CHEST t r e a t m e n t of the head in ju r e d pa t ien t req u ir in g INTERMITTENT POSITIVE PRESSURE VENTILATION (I.P.P.V.r R. LEW IS, D ip. Physio., C.T.P. (C ape Town)* p jS E M B E B 1977 F I S I O T E R A P I E 9 die pasi'ente m et lioofbeserings wat gedurende 1075 in G roote Schuur-hospitaal toegelaat is, het o n ­ cer 16% endotrageale buise o f ’n trageostomie benodig ^eV45% van die pasi'ente m et trageostom ies het inter- cn-llere n d e positiew e druk-ventilasie benodig. "'‘o n blyk dus wenslik, selfs essensieel, te w ees^dat die riioterapeut wat in ’n neurochirursiese eenheiit werk, , rat dit o o k ’n intensiewe sorgeenheid het, haar ye t bekw aam sover doeltrejfende respiratoriese fisio- Trapie aanbetref. D ie fisioterapie-prosedw es word bespreek. Of the recorded adm issions of head -in ju red patients A G roote S chuur H o sp ital during 1975, app roxim ately So/ required endotracheal in tu b atio n or a trach eo ­ stomy, and ap p ro x im ately 42% of these intubated or tracheostomised p atien ts req u ired in term itten t positive oressure ventilation. it seems desirable, if n o t essential, fo r a p hy sio ­ therapist w orking on a neurosu rgery u n it, containing an intensive C are U n it, to be com petent in the p e r­ formance of effective chest physiotherapy. First Aid Measures Today, im provem ent in resuscitation an d intensive care techniques ensures th e survival of p atien ts who, in form er tim es, w ould no t have been w ith us to necessitate discussion of th e head -in ju red p a tie n t re ­ quiring in term itten t positive pressure ventilation. Any head-injured p atien t who has som e degree of loss of consciousness needs a p aten t airw ay and ad e­ quate ventilation as first a id m easures. T hese can be achieved w ith positioning, suction o f the nasopharynx, insertion o f a m outh airw ay, endotracheal o r trach eo ­ stomy tube and, if spontaneous v en tilatio n is still in­ adequate, som e fo rm of artificial ventilation. Causes of respiratory distress in the head-injured patient 4 R espiratory distress in th e head -in ju red p a tie n t may *e due to one o f several causes, or a com bination of these. 1. A irways o b stru ctio n due to :— (a) the tongue falling back and occluding the a ir ­ way when the p atient is in the supine position; (b) in h alatio n of nasal secretions, vom itus o r blood from fractu res o f base o f skull, jaw and facial bones o r fro m facial lacerations. 2. D epression of brain-stem fu n ctio n leading to :— (a) loss o f control of ra te and depth of resp iratio n ; (b) depression o r loss of norm al cough reflex; (c) in ab ility to swallow m ucus, vom itus and blood. 3. A ssociated injuries. A pproxim ately one th ird o f all head -in ju red patients have associated injuries.1 T hese m ay re q u ire the physiotherapist to m odify her treatm en t and may include: * Lecturer, U n iv ersity o f C ape Tow n, t A dapted fro m a p ap er delivered at a p o st graduate course on “E a rly T reatm en t o f th e H ead-Injured P atient” held at the u niversity o f Cape T ow n, July 1976. (a) chest injuries involving chest wall, pleurae, lungs; (b) cervical cord lesions resulting in paralysis of re sp ira to ry muscles; (c) lim b fractures; (d) visceral damage. If the head -in ju red p atien t requires an anaesthetic fo r any reason the m agnitude of the p h y sio th e ra p ist’s task is increased. Importance of preventing respiratory inadequacy A restricted airw ay o r h am pered resp iratio n due to any o f the above causes can cause carb o n dioxide re ­ tention. A raised PCO? causes vasodilatation. V aso d ila­ tion w ithin the skull causes a raised in tracran ial p res­ sure w hich, directed dow n and centrally tow ards th e b ra in stem, can cause irreversible b rain dam age or death. Aims of treatment o f the head-injured patient on I.P.P.V. T h e p h y sio th erap ist’s role in the treatm ent of the p a tie n t’s chest during the p erio d o f assisted o r artificial ventilation m ay be a life-m aintaining, and a life-saving one. T h e aim s o f treatm ent a re :— 1. T o keep the p a tie n t’s chest clear an d to prevent atelectasis. 