Adrian - TBI on orthopaedic ward Flashcards
What are Adrian’s personal details?
Previously well 26-year man. A van driver who had a road traffic accident (head on collision at speed) 3 days ago and sustained a head injury/ L sided extradural haematoma, but no surgical intervention indicated. Some motor weakness R side, particularly his arm. He has not required ventilation or ICP monitoring. AVPU level of consciousness = V and GCS = 13.
Eating and drinking pureed diet with assistance and coughing spontaneously, particularly on drinking.
What’s Adrian’s past medical history?
Mild exercise induced asthmatic
What is Adrian’s drug history?
Nebulised salbutamol currently (usually Ventolin PRN)
Clarithromycin - for a chest infection
What is Adrian’s social history?
Lives with girlfriend
Currently renovating own house in spare time
Smoked 20 a day up to admission
What would you find on examination of Adrian?
Confused and sleepy in bed with the sides up. Verbalising slowly, but dysarthria makes it difficult to understand what he is saying. Tends to pull at face mask, FiO2 = 0.28, SpO2 = 95%.
BP = 120/75, ECG sinus rhythm
RR = 12, few coarse crackles on auscultation cleared with coughing, cough elicited spontaneously when turning
Right sided weakness, some increase in tone R UL
What would you assess on Adrian’s subjective assessment?
Patient approach as he has dysarthria.
General health, new feelings of illness or worsening of condition.
Level of pain.
Keep subjective minimal to avoid confusion, discomfort and / or distress.
What would you assess on Adrian’s objective assessment?
Auscultation
Palpation
Chest percussion note
Modified Ashworth Scale
Respiratory rate
BP and HR
Neuro-integrity
AVPU / GCS
Babinski / Clonus
Oxford Scale
How would you manage Coarse crackles on auscultation and why?
Mobilisation every 2 hours
Progression:
ACBT – depending on patient ability
Breathing control
Thoracic expansion
Breathing control
Thoracic expansion
Low volume huff
Breathing control
High volume huff
Why: Adrian is coughing spontaneously on mobilisation; based on his current presentation we would focus on mobilising him into a high side lying position and assess the effectiveness of sputum clearance. Active mobilisation such as rolling will help Adrian to regain function, strengthen intercostal muscles and to clear his chest. Mobilisation causes coughing which removes secretions effectively.
Coarse crackles on auscultation suggests there is secretions in the lungs. By doing ACBT we aim to remove the secretions. Thoracic expansion with a hold allows the air to have time to move through the collateral airways to get behind the secretions to increase movement of the secretions during expiration. Low volume huff moves secretions from the peripheral airways to the central airways, high volume huff moves the secretions out of the airways.
What evidence supports the use of mobilisations and ACBT?
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3563027/?report=reader
The active cycle of breathing technique:
A systematic review and meta-analysis
How would you manage Right sided weakness and why?
Warm up by asking Adrian if he can squeeze the muscles that you point to (point to bum, legs, calves and toes and upper limb).
Get him sitting on the edge of the edge of the bed with his feet on the floor by getting him to use his left (good) side to push up
Ensure Physio assistant is available for extra support
Provide clear and precise instructions and make patient fully aware of what is happening and why to avoid any distress / confusion.
Then do 8 equilibrium rhythmic stabilisations (ideally 3 times a day) and get him back into bed.
Progression: sitting Adrian on a wobble board / pillow. Adding ball.
Regression: Increasing BOS – sitting up in bed.
Why: We want Adrian to use his left arm (stronger arm) to sit up as this will improve his muscle strength. Sitting upright will also benefit VQ matching. Equilibrium rhythmic stabilisations are the simplest type of stabilisation, as Adrian only had the car crash 3 days ago and is very confused, we want to take things slow and steady with him. This will also improve his neural state. Aim of this is to strengthen his core muscles.
What evidence supports rythmic stabilisations?
Is it possible to stabilize the trunk using rhythmic stabilization in the upper limb? A cross-sectional study of asymptomatic individuals
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6071270/
(Dionisio et al., 2018)
How would you manage Increased muscle tone in right arm and why?
SIMS
Lumbrical grip on biceps as this is where he has high tone
Hold as stretch for 30 seconds
Twice a day
Adjunct:
Brushing & tapping – functional strengthening
Positioning for high tone
Why: SIMS relaxes muscles that are contracting causing his high tone and reduces contractures.
So that we can leave Adrian knowing that his upper limb is supported aiding him in being able to relax his muscles.
What evidence supports Sims?
An Intensive Programme of Passive Stretch and Motor Training to Manage Severe Knee Contractures after Traumatic Brain Injury: A Case Report - PMC (nih.gov)
What members of the MDT would be involved in Adrian’s case?
Smoking cessation advice.
Speech and language: dysarthria and swallowing, may need liquids thickened to reduce risk of aspiration.
Doctor: Reassess type of oxygen therapy / prescription. Discuss adding a humidifier for comfort and compliance
Nurses: monitor vitals.
Nurses / HCA: Extradural haematoma - Positioning 30-degree head elevation <30-degree hip flexion - Elevating the head reduces ICP; a potential risk with extradural haematoma. Keeping hip flexion below 30 degrees minimises compression of CSF.
All MDT: To be aware of mental state and provide positive reinforcement throughout treatments. Discuss potential for anti-depressants and psychological therapy when ready for discharge. Constant reassurance as he has suffered a traumatic injury (pulling at facemask may indicate anxiety).
