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 1: Penetrating Chest Injury and Physiotherapy
Thoracic trauma affects over 60% of trauma cases worldwide, with penetrating injuries presenting unique challenges. The damage to the thorax ranges from localized tissue injury in stab wounds to extensive internal devastation from high-velocity bullets that create shock waves and cavity formation throughout the chest. By understanding the pathophysiology of penetrating chest trauma and implementing evidence-based interventions, physiotherapists transform outcomes for these critically injured patients.
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. Good morning everyone and welcome back to Physiotherapy Trauma Talks. Today we start a new series of three episodes about the topic of trunk trauma, and in today's episode we are going to discuss penetrating chest trauma and the role of physiotherapy in managing such patients. So let's start.
Speaker 1:Traumatic injury remains a significant cause of morbidity and mortality in patients across the world, and it's been reported that more than 60% of trauma cases also include injury to the thorax. Thoracic trauma is classified according to the site of injury, so it can be skeletal, where there's fractures to the ribs or to the sternum. It can include injury to the lungs through lung laceration or lung contusion. It can also lead to injuries of the heart, and the great vessels of the thorax and the diaphragm may be injured through the penetrating injury. So thoracic injury, together with other traumatic injuries, increase the morbidity and mortality of patients exponentially, and this is because of the pain and the shortness of breath that follows thoracic injury. That predisposes a patient to developing complications that lead to a prolonged stay in the hospital and eventually a poor quality of life for months after the injury.
Speaker 1:Chest trauma can either be blunt or penetrating. In this episode we are going to discuss penetrating chest trauma only, and in the next episode we have a special guest, professor Kerry Battle from Swansea in Wales, who will be joining the discussion about blunt chest trauma. Who will be joining the discussion about blunt chest trauma? So as we continue the discussion about penetrating injury to the chest, it is important to remember that the forces that are applied to the chest during these type of injuries are distributed over a small area of the body and the organs injured are usually those that lie in the path of the penetrating object. Penetrating chest injury leads to loss of the negative intrapleural pressure that helps to stick the lung tissue to the chest wall and prevent it from internally collapsing on itself. So that negative intrapleural pressure is lost with a penetrating chest injury, as pressure enters into the intrapleural space and subsequently leads to collapse of the lung segments.
Speaker 1:Because of this inherent elastic recoil properties of the lung tissue, penetrating thoracic injury can be lethal, particularly if it involves the heart and the great vessels of the thorax, and therefore needs to be managed timely. Generally, penetrating injury to the thorax is often associated with the abuse of alcohol and use of illegal substances that lead to interpersonal conflict and causes the use of knives or machetes, or bullets from handguns in these confrontational situations that then lead to injury of the thorax. Suicide attempts that involve the use of guns may also lead to penetrating chest trauma, as well as flying debris and shrapnel from blast injuries, so during explosions, for instance, women and children who are in situations of domestic abuse may also sustain penetrating trauma as a result of the violence at home. So, because of these different causes of penetrating trauma, the extent of damage caused to the chest by penetrating objects depends on the shape, the size and the energy transfer potential of the object, as well as the distance between the person and the penetrating object. So, for instance, civilian gunshot wounds or stab wounds cause low energy penetrating trauma and only damages the tissues with which they come into direct contact. However, if disintegrating bullets were used in a handgun, it may cause more extensive damage as the bullet moves through the body. Axe and machete wounds may cause extensive superficial tissue damage that look horrendous but may not always lead to a great deal of internal injury and the patient has a good chance of successful recovery. The patient has a good chance of successful recovery. Fragments from explosive devices like grenades and bombs or bullets from machine guns cause high energy injuries. With these injuries, as the bullet enters the body, it causes the formation of shock waves and cavity formation behind the bullet, and it also entrains dust, particles and organisms in the surrounding atmosphere into this cavity that forms behind the bullet or this funnel, if you want, and it becomes entrapped within the body as the tissue closes with the subsiding shock waves and then are retained within the body and may lead to the development of infection soon after the injury took place.
