M A R C H , 1973 P H Y S I O T H E R A P Y Page 3 THE EARLY TREATMENT OF THE HEAD-INJURED PATIENT J O A N M c G U I R E , M.C.S.P. Senior. P h y s i o t h e r a p i s t in c h a r g e o f N e u r o - S u r g i c a l U n i t , C r o o k ' S c h m i r H o s p i t a l , C a p e T o w n . T h e m o s t i m p o r t a n t c o n s i d e r a t i o n w h e r e t h e r e is s o m e desrcc o f u n c o n s c i o u s n e s s in a p a t i e n t w i t h a h e a d - injury. is t o K E E P T H E A I R W A Y F R E E . T n c b r a i n receives n e a r l y 2 0 '. , o f t h e t o t a l c a r d i a c o u t p u t o f t h e body, a n d if" the a i r w a y is o b s t r u c t e d , t h e i n c r e a s e d CO, in c r e a s e s t he b l o o d v o l u m e w i t h i n t h e s k u l l d u e to va s o d i la ta ti o n . T h i s h as t h e elf ec t o f r a i s i n g i n t r a c r a n i a l pressure, w i t h s e c o n d a r y c o m p r e s s i o n a n d d e a t h of many b r a i n cells a n d r e s u l t a n t p e r m a n e n t b r a i n d a m a g e . S h i s m a y o c c u r v e r y r a p i d l y , e v e n in a p e r i o d o f o n l y \ few h o u r s . W h e r e t h e r e is c c r e b r a l o e d e m a o r a n y other c a u s e o f i n c r e a s e d p r e s s u r e w i t h i n t h e c r a n i u m , such as a s u b d u r a l h a e m a t o m a . o r t u m o u r , t h e s k u l l itself c a n n o t , o f c o u r s e , e x p a n d , so t h a t t h e p r e s s u r e is ex e r t e d d o w n w a r d s a n d c e n t r a l l y t o w a r d s t h e t e n ­ torial n o t c h a n d b r a i n s t e m . H e r e , w h e r e t h e r e ar c t ho usa nds o f fi bre s c o n v e r g i n g on a v e r y s m a l l a r e a , a great deal o f d a m a g e c a n b e d o n e , g i v i n g ris e to p r e s ­ sure on o n e o r m o r e c r a n i a l n e r v e s , v a r y i n g d e g r e e s o f spasticity, h e m i p l e g i a a n d so o n. T h e r e c t i c u l a r f o r m a ­ tion can a ls o b e d a m a g e d , w i t h r e s u l t a n t f u r t h e r d e p r e s ­ sion o f t h e c o n s c i o u s leve l. Degrees o f C o n sc io u sn e ss: 1. T h e p a t i e n t m a y b e d r o w s y , b u t c a n e a s i l y be­ m u s e d a n d c a n gi ve a g o o d a c c o u n t in t e r m s of n a m e , p l a c e , t i m e, etc. 2. D i s o r i e n t a t e d , b u t still a b l e t o tell t h e stall his n a m e a n d a d d r e s s . 3. O n l y a g r u n t , b u t a t least a n a t t e m p t at a v e r b a l re sp o ns e! W h e n t h e r e is n o l o n g e r a n y v e r b a l r e s p o n s e , a p a i n f u l s t i m u l u s c a n b e p r o d u c e d by r u b b i n g t h e p a t i e n t ’s s t e r n u m f i rm l y w i t h t he k n u c k l c . T h i s m a y t h e n gi ve rise to t h e f o l l o w i n g r eac ti on s:- 4. T h e p a t i e n t will a t t e m p t to p u s h a w a y t h e h a n d with b o t h o f his in a p u r p o s e f u l m a n n e r . It ca n also be n o t e d a t th i s j u n c t u r e w h e t h e r t h e r e is ;i c o m p l e t e o r p a r t i a l l y p a r a l y s e d a r m . 