2. T o be aw are of, to treat and to stim ulate the w hole patient at all times. it is alw ays essential to ap p reciate the nursing ro u tin e in the Intensive C are U nit. It is necessary to w ork closely w ith nursing staff, e.g. when tu rn in g an d p o si­ tioning th e p atient an d w hen treatin g his chest and pressure areas. T o tal care o f th e p atient is th e outcom e o f good team w ork in the Intensive C are U nit. Means o f treatment:— 1. Postural drainage Is tipping, even turning, th e head-injured p atien t perm issible? Yes, if th e neurosurgeon a n d /o r anaes­ thetist, the p a tie n t’s co n d itio n an d o th er in ­ juries (e.g. chest injuries and limb fractures) p erm it it. T h e outcom e o f in ad eq u ate treatm ent o f a serious chest condition m ay outw eigh the dangers of a possible raised in tracran ial pressure w ith postural drainage. T h e neurosurgeon m ay consider the raised in tracran ial pressure of little significance if the p atien t is tip p ed fo r the d u ratio n o f p h ysiotherapy treatm ent only. A lways p o sitio n the p atien t securely, replace restraints (if any) and be in a position to observe the p atien t constantly during th e p erio d of postural drainage. 2. “Sighing” T his procedure may be perform ed to com pensate for the loss o f the deep sigh m echanism . T h e p a tie n t’s condition m ay not perm it “sighing”, e.g. if he has a pneu m o th o rax o r low b lo o d pressure. 3. Manual techniques T hese include passive m o b ilizatio n o f tru n k and 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 10 P H Y S I O T H E R A P Y D E C E M B E R 1977 F o r m u l a : D i e i h y l a m i n e S i i l i c y l a t e 1 0 g N o p o x a m i n e 1 g E x c i p i e n t q . s . a d . lO O g 1. Rheumatic pains in joints and muscles 3. Muscle cramps and stiffness 2. Fibrositis 4. Other local pains and aches pain is our scene analgen ointment Formulation: T w o p ain -killing ingredients. dicihylam iiK a n d n o p o x a m in e , in a special o in tm e n t base io speed c u ta n e o u s p e n e tra tio n . Indications: R h e u m a tic pains in jo in ts and m u s c le s , lo w b a c k a c h e , f i b r o s i t i s , sp rain s a n d bruises, m u sc u la r cram ps an d stiffness, neuralgic pains. Action: S o o th in g , deep -p en etratin g , If:'." rap id p a in relief w ith local a n aesth etic 1 ‘ effect. Application: M assag e gcnily im o i Ik- skin a ro u n d th e affected area until com pletely a b ­ so rb ed . A pp ly as often as required. Another pain-fighting product in the A N A LG E N tradition ©|Noristan Laboratories (Pty) Ltd, Silverton, Pretoria. Formula: Latema, Paris. For full prescribing information, contact Noristan Laboratories direct. Papageorge/38/9 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) pgSEM B ER 1977 F I S I O T E R A P I E -11 shoulder girdle, percussion, shaking, rib springing and vibrations. If the p atien t has chest injuries, carefully ap p lied v ibrations m ay be th e only safe technique. 4 . Suctioning The p hysiotherapist aim s to reach, w ith th e suction catheter, the secretions she has m obilised by means of postural drainage, “sighing” and m anual tech­ niques, and, if possible, to stim ulate a cough reflex. T he p hysiotherapist m ust keep her technique as sterile as possible and suction as quickly b u t as effectively as possible. Suction o f th e nose and m outh m ust be perform ed if the p atien t cannot swallow. If th e p atien t has a fra c tu re o f th e base of the skull w ith a cerebrospinal fluid leak, as a clear colourless rh in o rrh e a or w ith bleeding via the nose, nasal suctioning m ust be om itted. 