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
Understanding the Body's Response to Trauma
Ever wondered how trauma affects the body on multiple levels, or why early rehabilitation is crucial for optimal healing? This episode sheds light on these questions, emphasizing the unexpected nature of trauma and the widespread challenges it presents physically, emotionally, cognitively, and socially. The discussion highlights the importance of holistic care, understanding the metabolic response to injury, and implementing strategies for effective rehabilitation.
• Defining trauma and its unexpected nature
• Physiological response to injury and blood loss
• Importance of hemostasis in wound healing
• Complications arising from blood loss
• Metabolic phases post-injury: ebb, flow, recovery
• Role of inflammation and cytokines in trauma
• Effects on musculoskeletal function and rehabilitation
• Key considerations for physiotherapy management
• Importance of addressing cognitive and emotional recovery
Hi there, fellow physiotherapists. I am Helene van Aswegen, 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. In this episode, we are going to take a closer look at how injury affects the body. We know that trauma, by its very nature, is unexpected, although in some cases it may be self-inflicted. But most of us don't plan to be involved in a traumatic event when we leave our homes in the morning to go to work or to meet up with friends and family. Because trauma is so unexpected, it can affect anyone, from children to adults in the prime of their economically productive lives and older people, and therefore some of the patients that we see in the trauma setting may have a good health and others may present with comorbidities. The incidence of traumatic injury rises year on year and in June 2024, the World Health Organization reported that unintentional and intentional injury takes the lives of more than 4 million people worldwide. In children, trauma accounts for more childhood deaths than measles, diphtheria, polio, pertussis and tetanus combined. Therefore, trauma is rightly referred to as an epidemic on a worldwide level. Injury which is inflicted on the body impacts a person not just physically, but also on an emotional and cognitive and social level, so it has a true biopsychosocial impact on a person's life. As a result of injury, patients may also develop symptoms related to post-traumatic stress syndrome and post-intensive care syndrome, leading to cognitive function impairments that may persist for months to years after injury. They may also need to develop a new self-identity due to disfigurement inflicted by the injuries that they sustained, and this can impact on their family dynamics, relationships with others and lead to social isolation. In one of our future episodes, we will learn how psychology can assist patients with these problems. It is therefore our responsibility, as physiotherapists who work in trauma care, to share our knowledge and insights about this field of the profession with each other to ensure that we provide the best possible holistic care to our patients as they recover from their injuries.
Speaker 1:I am going to share with you my understanding of how injury affects the body and how these concepts have influenced my approach to patient care. As you listen to the rest of this episode, remember that I'm a physiotherapist, not a physiologist, so if I get something wrong. Don't judge me too harshly. I am sure you agree with me that injury to the body leads to blood loss, pain and a metabolic response. Blood loss can be internal, due to organ injury, or external, due to open skin wounds or bony fragments that protrude through the skin. Pain experienced varies in intensity depending on the amount of tissue injury that the patient sustained, but it is also dependent on other factors such as age, the emotional state of the person at the time of injury and the subsequent surgery received. Pain and pain management in trauma care will be discussed in our next episode with Professor Romy Parker, so make sure to tune in for that.
Speaker 1:In this episode we focus more on blood loss and the metabolic response to injury. Blood loss occurs at the time of injury, but in the hospital, patients experience further blood loss through test procedures such as full blood count measures and arterial blood gas measurements, the placement of lines for monitoring of the patient's condition and drug administration, and through the subsequent surgeries that they receive to manage the injuries. We have all injured ourselves at some point in our lives. For example, when you accidentally cut yourself as you prepare a meal. The normal physiological response to injury and active bleeding is vasoconstriction, which happens within 20 seconds after injury is sustained to the vascular wall. The aim of this is to reduce blood flow to limit blood loss.