5. T h e p a t i e n t e x t e n d s his legs, fle xes hi s e l b o w s , a n d cl enc hes his fists. T h i s is k n o w n a s t h e d e c o r t i c a t e po stu re , p r o b a b l y i n d i c a t i n g t h a t t h e c o r t e x is n o t r es p o n d i n g , o n l y t h e b r a i n s t e m a n d d i e n c e p h a l o n . (See i l l u s t r a t i o n N o . I.) 6. T h e p a t i e n t e x t e n d s a n d i n t e r n a l l y r o t a t e s h is a r m s and e x t e n d s his legs. T h i s is t h e d e c e r e b r a t e p o s t u r e , p r o b a b l y i n d i c a t i n g t h a t t h e b r a i n s t e m a l o n e c o n ­ trols th e p a t i e n t ’s r e a c t i o n s , a n d t h e o u t l o o k is m o r e se ri o u s . (Se e i l l u s t r a t i o n N o . 2.) 7. T h e p a t i e n t is in a c o m a , w i t h c o m p l e t e la c k o f r esp o n se to a n y s t i m u l u s , t h e l i m b s a r e flaccid a n d the o u t l o o k is g r a v e . Patients, if a d e q u a t e l y n u r s e d , c a n r e m a i n f o r m o n t h s , or even ye ar s, w i t h o u t r e g a i n i n g c o n s c i o u s n e s s in a n y of the states d e s c r i b e d , in 5, 6, a n d 7. Observations: Because th e p a t i e n t ’s c o n d i t i o n c a n a l t e r so r a p i d l y , it is e x t r e m e l y i m p o r t a n t t h a t d u r i n g d a i l y t r e a t m e n t accurate o b s e r v a t i o n s a r e m a d e b y t h e p h y s i o t h e r a p i s t of the p a t i e n t ’s r e a c t i o n s , a n d a n y d e t e r i o r a t i o n i m ­ m e d i a t e l y r e p o r t e d to t h e d o c t o r . T h e r e a r e t w o c o n d i ­ t i o n s in p a i l i c u J a r t h a t call f o r u r g e n t a c t i o n : — ! F u r t h e r d e t e r i o r a t i o n o f c o n s c i o u s n c s s . i n d i c a t i n g o r i n c r e a s i n g i n t r a c r a n i a l p r e s s u r e , w i t h c e r e b r a l s h i f t a n d b r a i n s t e m c o m p r e s s i o n . 2, A s l u g g i s h l y r e a c t i n g o r c o m p l e t e l y fixed p u p i l to l ig ht , s h o w i n g t h a t t h e 3r d c r a n i a l n e r v e ( o c u l o ­ m o t o r ) h a s a l s o b e c o m e i n v o l v e d a t t h e t e n t o r i a l n o t c h . D e g ree s o f P a ra ly s is : I. M o n o p a r e s i s , o n e l i m b o n l y i n v o l v e d , u s u a l l y t h e a r m . If t h e fa c e a n d leg o n t h a t sid e a r e n o t p a r a ­ lyse d o n e m u s t s u s p e c t a local i n j u r y su c h as a b r a c h i a l p l e x u s lesion . F ig. 1. T h e ty p ic a l d e c o rtic a tc p o s itio n o f a ch ild w ith a se v e re b ra in -s te n i in ju ry , a f te r m a n y m o n th s in h o sp ita l. 2. H e m i p a r e s i s o r h e m i p l e g i a , d e p e n d i n g o n th e d e g r e e o f t h e p a r a l y s i s . It h a s b e e n n o t i c e d t h a t a l t h o u g h a p a t i e n t m a y h a v e a le f t s u b d u r a l h a e m a ­ t o m a , it d o e s n o t n e c e s s a r i l y f o l l o w t h a t h e will 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. ) Page 4 P H Y S I O T H E R A P Y M A RCH , 1973 \ It costs you LESS to insure through your Own Association \ \ X Your Own Association COLONIAL © MUTUAL To the Trustees, S.A . S O C IE T Y O F P H Y S IO T H E R A P IS T S, Group Endow m ent Fund, P.O. Box 1194, Johannesburg. W ithout obligation, please tell me how I can obtain M A X IM U M protection at M I N I M U M cost— plus valuable disa b ility benefits— by injuring through my own A sso c ia tio n Group Endowment Fund. N A M E ______________________________________________ _________ A D D R E S S __________________ _________________________________ _ A g e