Speaker 1:Patients with chest trauma are managed according to the advanced life support guidelines when they are admitted to the emergency or casualty department of the hospital, and for those of you that have listened to episode four of this podcast series, you may recall the very eloquent description of the ATL-S procedures that are applied in the emergency room, as Professor Hardcastle spoke to us about this. So if you need a reminder of what this all entails, please take time to listen to episode four again. So as the patient with penetrating chest trauma comes to the emergency department, the most important thing that the doctors do is to screen the patient for the lethal six injuries and, as the name suggests, these are injuries that are immediately life-threatening and need to be dealt with as soon as possible. So the lethal six injuries that patients are screened for include airway obstruction, tension pneumothorax, an open pneumothorax, a massive hemothorax, a flail chest and cardiac tamponade. Hemothorax, a flail chest and cardiac tamponade. So the reason tension hemothorax, open hemothorax and a massive hemo-hemothorax are screened for is because of the effect of the loss of pressure within the thoracic cavity. With these types of injuries that leads to massive segments of the lung collapsing, leading to poor gas exchange and oxygenation, and the excessive air and the excessive blood in the pleural space, if it's not drained effectively, just applies more and more pressure to the lungs and prevents it from expanding. So this causes movement of the blood vessels across to the other side of the chest and the inferior and superior vena cava are being compressed. So the return of blood to the heart is impeded and the patient is at risk of cardiac arrest. With cardiac tamponade there is leakage of blood into the pericardial sac around the heart, which then increases in volume and prevents the heart from contracting effectively and expanding effectively to supply a proper stroke volume and, again, the risk of cardiac arrest. So if the patient presents with any of these conditions, these will be attended to immediately, and if they don't, then the doctor knows that the patient is in a more stable condition. So after they've screened for the lethal six injuries, the next step is for the doctors to screen the patient for the hidden six injuries. These injuries are not immediately life-threatening, but may cause significant deterioration in the patient's condition in the next few hours or days after injury and therefore need to be identified and managed appropriately. These include pulmonary contusion, blunt cardiac injury, traumatic disruption of the aorta, traumatic diaphragmatic rupture, tracheobronchial injury and esophageal injury.
Speaker 1:Now, most penetrating chest injuries can be managed by placing a simple intercostal drainage system into the thoracic cage and in 85% of cases this would be adequate to deal with the excessive air and blood in the pleural space and patients would recover. However, for the small number of patients that have blood vessel injury or diaphragmatic injury that needs surgical intervention, this would be done over and above the insertion of the intercostal chest drainage system. Cardiac airway and great vessel injuries, as well as diaphragmatic injuries are often monitored closely and, if needed, surgery will be done, as I've mentioned, and the surgical access points that the surgeons use for cardiac injury is through a median sternotomy. They also access the chest through a high anterolateral thoracotomy or a lateral thoracotomy and if a diaphragm repair needs to be done, this is sometimes done through a laparotomy approach. So patients with penetrating injury may need surgery, as I've mentioned, and therefore from a physiotherapy point of view, it is important to think about precautions in relation to surgery as we manage these patients.
Speaker 1:Complications that these patients may develop is firstly, atelectasis, for the reasons mentioned already, with the loss of pressure from the intrapleural space, pneumonia that may develop either because of infection into the chest cavity at the time of injury or during the hospital, when hospital acquired pneumonia is contracted, and then post-traumatic empyema may also develop. Empyema is often the result of a retained hemothorax. This means that not all of the blood that accumulated in the intrapleural space was effectively drained through the intercostal chest drainage system. So empyema is the result of blood that has congealed in the intrapleural space and is causing a breeding ground for infection. Empyema is diagnosed through performing a chest CT scan and the patient also would present, with clinical symptoms such as a fever, worsening respiratory function and an increased leukocyte count on a blood test, can be managed by insertion of a second intercostal drainage system to facilitate evacuation of the infective matter from the interplural space. If this is not deemed adequate, the next step would be to perform a video-assisted thoracoscopy drainage of the infective matter and lastly, if that's not effective, thoracotomy will be done for a decortication, and this means that the thoracic surgeon basically chisels the infective matter off the surface of the lung to allow for it to re-expand. More recently, fibrinolytic medications such as streptokinase or urokinase have been administered into the intrapleural space to assist with resolution of the infection, and it has reduced the need for surgical intervention to less than 40%. So it's great to see that there are various options for the treatment of empyema and that it does not always necessitate surgery.