5 . Communication Most im p o rtan t o f all th e unconscious p a tie n t leads a very lonely life, so talk to him .2 Speak to the | patient in his own language if you can. Call the patient by his C h ristian nam e .Tell the patient w hat you are doing, w hat you are going to do, why you want to do it, an d how you w ant him to try to help you. The level of consciousness o f the p atien t will d eter­ mine how active a p a rt he plays in his treatm ent, but he m ust be given th e benefit o f th e doubt, and every encouragem ent. Do not be silent during treatm ent. D o n o t shout at the patient. D o not exclude the p atien t fro m your conversation w ith colleagues. N ever pass discourag­ ing rem arks ab o u t the p a tie n t’s condition and p ro g ­ nosis w ithin possible hearing of even the ap p aren tly deeply unconscious patient. T h e p atien t who recovers consciousness and is m aintained on assisted v en tila­ tion because of chest injuries needs limitless re­ assurance. Frequency o f treatment The p atien t m ust be treated as often as his condition demands and circum stances perm it, rem em bering th at physiotherapy m u st be com bined with the nursing programme, e.g. the norm al turning, feeding and o b ­ servation routines. CONCLUSION It is a sobering thought and a clear injunction to the nseientious physiotherapist when o ne realizes th at inadequate ventilation o f the head-injured patient, and that includes the consequences o f ineffective chest physiotherapy, m ay m ake an otherw ise recoverable brain injury, irrecoverable. References 1. Jennet, W. Bryan. A n Introduction to N eurosurgery, 3rd Ed. W illiam H einem an M edical Books L td., L ondon, 1973. 2. M cG uire, J. T he E arly T reatm ent o f the H ead- injured patient, S. A fr. Jnl. o f Physiother., 29, 1, 3, 1973. 3. P roctor, H . H ead Injuries, Physiother. Jnl. o f Char. Soc., 59, 12, 385, 1973. FILMS FILMS TO BE A D D E D TO R EV ISED CATALOGUE — N.B. M ost have n o t been reviewed b u t are taken fro m the new C atalogues. PAEDIATRICS 1. D evelopm ental tests in the early diagnosis o f C erebral Palsy (1964) (33), 16 mns, B /W , So. B eautifully m ade film presenting 10 sim ple tests fo r C erebral Palsy. 2. C hild D evelopm ent — T h e Tw elve M onths E x am i­ n a tio n (6) Cat. N o. 50 2 31 B — 13 mns. 3. C hild D evelopm ent — T h e T w o Y ear E x am in atio n (8) Cat. N o. 50 360 B — 15y mns. G E N ER A L M E DICIN E A N D SU R G ER Y 1. C linical L eprosy (8) — Cat. N o. U A /859 C ORTHOPAEDICS 1. T e n d o n free g rafting d em onstrated on a case of L eprosy o f th e H a n d (6) C. So. 20 mns. 2. T o tal H ip R eplacem ent (18) 22 mns, C. So. 3. T o ta l K nee R eplacem ent (18) 41 mns, C. So. Shows 4 different types o f total knee replacem ent p ro ­ cedures. CARDIO-THORACIC 1. A uscultation o f th e H e a rt — M itral Stenosis (18) 20 mns, C. So. Shows tech n iq u e o f au scu ltatio n and its use in diagnosis o f M itral Stenosis. 2. Surgical treatm ent o f C o ro n ary H e a rt D isease (18) 22 mns, C. So. 3. T ra n sa o rtic re p a ir o f V en tricu lar Septal D efect (18) 18 m ns C. So. 4. T h e C ough — D iagnosis, M anagem ent, R esearch (18) 26 mns, C. So. Illustrates m echanism , function, diagnosis and m anagem ent o f the Cough. OBSTETRICS 1. N o rm al L ab o u r (18) 14 mns. C. So. N.B. F IL M Q U E R IE S F O R LILLY LABOR A ­ TORIES (18) S H O U L D BE A D D R E SSE D T O : T h e M edical C o-ordinator, Lilly E d ucational R esources P rogram m e P.O. Box 98 ISA N D O 1600 M A IT LA N D T EC H N IQ UE — B A D R A G A Z D A T E A N D P L A C E SU B JEC T May, 1 - 1 9 Postgraduate Study C enter Bad R agaz O R G A N IZ E R A N D A D D R E SS F O R A PP L IC A T IO N S G IS E L A R O L F M A P O S T G R A D U A T E ST U D Y C E N T R E M E D IC A L D E P A R T M E N T 7310 B AD R A G A Z /S W IT Z E R L A N D E X A M IN A T IO N , A SSESSM EN T A N D T R E A T M E N T BY PA SSIV E M O V E M E N T N U M B E R S L IM IT E D TO 24 A C T IV E P A R T IC IP A N T S C O U R SE L E A D E R M R . G . D . M A IT L A N D A .U.A., F.C .S.P., M .A .P.A. C O U R SE F E E sFr. 1 200. — w ith o u t accom m odation sF r 1 400. — w ith accom m odation T he 3 week course program m e will include lectures and dem onstrations by M r. G. D . M aitland, an d p rac­ tical w ork w ith p atien t by course m em bers. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )