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Guest Editorial: Polytrauma: A New Frontier in Rehabilitation Nursing
Wounded warriors from Operations Iraqi and Enduring Freedom (OIF/OEF) are presenting new healthcare challenges for rehabilitation nurses in the military and Veterans Health Administration. Rather than presenting with a single trauma or impairment, these wounded warriors present with complex, multiple injuries in unpredictable patterns, known as polytrauma/blast-related injury (PT/BRI). Of the Army personnel wounded in action in Iraq and evacuated between March 2003 and July 2005, 65.9% sustained injuries as a result of explosions (Office of the Surgeon General, 2005). Explosions include improvised explosive devices, land mines, hand grenades, and rocket-propelled grenades. Because of the variation in the type and strength of explosive devices, proximity to explosions, presence of intervening protective or hazardous barriers, and whether or not an explosion occurred in confined or open space (among other factors), the injuries sustained are unique (DeWitte & Tracy, 2005), and often general rehabilitation practices have been inadequate.
Exposure to a blast can result in one or more levels of injuries: primary, secondary, tertiary, and quaternary or miscellaneous injuries (Wightman & Gladish, 2001). Primary injuries result directly from the high explosive blast wave that compresses material it encounters. Air-filled organs (e.g., ear, lung, gastrointestinal tract) and organs surrounded by fluid-filled cavities (e.g., brain, spinal cord) are especially susceptible (Elsayed, 1997; Elsayed & Gorbunov, 2006; Mayorga, 1997). Secondary injuries result from flying debris and bomb fragments and shrapnel. Any body part can be affected, including the head and soft tissue, and shrapnel wounds may be grossly contaminated. Tertiary injuries are a result of the body being thrown by explosion shock wave and dynamic overpressure. In most cases, only people in very close proximity to the explosion sustain tertiary PT/BRI, unless the explosion was of extremely high energy or focused in some way, such as through a door or hatch. These traumatic injuries include broken bones, spinal cord injuries, traumatic head injuries, and other injuries related to falls or impact. Quaternary injuries include burns, soft tissue injuries, fractures, traumatic amputations, toxic inhalations and exposures, and crush injuries from collapsed structures and displaced heavy objects.
Modern body armor, surgical subspecialties at the front, forward surgical teams, and reduced travel time to medical facilities have helped reduce blast-related mortality (Brennan, 2006). Whereas 30% of servicemembers in World War II and 24% in Vietnam died from their injuries, 10% of wounded servicemembers deployed to OIF have died from their injuries (Gawande, 2004). With more soldiers surviving PT/BRI, the focus of medical treatment is now moving to postacute care in order to reduce physical, cognitive, emotional, and functional disabilities (Scott, Vanderploeg, Belanger, & Sholten, 2005). Because many injuries may not be immediately manifested during acute treatment, and because the very nature of polytrauma dictates attention is first directed to primary life-threatening injuries, the role of healthcare providers in rehabilitation or primary care is often to “uncover” and treat additional injuries or provide subsequent care to injuries previously identified. The clinical course of PT/BRI varies widely and the interaction effect among multiple injuries is unknown (Warden, 2006). Early identification of comorbidities is generally associated with improved patient outcomes and cost savings (Arlinger, 2003). Characterizing PT/BRI is challenging because medical and psychiatric sequelae, such as ear trauma and resultant hearing loss, concussion and resultant cognitive and vestibular deficits, posttraumatic stress disorder, and acute stress reactions, can easily be overlooked when attention is focused on more “visible” injuries (Gordon et al., 1998; Scott et al., 2005; Scott, Fletcher, Pulliam, & Harris, 1986; Trudeau et al., 1998).
This journal issue focuses on early attempts to build science associated with PT/BRI. I applaud these authors for their dedication toward achieving the overall goal of reducing the burden of illness, injury, and disability, and to improve health, functional status, and quality of life for wounded warriors.
Arlinger, S. (2003). Negative consequences of uncorrected hearing loss—A review. International Journal of Audiology, 42(Suppl. 2), S17–S20.
Brennan, J. (2006). Experience of first deployed otolaryngology team in Operation Iraqi Freedom: The changing face of combat injuries. Otolaryngology-Head and Neck Surgery, 134, 100–105.
DeWitte, M., & Tracy, E. (2005). Challenges of blast injury. Topics in Emergency Medicine, 27(3), 176–179.
Elsayed, N. M. (1997). Toxicology of blast overpressure. Toxicology, 121, 1–15.
Elsayed, N. M., & Gorbunov, N. V. (2006). Pulmonary biochemical and histological alterations after repeated low-level blast overpressure exposures. Toxicological Sciences, 95(1), 289–296.
Gawande, A. (2004). Casualties of war—Military care for the wounded from Iraq and Afghanistan. New England Journal of Medicine, 351, 2471–2475.
Gordon, W. A., Brown, M., Sliwinski, M., Hibbard, M. R., Patti, N., Weiss, M. J., et al. (1998). The enigma of “hidden” traumatic brain injury. Journal of Head Trauma Rehabilitation, 13, 39–56.
Mayorga, M. A. (1997). The pathology of primary blast overpressure injury. Toxicology. 121, 17–28.
Office of the Surgeon General. (2005). Annex C: Evacuation Assessment Operation Iraqi Freedom (OIF-II) Mental Health Advisory Team (MHAT-II). Retrieved July 23, 2008, from www.armymedicine.army.mil/reports/mhat/mhat_ii/ANNEX_C.pdf.
Scott, B. A., Fletcher, J. R., Pulliam, M. W., & Harris, R. D. (1986). The Beirut terrorist bombing. Neurosurgery, 18, 107–110.
Scott, S. G., Vanderploeg, R. D., Belanger, H. G., & Sholten, J. D. (2005). Blast injuries: Evaluating and treating the postacute sequelae. Federal Practitioner, 22(1), 66–75.
Trudeau, D. L., Anderson, J., Hansen, L. M., Shagalov, D. N., Schmoller, J., Nugent, S., et al. (1998). Findings of mild traumatic brain injury in combat veterans with PTSD and a history of blast concussion. Journal of Neuropsychiatry and Clinical Neuroscience, 10, 308–313.
Warden, D. (2006). Military TBI during the Iraq and Afghanistan wars. Journal of Head Trauma Rehabilitation, 21(5), 398–402.
Wightman, J. M., & Gladish, S. L. (2001). Explosions and blast injuries. Annals of Emergency Medicine, 37, 664–78.