Speaker 1:So let's think about some impairments that patients may present with as a result of penetrating chest trauma. As a result of penetrating chest trauma. So any trauma leads to pain, and this could be pain at the site of the injury. But after placement of the intercostal drainage system, there is also pain and discomfort around the insertion site of the tube into the intrapleural space insertion site of the tube into the intrapleural space. So patients present with insufficient inspiratory lung capacity, poor lung compliance and reduced lung volumes for these reasons, and also not just pain causing these impairments but the retention of air and blood in the pleural cavity and pulmonary contusion if that occurred as a result of a gunshot wound where the bullet traveled through the lung tissue.
Speaker 1:Impaired gas exchange and oxygenation is another problem that patients present with for these same reasons. And then there may be decreased active shoulder joint and trunk range of motion because of the presence of the intercostal drainage tube on that side of the chest. But also due to post-operative pain, if the patient had surgery, there may be temporary weakness of the arm on the affected side of the thorax. In some cases the intercostal drainage tube compresses the first thoracic nerve or the third to the sixth intercostal nerves and impairs muscle activity on that side of the thorax. Patients may also present with a protective side flexed trunk posture towards the affected side of the thorax. So this is again due to pain and the presence of the intercostal drainage tube. And then for patients who were more severely injured and needed admission to the intensive care unit and had a prolonged stay, they may present with generalized muscle wasting and weakness and poor cardiorespiratory exercise endurance.
Speaker 1:So what can we as physiotherapists offer these patients? One aim and an important aim of management is education, and for this patient population should focus on education about pain management strategies. So it's important to teach your patient how to support the wound and the drainage tube insertion site on the chest wall when they cough and when they sneeze, and also educate them about the use of controlled deep breathing and relaxation that assists in a non-pharmacological manner to control the pain. Secondly, it is important to try and restore a normal breathing pattern for these patients. Because they are in pain and discomfort and they feel short of breath. They often breathe more apically and do not get proper expansion of the basal lung segments. So it's important to teach them how to do diaphragmatic breathing with lateral costal or lateral basal expansion, so that you can utilize or restore normal lung volumes as the patient breathes in deeply. This also helps to facilitate the removal of excess air and blood from the pleural space from the inside out, so from the lungs that expand and pushes the air or blood into the intercostal drainage tube that then gets drained out of the chest wall into the collection bottle. Another method of really focusing on removing this excess air and blood from the interpleural space is through early active exercises of the shoulders, the arms and the trunk, and doing this in sitting and as soon as your patient is stable enough to stand and move out of the bed, to continue with trunk rotations and side flexion exercises, shoulder elevation exercises combined with deep breathing, and then introducing functional activities such as marching on the spot by the patient's bedside, progressing to brisk, walking away from the bedside If there's access to a stationary bicycle on the ward, do cycling exercise with a patient and finally, stair climbing. The purpose of all of these activities is to encourage deep breathing, again to facilitate removal of the air and blood from the intrapleural space.
Speaker 1:Interestingly, in the 1990s here in South Africa two physiotherapy clinical trials were published on patients with penetrating trauma that led to hemonymer thorax, and it was found that patients who received physiotherapy within the first seven hours after insertion of the intercostal drain and was then treated with early active exercise from the time of first physiotherapy contact had a much shorter hospital length of stay because of quicker resolution of the hemothorax. They had less incidences of spike in temperature, so in other words less infective complications and they were discharged from the hospital sooner, and this was compared to patients who only received physiotherapy during normal working hours. But I suppose it depends on the staffing levels at your local hospital whether this approach would be feasible or not. And also we tend to see these patients in the emergency department already after they were stabilized to start with early active exercises and don't wait for them to be transferred to the ward before physiotherapy is initiated. So just a very active approach to these patients in our South African healthcare setting, particularly because the patients that we see with these types of injuries are usually younger adults, so they are able to be physically active sooner.