next Birthday ____________________________ Occupation W here employed ___________________________________________ How much can you afford to pay each month Enjoy the SouthAfrican way of life Growth with Security M t makes more rands and j South African Permanent Building Society G r a n t 1020 A. C. MILLER & CO. ORTHOPAEDIC M ECHANICIANS ^ • Technicians registered with S.A. Medical and Dental Council specialising in the following: O R T H O P A E D IC A P P L IA N C E S , S U R G IC A L C O R S E T S , C E R V IC A L C O L L A R S, C H IL D R E N 'S S H O E S A N D B O O T S, A R T IF IC IA L LIM B S, L A T E S T IN P L A S T IC M O D IF IC A T IO N . H IR IN G A N D SE L L IN G OF H O S P IT A L EQ UIP­ M E N T A N D S IC K R O O M R E Q U ISIT E S , e.g. W H E E L C H A IR S , C O M M O D E S , H O SP IT A L B E D S, W A L K IN G A ID S , T R A C T IO N A P P A R A T U S , etc. e Telephone P.O. Box 3412 23-2496 ‘ 275 Bree Street Johannesburg / 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. ) M A R C H , 1973 P H Y S I O T H E R A P Y Page 5 Fig. 2. T h e ty p ic a l in te rn a lly ro ta te d a rm o f a decere brate p a tie n t. A n y e x te rn a l s tim u lu s w ill p ro d u c e ex> tren ie e x te n s o r sp a sm in th e lim b. a l w a y s h a v e a h e m i p l e g i a o n his r ig lu sid e, as w o u l d o c c u r w i t h a c a s e o f C V A . In o n e o u t o f five c a s e s t h e p a r a l y s i s is on ( h e s a m e side as th e c o m p r e s s i n g s u r f a c e h a e m a t o m a . T h i s is b e c a u s e the e x p a n d i n g le s io n o n the o n e s id e will c a u s e a b r a i n s h i f t t o t h e o p p o s i t e side so t h a t t h e o p p o s i t e ce r e b r a l p e d u n c l e will b e c o m p r e s s e d b y t h e e d g e of t h e t e n t o r i u m c e r e b e l l i , t h u s p a r a l y s i n g fibres whi ch will d e c u s s a t c t o t h e l i m b s o n t h e si d e o f the e x p a n d i n g lesion . 3. A, F l a c i d h e m i p l e g i a . B, S p a s t i c h e m i p l e g i a . 4. P a r a p l e g i a - P a r a l y s i s o f b o t h legs u s u a l l y se en with s p i n a l i n j u r i e s b u t r a r e l y a l s o w i t h c e r t a i n i n t r a c c r e b r a l l es io ns at t h e v e r t e x . 5. T e t r a p l e g i a - P a r a l y s i s o f all f o u r l i m b s , u s u a l l y in d i ca t i n g hi gh ce r v i c a l s p i n a l c o r d i n j u r y . Tipping: Any u n c o n s c i o u s p a t i e n t w h o h a s s e c r e t i o n s in his chest, h as t h e f o o t o f t h e b ed r a i s e d s e v e n i n c h e s to assure c o n t i n u o u s sl i g h t d r a i n a g e . T h i s h e i g h t d o e s n o t constitute p o s t u r a l d r a i n a g e f o r t r e a t m e n t o f t h e c h e s t ; the bed c a n be f u r t h e r e l e v a t e d i f t h a t is r e q u i r e d . It does, h o w e v e r , e n s u r e t h a t t h e s e c r e t i o n s f r o m th e trachea flow f re e ly i n t o t h e m o u t h . W h e n t h e p a t i e n t is lying in a h o s p i t a l b ed w i t h a s a g g i n g m a t t r e s s , t h e secretions t e n d to r e m a i n in t h e c h e s t a n d p r o d u c e respiratory c o m p l i c a t i o n s v e r y e a s i l y . It m i g h t be thought t h a t th e o e d e m a w i t h i n t h e h e a d w o u l d i n c r e a s e by c o n t i n u o u s t i p p i n g , b u t a n o b s t r u c t e d a i r w a y will p r o d u c e a m u c h g r e a t e r i n c r e a s e in i n t r a c r a n i a l p r e s s u r e . In c a s e s o f a s s a u l t , t h e r e is o f t e n e x t e r n a l o e d e m a a n d h e r e o n e h e s i t a t e s to ti p e x c e p t f o r t h e d u r a t i o n o f a sp ec ifi c c h e s t t r e a t m e n t . I t is a l s o u n w i s e t o t i p o b e s e p a t i e n t s d u e to t h e i n c r e a s e d e f f o r t r e q u i r e d t o m o v e t he h e a v y a b d o m i n a l c o n t e n t s p r e s s i n g u p w a r d s a g a i n s t t he d i a p h r a g m . T h e im p o rta n c e o f su c tio n in g : W h e r e t h e r e h a s b e e n a b r a i n - s t e m le s io n , o r v e r y l o w level o f c o n s c i o u s n e s s , t he c o u g h r efl ex is s o m e t i m e s d e p r e s s e d o r a b s e n t . In a d d i t i o n , n o u n c o n s c i o u s i m ­ m o b i l e p a t i e n t c o u g h s w i t h o u t e x t e r n a l s t i m u l a t i o n . H e n c c it is a b s o l u t e l y e s s e n t i a l t o as se s s w h e t h e r th e p a t i e n t h a s a n y s e c r e t i o n s by s t i m u l a t i n g h i m t o c o u g h . P a s s i n g a m o i s t e n e d s u c t i o n c a t h e t e r g e n t l y d o w n t he p a t i e n t ' s p h a r y n x via his n o s e , u s u a l l y suffices. I f the c o u g h is n o n - p r o d u c t i v e , if h e is b e i n g t u r n e d a t t w o - h o u r l y i n t e r v a l s , a n d n o a n a e s t h e t i c h a s b e e n g i v e n , t h e c h e s t s h o u l d r e m a i n c l e a r . A q u i c k d a i l y c h e c k is, h o w ­ e v e r , n e c c s s s a r y a n d a r o u t i n e c h e s t t r e a t m e n t c a r r i e d o u t a f t e r a n y o p e r a t i o n . D o n o t s u c t i o n t h r o u g h the n o s e if t h e r e h a s b e e n m u c h b l e e d i n g f r o m it, o r w h e r e c e r e b r o s p i n a l fluid is l e a k i n g f r o m th e n os e . T u rn in g : T h e p a t i e n t is t u r n e d f r o m s i d e t o si d e b y t h e n u r s e s e v e r y t w o h o u r s . A p i l l o w is p l a c e d a t his b a c k to k e e p h i m so. a n d w h e r e t h e r e is a n y p a r a l y s i s o f the l o w e r l i m b s a p i l l o w is p l a c e d b e t w e e n t h e k n e e s . I f he is v e r y r est les s, h e m a y b e f o u n d l y i n g on h is b a c k , b u t th i s is n o t a g o o d p o s i t i o n f o r t h e u n c o n s c i o u s p a t i e n t a s t h e j a w a n d t o n g u e will d r o p b a c k a n d b l o c k his a i r w a y . R a t h e r u se a b o l s t e r u n d e r o n e si d e o f th e m a t t r e s s , a n d p ad t h e c o t s i d e s w i t h p i l l o w s so t h a t he r e m a i n s o n hi s side, p r e f e r a b l y s l i g h t l y p r o n e . L i g h t h a n d c u f f s m a d e o f f o a m r u b b e r a n d V e l c r o f r e q u e n t l y h a v e to b e u se d in th i s t y p e o f c a s e t o p r e v e n t t h e p u l l i n g o u t o f R y l e s t u b i n g , d r i p s , etc. P h y s io th e ra p y T r e a tm e n t: M o s t h e a d - i n j u i i e s fall i n t o o n e o f t h r e e m a i n c a t e ­ g o r i es : (a) T h e m i n o r i n j u r y , s u c h a s t h e s e m i - c o n s c i o u s p a t i e n t w i t h a d e p r e s s e d f r a c t u r e o r h a e m a t o m a , w h o r e c o v e r s