Speaker 1:Next in the sequence of events is the endothelial cells from the damaged blood vessels that activate platelet formation. The circulating platelets start adhering to the blood vessel walls at the site of injury to initiate a clot. The blood vessel walls at the site of injury to initiate a clot. A series of enzyme reactions then occur to produce the enzyme thrombin, which is the key enzyme for facilitating blood clotting or coagulation, and the average time for blood to start clotting is 10 to 13 seconds. Fibrin is lastly produced to form a stable clot. All of these interactions occur to maintain the integrity of the circulatory system and to stop blood loss, and this is the first stage of wound healing and is commonly referred to as hemostasis. When bleeding has stopped.
Speaker 1:The next step in wound healing is fibrinolysis. This is the process that helps to restore blood flow through the previously injured area. It starts with the endothelial cells that secrete tissue plasminogen activator to dissolve the blood clot. Plasminogen breaks up the fibrin in the clot and dissolves the clot to restore blood flow. Fibrinolysis takes several hours or days to be completed and, in essence, restores hemostatic balance. So this is how our bodies respond to injury and blood loss under normal circumstances due to minor injury. Traumatic injury of moderate to severe intensity triggers inflammation throughout the body and disrupts this normal process of obtaining hemostatic balance, and this leads to uncontrolled bleeding and uncontrolled thrombus or blood clot formation.
Speaker 1:Venous thromboembolism is a well-known complication that develops in adults and children after traumatic injury and puts them at risk of developing deep venous thrombosis or pulmonary embolism. The risk for developing these complications is higher in patients with lower limb fractures, those of older age with poor perfusion or prolonged immobility, and to have a central venous pressure line in situ. So how do organs in the body respond to blood loss? Respond to blood loss when 15 to 30 percent of total blood volume is lost, a patient presents with elevated heart rate and diastolic blood pressure, and the diastolic blood pressure is high because of the vasoconstriction which is the normal part of hemostasis that we discussed previously. The patient may also have an increased respiratory rate, higher than 20 breaths per minute, due to lack of tissue oxygenation. Their extremities will be cold to touch and they may present with peripheral cyanosis.
Speaker 1:The kidneys are affected through developing oliguria or a reduction in urine production because of poor kidney perfusion, from the lower circulating blood volume or the production of antidiuretic hormone and aldosterone production. Antidiuretic hormone causes the kidneys to release less water and decreasing the amount of urine produced. Aldosterone signals the kidneys and the colon to release more sodium into the blood circulation and thereby causes the body to retain water to increase the circulating blood volume. The circulating blood volume, the skeletal muscles and splanchnic organs such as gastrointestinal tract, the liver, the pancreas and the spleen are all adversely affected by oxygen deprivation. So impairment in function becomes obvious.
Speaker 1:If 30 to 40 percent of total blood volume is lost, the patient presents with tachycardia and a drop in systolic and diastolic blood pressure, together with persistently high respiratory rate. They may have a pale appearance and poor peripheral circulation and at this stage the kidneys stop producing urine altogether. The patient may develop mental confusion and anxiety. In the worst case scenario, where more than 40% of total blood volume is lost, the patient presents with bradycardia and, in extreme situations, an unrecordable blood pressure, and is often unresponsive. So from the time that the paramedics find the patient at the scene of the accident to the time that they drop them at the emergency department of the nearest hospital and the trauma surgeons take over. Their main priority of care is to stop active bleeding and limit the amount of total blood lost from the patient's circulation.