Speaker 1:Of course it is important to make sure that there's no retained secretions in the patient's airways. So it's very important to encourage active coughing, and the action of coughing actually also assists with removal of excess air and blood from the pleural space. If the patient does have retained secretions that they are not able to cough up effectively, think about teaching them how to do the forced expiratory technique or huffing If the action of coughing is too painful. Also think about introducing a nebulization therapy, so putting the patient on frequent normal saline or mucolytic therapy to help with evacuation of secretions and for those that are on mechanical ventilation, think about introducing an active humidification system, these water reservoir systems that can be connected into the mechanical ventilation circuit. The use of incentive spirometry, oscillating PEP therapy and breath stacking can also be very beneficial, together with active exercises of the arms and the trunk and functional activities to try and restore lung volumes.
Speaker 1:Some patients with penetrating chest trauma have other additional injuries that require management in the intensive care unit and therefore have a prolonged stay. So it's important to think about strategies of respiratory muscle training to facilitate successful weaning of the patient from mechanical ventilation as soon as they are stable and awake enough to cooperate with you, and also then to remember that whole body conditioning is very important. So resistance training of the peripheral muscles, working on core muscle strength if no abdominal surgery was done, and also to aim to get your patient to transfer independently from the bed to the chair. This independent transferability from the bed to the chair before ICU discharge has been associated in other ICU populations with more functional independence of the patient on the ward and a shorter hospital length of stay. So independent transferability while the patient is in ICU is an important aim to try and achieve.
Speaker 1:Of course, all of this may not be possible if the patient is not on adequate analgesia. So be sure to communicate regularly with the patient's trauma team about pain management strategies to optimize their ability to participate in physiotherapy with you. Also, remember to educate your patient about the intercostal drainage system to be aware of where the tube and the bottle are as they move in and around the bed to avoid it getting stuck and pulling on the insertion site on the chest wall. And if your patient did require a stenotomy because of penetrating injury to the heart, it's important to remind them of precautions of movement after the stenotomy to ensure that effective healing can take place.
Speaker 1:As we've mentioned in previous episodes, using appropriate outcome measures are important, and I want to refer you back to episode 10 of our series, where Professor Rinal Ruiz had such a lovely discussion with me about all the various outcome measures for physical function and quality of life and mental health that are available for us to use within the trauma setting. So please ensure that you go and listen to that episode again. So I suppose the take-home message about the inpatient management of these types of patients with penetrating chest trauma is that your first priority of care should be to educate your patient on how to manage their pain and secondly, to facilitate effective clearance of air and blood that are retained within the intrapleural space, then ensuring that the patients have adequate range of motion of their arms, their shoulders and their trunk before they are discharged home. Ensure that there's no retained secretions and that they have reached a functional level where they have independence in function by the time they go home. It's also important to educate your patient as you plan for discharge about wound care of the injury on the chest wall or the ICD insurgent site, to monitor it and to know which signs to look out for that could be indicative of infection in the wound.
Speaker 1:And then try to do a telephonic follow-up with a patient at least at one month after discharge, to screen and see which patients have continued respiratory or musculoskeletal impairments and to then bring those patients back to your outpatient department for a complete assessment to see what management may be required. Also, consider if your hospital offers trauma follow-up clinics for patients that are run by the surgeon and the nursing staff. Consider talking to them, adding a physiotherapy service to this follow-up clinic as well. So that's about it for our discussion on penetrating chest trauma. Thank you for your continued interest in physiotherapy and trauma care and join me next time for a discussion on physiotherapy management of patients with blunt chest wall injury with Professor Kerry Battle from Wales. Thank you for listening.