full c o n s c i o u s n e s s w i t h i n a fe w h o u r s o r d a y s ; (b) T h e p a t i e n t w h o r e m a i n s u n c o n s c i o u s f o r se v e ra l w e e k s , h a s h a d a t r a c h e o s t o m y p e r f o r m e d , a n d h a s p r o b a b l y a m i l d d e g r e e o f s p a s t i c h e m i p l e g i a ; (c) T h e se v e re b r a i n - s t e m le s io n , t h e p a t i e n t w i t h a t r a c h e o s t o m y , a n d d e c o r t i c a t e o r d e c e r e b r a t e r e ­ a c t i o n s a n d c o n s i d e r a b l e g e n e r a l i s e d s p a s m . AH th e a b o v e m a y o c c u r in a p a t i e n t w i t h m u l t i p l e in j u r i e s s u c h as l i m b f r a c t u r e s , h a e m a t h o r a x . o r vi sc er al i n j u r y , in w h i c h ca s e t h e t r e a t m e n t w o u l d h a v e t o be a d j u s t e d a c c o r d i n g l y . T h e f o l l o w i n g s u g g e s t e d t r e a t ­ m e n t s a r e f o r t h e h e a d - i n j u r y on l y . I. T H E M I N O R I N J U R Y : ( a) C h e s t r o u t i n e as c o n s i d e r e d e a r l i e r . (b) C h e c k all l i m b s t o see if t h e r e is a n y w e a k n e s s . A p a i n f u l s t i m u l u s o n t h e m u s c l e s will p r o d u c e i r r i t a b l e m o v e m e n t s a n d m a k e o b v i o u s a n y h e m i ­ pl eg ia. P a s s i v e m o v e m e n t s a r e t h e n gi v e n f o r it. w i t h d a i l y v e r b a l a n d a c t i v e a t t e m p t s t o s t i m u l a t e t h e p a t i e n t to m o v e t h e li m b s . R e c o v e r y w it h thi s t y p e o f ca s e is u s u a l l y r a p i d a n d u n e v e n t f u l . 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. ) Page 6 P H Y S I O T H E R A P Y M A RCH , 1973 2. T H E M O R E S E V E R E I N J U R Y : T h e b a s i c t r e a t m e n t is t h e s a m e , b u t m o r e a t t e n t i o n m u s t be g i v e n t o k e e p i n g t h e c h e s t c l e a r . T h e p a t i e n t m a y h a v e n o a c t i v e m o v e m e n t e x c e p t f o r e x t e n s o r s p a s m in o n e a r m a n d leg a t t h e s l i g h t e s t e x t e r n a l s t i m u l u s . A s t h e c e r e b r a l l e s i o n s a n d his g e n e r a l c o n d i t i o n i m ­ p r o v e , s p o n t a n e o u s m o v e m e n t s o f h is n o r m a l l i m b s will b e t n e first t o r e t u r n . T o d o p a s s i v e m o v e m e n t s o n t h e a f f e c t e d si d e , th e e x t e n s o r s p a s m in t h e leg c a n u s u a l l y b e r e l a x e d b y s l i g h t l y a b d u c t i n g a n d i n t e r n a l l y r o t a t i n g t h e h i p , t h e n f i rm l y f lex in g t h e t o e s a n d b e n d i n g t h e k n e e a t t h e s a m e t i m e. I f t h e s p a s m still p e r s i s t s , d o n o t f o r c e the m o v e m e n t , b u t s h a k e a n d r o l l t h e l i m b b e f o r e r e p e a t i n g t h e p r o c e d u r e . T n e a n k l e c a n b es t be d o r s i - f l e x e d w h i l s t t h e k n e e is b e n t . H o l d i n g t h e f o o t f i rm l y in t h a t p o s i ­ t i o n , s l o w l y s t r a i g h t e n t h e k n e e t o o b t a i n t h e f u l le s t st r e t c h . T h e s p a s m o f t h e A c h i l l e s t e n d o n , w h i c h c a n be v e r y se v e re a t t i m e s , i m p r o v e s r a p i d l y a s c o n s c i o u s ­ ne s s is r e g a i n e d , a n d n o s p l i n t i n g o r s a n d b a g s h a v e b e e n f o u n d n e c e s s a r y . P a s s i v e m o v e m e n t s d o n e s e v e r a l t i m e s a d a y se e m t o p r o d u c e t h e b e s t r e s u l t s . O n c e t h e p a t i e n t is s t a n d i n g , t h e s p a s m r e l a x e s a n d t h e w e i g h t o f t h e b o d y s t r e t c h e s t h e l a s t f e w d e g r e e s o f t h e r a n g e . T h e e x t e n s o r s p a s m i n t h e a r m c a n , a f t e r a w e e k o r so, e v o l v e i n t o a f l e x o r s p a s m o f t h e e l b o w , w h i c h m a y p r o v e d if fic u lt t o c o p e w i t h . T h e s h o u l d e r s h o u l d be m o b i l i s e d g e n t l y b e c a u s e o f t h e d a n g e r o f a f r o z e n s h o u l d e r d u e t o c a p s u l a r t e a r i n g . A b d u c t a n d e x t e r n a l l y r o t a t e th e a r m a n d w h i l e e l e v a t i n g it, s l i g h t l y s h a k e a n d g r a d u a l l y s t r e t c h it a t t h e e l b o w . W h e r e r e s i s t e n c e is f elt, b r i n g t h e a r m d o w n a g a i n a n d r e p e a t t h e w h o l e p r o c e s s u n t i l y o u h a v e o b t a i n e d as g r e a t a r a n g e o f m o v e m e n t a s p o s s i b l e w i t h o u t f o r c i n g . F i n a l l y , m o b i l i s e w r i st a n d fi ng ers in t h e e l e v a t e d p o s i t i o n . P r o v i d i n g t h e p a t i e n t ' s t e m p e r a t u r e a n d B P is n o r m a l , a n d h e s e e m s t o b e i m p r o v i n g i n h i s r e a c t i o n s , h e c a n g r a d u a l l y be sa t u p , first i n b e d , a n d w i t h i n a d a y or t w o , o u t in a c h a i r , w i t h h e a d a n d a r m s f i r m l y s u p ­ p o r t e d . I f c i r c u m s t a n c e s p e r m i t , h e c a n b e p u t i n a c o l d b a t h d a i l y b y t h e n u r s i n g staff, e v e n w i t h t h e t r a c h e o ­ s t o m y t u b e still in sit u. T h e s t i m u l a t i o n p r o d u c e d by c o l d w a t e r a n d s i t t i n g u p , i m p r o v e s t h e c o n s c i o u s st a t e r a p i d l y . A t t h i s s t a g e , a r e s p o n s e t o c o m m a n d m a y be f o r t h c o m i n g . A t t h e r e q u e s t : “ S q u e e z e m y h a n d ” , o n e m a y fe el a sl i g h t g r i p , w h i c h i n d i c a t e s t h a t a l t h o u g h t h e p a t i e n t m a y n o t s e e m a w a k e o r r e g i s t e r i n g a n y t h i n g g o i n g on a b o u t h i m , a n d is n o t a t t e m p t i n g t o v o c a l i s e , he c a n a t l e a s t h e a r a n d c o m p r e h e n d . N o w th e r e h a b i l i t a t i o n p r o g r a m m e c a n c o m m e n c e . T h e p a t i e n t m a y be c o n f u s e d a n d m a y o n l y r e a c t t o a f e w c o m m a n d s a t first, b u t w i t h c o n s t a n t s t i m u l u s o f m o v e m e n t a n d t h e p h y s i o t h e r a p i s t ’s v o i c e , i m p r o v e m e n t c a n be r a p i d . M a t r o u t i n e s h o u l d b e s t a r t e d , w i t h p a r ­ t i c u l a r a t t e n t i o n t o h e a d c o n t r o l a n d b a l a n c e . T o b e g i n w i t h o n e h a s t o p u t t h e p a t i e n t i n t o t h e d e s i r e d p o s i ­ t i o n s , e.g. w i t h t h e p a t i e n t in s u p i n e , lift a n d t u r n his h e a d t o e n c o u r a g e h i m t o r o l l ; r a i s e hi s h i p s i n b r i d g ­ i ng. R o l l h i m i n t o p r o n e - l y i n g , r e m e m b e r i n g t h a