominal content supported as we start mobilizing the patient out of bed. In these cases, again, vigilance for postural hypotension and hemodynamic stability is very important.
Speaker 1:As with all things, if you are unsure about what would be safe to do or not, speak to the trauma surgeon and to your senior physiotherapist that might be working with you in the unit block. And before we mobilize them out of bed, it is important to perform a motor assessment so to see how strong their limbs are, before we start thinking about mobilization by the bedside. So remember to do muscle strength testing for these patients and then, very importantly, for any patient who had a laparotomy incision, we do not do any resisted hip exercises, like straight leg raises, for instance, or resisted hip flexion exercises, until the wound has been successfully closed. This is to avoid any strain on the abdominal wound as it is healing after surgery. We discussed a little bit earlier about the fact that patients may develop increased intra-abdominal pressure when they've had repeated laparotomy procedures.
Speaker 1:So after closure of a prolonged open abdomen, there is a risk of development of abdominal compartment syndrome and in this case physiotherapy intervention is not indicated. So make sure to have regular discussions with a surgeon and ask about the risk of abdominal compartment syndrome when they have surgically closed a wound that has been open for a prolonged period of time. So when it comes to discharge planning, continued education of the patient, particularly about their home exercise program, is important and include in this education about wound care and what the patient needs to look out for with regard to wound discharge and opening of the wound, and when they need to come back to the hospital for follow-up if these scenarios arise. It's always good after discharge to follow the patient up telephonically after several weeks to find out whether they still present with limitations in function and whether maybe they have developed signs and symptoms of post-intensive care syndrome. So in these cases it's important to make an appointment to see the patient to do a thorough assessment of them and then to include any other healthcare services that they may be in need of through formal referral. So we don't tend to see all patients who had abdominal injuries on a regular basis after hospital discharge, but those that do have impairments in their recovery would need such intervention so that we can improve their recovery and return to work as soon as possible and to improve their quality of life to a higher level than what they had after hospital discharge. So also investigate whether there are support groups in the area where the patient lives that they could attend for counseling, or refer them to a psychologist for one-to-one counseling if the patient expresses the need.
Speaker 1:I remember years ago we had a patient come into the hospital with abdominal trauma. This person was out at night and went and visited a club with some of his friends. Went and visited a club with some of his friends and when they were on their way home they were stopped by people who assaulted them because they wanted to rob them. So this 32-year-old man was stabbed 22 times in his trunk and several of these injuries were to his abdominal compartment. Of these injuries were to his abdominal compartment. So he was admitted because of his severe hemodynamic instability. He underwent damage control surgery to have his spleen removed and to stop the internal bleeding and had two more repeat laparotomy procedures for small bowel repair and to remove the infective matter that developed because he had sepsis in his abdomen as well. So he was eventually extubated after 26 days on mechanical ventilation and then made a fairly good recovery and was discharged two weeks later.
Speaker 1:Made a fairly good recovery and was discharged two weeks later.
Speaker 1:And when I followed him up at three months after discharge he mentioned to me that he is just so grateful to be alive and that he doesn't worry too much about his physical limitations at that point because he is very grateful to have a second chance at life, to have cheated death. So it was so encouraging to walk the journey with this patient towards full recovery, particularly because of his positive mindset and his willingness to continue with physiotherapy rehabilitation long after discharge from the hospital. So many of these cases can be quite inspiring from a physiotherapy rehabilitation point of view. So, in conclusion, I would like to say that we need to just be vigilant with these patients to make sure that we communicate properly with the multidisciplinary team looking after the patient about our plans, make sure that whatever intervention we use is safe and effective and that we think about rehabilitation after discharge and prepare the patient accordingly, charge and prepare the patient accordingly. So thank you for your interest in this episode, thank you for your continued interest in our podcast series and I'll see you next time.