Speaker 1:The reason for this is because inadequate restoration of the circulating blood volume through fluid administration and the administration of blood products is the associated development of widespread inflammation and the release of inflammatory cytokines throughout the patient's circulatory system. Throughout the patient's circulatory system. I'm sure you've heard of the term, the development of a cytokine storm, and this refers to the fact that more pro-inflammatory cytokines are released in this hyper-inflammatory stage and less anti-inflammatory cytokines are produced. So there's not enough cytokines to suppress the pro-inflammatory cytokine activity. In the days following the traumatic injury, patients may develop generalized edema, and there are two processes that are responsible for this development of edema. The first is this increased pro-inflammatory cytokine activity that leads to membrane injury of many vessels in the body and causes leakage of plasma into the interstitium and loss of circulating volume within the vascular system, leading to generalized edema. Just to refresh our memories, the interstitium is an intricate web of living spaces throughout the body that looks almost like a honeycomb network of fluid-filled openings within and between the tissues and the organs that span the body and acts as a thoroughfare. So with the increase in pro-inflammatory cytokine activity, more fluid leaks into these spaces in the interstitium and less are maintained within the vascular system, leading to generalized edema. Leading to generalized edema. The second process in the development of generalized edema is that albumin, which is produced by the liver and is the most abundant plasma protein, responsible for maintaining oncotic pressure, is suppressed in its production. So this is a consequence of the heightened pro-inflammatory cytokine activity. But also acute kidney injury due to trauma leads to albumin being excreted through the urine and therefore we get a loss of albumin from the vascular system. The increased vascular permeability that occurs in the presence of burns and in the presence of sepsis also leads to a loss of albumin into the extravascular spaces. Complications associated with hypoalbuminemia include anisarka, and that is this massive generalized edema that we've been talking about.
Speaker 1:Because of blood loss and the displacement of fluid from the vascular system into the extravascular spaces, which we've just discussed, many patients with traumatic injury are at risk of developing a state of shock. Those that develop shock have delayed mitochondrial activity and cell functioning becomes impaired. So many patients who are in shock also develop lactic acidosis as a result, because of the widespread inadequate tissue perfusion. So often, when you look at these patients' arterial blood gases, they will present with metabolic acidosis. The types of shock that may develop is firstly, hypovolemic shock, which is blood loss from organ or tissue injury or loss of blood plasma through burn injuries, and hypovolemic shock is seen in patients who have more than 20% of their total blood volume lost.
Speaker 1:Another form of shock is obstructive shock, and an example is obstruction to cardiac filling because of cardiac tamponade resulting from injury to the heart through penetrating trauma or due to attention pneumothorax. That obstructs cardiac filling. Next we get distributive shock, or also known as vasodilatory shock, and this is where peripheral vascular dilatation causes a drop in the systemic vascular resistance and therefore inadequate return of blood to the heart, the kidneys and the brain, and this is caused by one of three types of shock. The first cause of distributive shock is neurogenic shock, and this is where we have loss of sympathetic control of the blood vessels, resulting in massive dilatation of the arterioles and the venules throughout the body and less return of the blood to the heart, and this is often encountered in patients with acute spinal cord injury or traumatic brain injury. The second cause of distributive shock is anaphylactic shock, and this is an allergic reaction to blood products or drugs administered to the patient during resuscitation in the emergency department or in theatre or in the ICU. And the third cause of distributive shock is septic shock, which is the systemic response of the body to gram-negative or gram-positive bacterial or fungal infections, and it develops in the later stages of their hospital stay.
Speaker 1:Septic shock is a severe form of sepsis where multiple chemicals, including cytokines, nitric oxide, reactive oxygen species and vasodilators, are released into the bloodstream and cause damage to organs and tissues. Oxygen consumption is therefore reduced or impaired at cellular and tissue level. These patients can proceed and develop a condition called disseminated intravascular coagulation, which leads to spontaneous bleeding from the organs, the tissues, the cavities and sites in the body where lines are inserted, and at the same time you get the formation of microvascular thrombi. So disseminated intravascular coagulation can simultaneously lead to spontaneous bleeding and thrombus formation. Multiple organ dysfunction syndrome often ensues and the patient's prospect of survival is impaired.