t i f he still h a s a t r a c h e o s t o m y , a p i l l o w m u s t b e p u t u n d e r h is ch e s t . P l a c e h i s e l b o w s u n d e r hi s s h o u l d e r s w i t h hi s h a n d s f o r w a r d s , a n d e n c o u r a g e h i m t o lift h i s h e a d . Br isk s t i m u l a t i o n o f t h e t r a p e z i u s m u s c l e a n d a s s i s t a n c e in r a i s i n g t h e h e a d m a y w e l l p r o d u c e c o - o p e r a t i o n f r o m t h e p a t i e n t e v e n i f h e c a n n o t h o l d h i s h e a d u p f o r lo n g . T h i s m i g h t suffice f o r t h e first m a t t r e a t m e n t a s h e is o f t e n o n l y s e m i - c o n s c i o u s a t t h i s s t a g e . N e x t d a y tr y s i t t i n g .the p a t i e n t u p f r o m s i d e - l y i n g , l e a n i n g o n o n e e l b o w o r t h e o u t s t r e t c h e d a r m , o r p u t t i n g h i m i n t o f o u r p o i n t k n e e l i n g . A s e c o n d p e r s o n ’s h e l p m a y be n e e d e d h e r e , t o a l l o w o n e t o c o n c e n t r a t e o n a p o s s i b l e h e m i p l e g i a a r m . E n c o u r a g e t h e t r i c e p s b y s k i n s t i m u l a ­ t i o n a n d g iv e f u r t h e r c o n s t a n t r e m i n d e r s t o t h e patie nt t o k e e p h i s h e a d u p . P u t h i m i n t o l o n g sit t i n g , leaning b a c k o n h is h a n d s a n d y o u m a y find h i m p u s h i n g him ­ s e lf f o r w a r d a l o n g t h e m a t . I f h e re s i s t s long-sitting, let h i m sit c r o s s - l e g g e d , a s b a l a n c e is e a s i e r i n that p o s i t i o n . A l l t h e t i m e o n e t r ie s t o m a k e t h e p a t i e n t use h i s o w n b a l a n c i n g m e c h a n i s m s a n d t o r e g a i n s o m e of h is p o s t u r a l b o d y - r i g h t i n g re fle xe s. E v e n a se mi-con- s c i o u s p a t i e n t w i t h m i n i m a l p a r e s i s , w h e n p u t i n t o four p o i n t k n e e l i n g h a s b e e n k n o w n t o a t t e m p t t o g e t him­ se lf t o h i s f e e t w i t h o u t a n y c o m m a n d s b e i n g g i v en , and a t t e m p t t o w a l k w i t h t h e a s s i s t a n c e o f t h e p h y s i o t h e r a ­ pi st. O n e s h o u l d n o t h a v e a n y fixed i d e a s o n t r ea tm en t, F ig. 3. T h e fe et o f a p a tie n t w ith a lo n g -te rm brain­ ste m in ju ry . a n d o n e h a s t o " p l a y it b y e a r ” a g o o d d e a l o f t h e time, a s n o t w o c a s e s a r e t h e s a m e . O n l y w h e n t h e patient is f u l l y c o n s c i o u s , c a n o n e b e g i n a n y st r e n g t h e n i n g ex e r c i se s. I t is t h e n a l s o t h a t o n e c a n e n c o u r a g e att em pt s to s p e a k , a n d gi ve h i m p e n a n d p a p e r t o s e e i f h e can w r i t e hi s n a m e , a n d so o n . A t t h i s st a g e , t h e h e l p of th e s p e e c h t h e r a p i s t c a n b e en l i st e d . 