Speaker 1:Another form of shock that is seen in patients with traumatic injury is cardiogenic shock, and this is often when the left ventricle function is impaired by injury such as contusion of the heart during a motor vehicle accident or during falls from a height. This impaired left ventricle function can lead to decreased stroke volume and cardiac output, low blood pressure and inadequate tissue perfusion. And the last form of shock that we see in patients with traumatic injury is refractory or irreversible shock. This signals organ failure despite the administration of adequate therapy, and brain damage and cell death often occurs at this stage. So, to summarize, traumatic injury impacts how the body responds to blood loss, and moderate to severe injury often leads to impairment of the normal hemostasis of the body.
Speaker 1:The amount of blood lost from the body impacts the function of the kidneys, the cardiovascular system, the brain, the splanchnic organs and the skeletal muscles. Blood loss leads to an inflammatory response throughout the body, which becomes a heightened pro-inflammatory response with a suppressed anti-inflammatory response, commonly referred to as the cytokine storm. This cytokine storm causes damage to many of the blood vessels throughout the body, leading to leakage of plasma and fluids into the extravascular spaces, and patients develop generalized edema. Depending on the amount of blood loss and other reactions throughout the body due to traumatic injury, blood loss and the patient's response to the inflammatory reactions throughout the body, many patients with traumatic injury may present with a state of shock.
Speaker 1:So let's take a look at the metabolic response to injury, which begins within several hours after injury and is made up of three phases the ebb phase, the flow phase and the recovery phase. The ebb phase is characterized by hypometabolism, reduced oxygen consumption and decreased cardiac output to conserve energy immediately after the traumatic event. It is short in duration and has limited clinical relevance. The flow phase is characterized by hypermetabolism, increased oxygen consumption and elevated cardiac output to support the body's increased energy needs for healing and immune response. It occurs after resuscitation from a state of shock has been completed and is known as a state of hypercatabolism, and leads to severe complications after major trauma. The recovery phase is where the body gradually returns to normal metabolic function, focusing on tissue repair and regeneration, and takes place over several months after injury.
Speaker 1:An aspect of the flow phase is a hormone response to injury. This is an increase in production of growth hormone, cortisol and catecholamines, and less insulin that is released through the blood circulation, and the purpose of this hormonal response is to mobilize energy stores in the body to be available during the flow phase. These energy stores are accessed through a process of gluconeogenesis, which is the creation of glucose from stored fats and proteins. We also get lipolysis, which is the release of glycerol and fatty acids into the system, and there's also massive muscle protein breakdown leading to hypoproteinemia, and all of these mechanisms contribute to the stress response of the body after injury.
Speaker 1:Another important aspect of the metabolic response to injury is the cytokine release, and we've already touched on it when we discussed the cytokine storm. The overactivity of the pro-inflammatory cytokines and underactivity of the anti-inflammatory cytokines cause a heightened level of inflammation throughout the body that can predispose the patient to developing systemic inflammatory response syndrome, and in this case the patient's immune system falls into disarray and they become susceptible to infection, which increases their risk of developing sepsis and, ultimately, multiple organ dysfunction syndrome and failure. This immunosuppression is also associated with a hypercatabolism of the flow phase after injury. The musculoskeletal changes that take place as a result of inflammation is particularly important for us as physiotherapists to understand, and these include myopathy or muscle fiber dysfunction, decreased muscle myofilament function, the muscle protein breakdown that we've discussed already, and an atrophic appearance to the muscles. Sepsis is directly related to the development of peripheral and respiratory muscle myopathy. So patients in the trauma ICU or ward don't only develop an atrophic appearance because they are immobile as they await surgery or need time to stabilize after severe injury, but also because of the impact of this cytokine imbalance, the release of inflammatory mediators and the development of sepsis on their musculoskeletal function.
Speaker 1:Another consequence of the metabolic response to injury is the development of insulin resistance, leading to raised blood glucose levels. This hyperglycemia is directly related to the patient's risk of mortality after traumatic injury. So patients in the trauma ICU receive insulin therapy, not because they are necessarily diabetic, but in an attempt to maintain a normal range of blood glucose to improve the patient's clinical outcomes and reduce the risk of mortality. Nutritional support is therefore a very important part of the management of patients with traumatic injury, and in one of our future episodes we will be discussing the role of the dietician in the management of patients with injury. So stay tuned for that episode.
Speaker 1:So how does all of this relate to us as physiotherapists? You'll remember, at the beginning of this episode I mentioned that trauma affects anyone, so an important element of your patient assessment is to ensure that you identify all the comorbidities that they may present with and, as soon as they are awake and able to respond to you, it is important to find out how they manage their comorbidities on a daily basis and then include any appropriate education to the patient about the management of their chronic diseases as you do a holistic treatment plan for this patient. It is also very important to establish the patient's cardiovascular stability before we do treatment. As you can imagine, those patients who are in a state of shock may not be appropriate for physiotherapy intervention until they have stabilized. Another aspect of physiotherapy assessment is to understand the patient's blood gas results. Remember that patients who are in a state of shock may present with metabolic acidosis, and the respiratory system response to metabolic acidosis is hyperventilation. So make a mental note that while your patient is in a metabolic acidosis state, it may not be possible to normalize such patient's breathing pattern until their metabolic acidosis has been reversed.
Speaker 1:With regards to the patient's risk of spontaneous bleeding, it is important to understand the patient's platelet levels. The platelet count is used to tell us whether the patient's blood is clotting normally or not, so make sure that you monitor this on a daily basis, especially for patients with more severe injury, to determine if it is safe to proceed with treatment. Your local laboratory should have the normal platelet range values available for you in order to make a judgment regarding the patient's blood clotting. It is also important to consider whether the clotting time is normal or not, and this is identified through the patient's prothrombin time and international normalized ratio, or INR counts. Again consult your local laboratory for the normal values for these parameters. A patient that presents with persistently low platelet counts and high PT and INR levels are at a high risk of spontaneous bleeding and therefore it's important to discuss with the trauma team the appropriateness of physiotherapy intervention at that stage.
Speaker 1:Blood loss can affect the patient's hemoglobin levels and have an impact on oxygenation at tissue level. So patients with a sudden drop in hemoglobin count may present with sudden internal bleeding. In these cases it is important to withhold physiotherapy treatment until the cause of the bleeding had been identified and has been appropriately managed by the trauma team. Again consult your laboratory in your hospital for the normal hemoglobin counts.
Speaker 1:It is important to assess the quality of the patient's peripheral circulation, particularly for those patients who lost a large volume of blood. Who lost a large volume of blood. So a capillary refill test can be done to assess the quality of the patient's peripheral circulation, and this test involves applying a small amount of pressure to the tip of the finger until it becomes white and then releasing the pressure and counting the number of seconds that it takes for the red coloration to return and normally, within three seconds, the capillary refill should have taken place and the red color at the fingertip returned to normal. Remember that patients who present with generalized edema have developed this edema because of kidney dysfunction and low albumin levels in the circulating blood and therefore physiotherapy intervention to reduce the edema is very limited. However, if a patient has got localized edema around a joint as a result of their injuries, this can be managed with elevation of the limb and gentle circulation exercises if appropriate.
Speaker 1:Patients who survived sepsis present with more peripheral and respiratory muscle weakness due to the factors that we've already discussed, and therefore it is important to assist the strength of these muscles, to put in place an appropriate strength training program to assist with weaning these patients off mechanical ventilation as soon as possible.
Speaker 1:And then early rehabilitation for patients with traumatic injury should always be at the forefront of our mind, always be at the forefront of our mind, and we should implement appropriate early rehabilitation exercises during patients' sedation vacations and after their sedation is stopped and they are able to cooperate with you as we end off. I hope that I have given you some food for thought about the effects of traumatic injury on the body and what to consider in your approach to patient care. If you have any comments or questions about this episode, please send me an email using the contact details shared in the show notes. I'd love to hear from you. Join me next time when I discuss pain and pain management in trauma care with Professor Romy Parker, director of the Pain Management Unit at the University of Cape Town.