3. S E V E R E B R A 1 N -S T E M I N J U R Y : T h e b a s i c t r e a t m e n t is a s b e f o r e , k e e p i n g t h e chest c l e a r , a n d m o b i l i s i n g t h e p a t i e n t a s m u c h a s possible. M a n y b r a i n - s t e r n i n j u r e d , h o w e v e r , h a v e g r o s s spasticity a n d m a i n t a i n it f o r m a n y m o n t h s , w i t h n o s p o n t a n e o u s m o v e m e n t . O n e c a n o n l y a t t e m p t t o k e e p t h e patie nt m o b i l e in t h e h o p e t h a t h e will e v e n t u a l l y r e g a i n co n­ s c i o u s n e s s , w i t h m i n i m a l fixed c o n t r a c t u r e s . It h a s been 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. ) MARCH, 1973 P H Y S I O T H E R A P Y Page 7 found th a t w h e th e r th e p a tie n t is in sid e -ly in g o r su p in e , a sandbag p la c e d so t h a t th e h e a d is flexed f o r w a r d a little, c a n so m e tim e s re lie v e th e sp a sm . W h e n h e h a s been tu rn e d in to p ro n e -ly in g , lea v e h im f o r a s h o rt time w ith h is a rm s u p a b o v e h is h e a d . W h e re th e r e is a very sp a stic h ip o r k n e e , b rin g th e p a tie n t in s u p in e to the edge o f th e b e d a n d in a d d itio n to a s h a k in g o f the leg a n d a b d u c tio n o f th e h ip , b e n d th e k n e e o ver the edge o f th e b ed a s t h e to e s a re flexed. P la c e th e leg b ack o n th e b e d w ith th e k n e e s till b e n t a n d slo w ly increase h ip flexion. T h is , in tu r n , in c re a s e s th e k n e e flexion, b u t th e fu ll ra n g e m a y b e im p o s sib le . T h e lo n g ­ term case w ith th e t ig h t A c h ille s te n d o n is a g r e a t p r o b ­ lem (See illu s tra tio n N o . 3). I f th is ty p e o f p a tie n t starts to w a lk , a te n d o n le n g th e n in g o p e ra tio n m a y have to be d o n e d e sp ite a ll o n e ’s e ffo rts. I t is n o t sufficient just to m o b ilse th e lim b s. R o ta te th e h e a d ; m o b ilise the sh o u ld e r-b la d e s ; r o ta te th e tr u n k w h e n th e p a tie n t is on his sid e , o r, if th e legs a re n o t to o stiff, u se o ne as a fu lc ru m f o r r o ta tin g th e tr u n k w h e n su p in e . - Finally, re m e m b e r in all c a s e s:— W hen tip p in g a p a tie n t f o r c h e s t d ra in a g e a n d som eone else h a s to b e a tte n d e d to , p u ll b a c k th e c u rta in s so t h a t th e p a tie n t is u n d e r c o n s ta n t su r- veilance. N o h e a d -in ju re d p a tie n t s h o u ld b e left alone b e h in d c u rta in s , a s h e m a y o b s tru c t h is a ir ­ way o r h a v e a s e iz u re w ith o u t a n y b o d y b e in g a t hand. I t is im p o r ta n t t h a t th e fit c a n b e se e n b y a n y staff th e re , a n d th a t its fe a tu r e s b e n o te d : w h e th e r occurring ju s t in th e fa ce , o r w h e th e r th e a rm a n d leg a re a lso in v o lv e d , a n d th e e x a c t tim e it lasts. I f o n e w itn e sse s a fit, i t s h o u ld a lw a y s b e r e p o rte d t o th e s iste r im m e d ia te ly . 2. R e p la c e c o ts id e s o n th e b e d . A h e a d -in ju re d p a tie n t is so m e tim e s c o n fu s e d a n d v e ry re stle ss a n d m a y fa ll o u t o f b e d re p e a te d ly . 3. I t is n o t a lw a y s p o s s ib le to e x a c tly lo c a te th e b ra in lesio n , a n d w ith so m e in ju rie s th e p a tie n t is a b le t o ta k e in w h a t is b e in g s a id a r o u n d h im e ven th o u g h h e is q u ite u n a b le to in d ic a te th is. T h e r e ­ fo re , o n e s h o u ld b e v e ry c a r e f u l o f w h a t is said. A n y d e s p o n d e n t s ta te m e n t c a n b e le ft u n s a id u n til la te r. 4. T h e u n c o n s c io u s p a tie n t le a d s a v e ry lo n e ly life , so ta lk t o h im . B y s o d o in g , o n e stim u la te s h is m e n ta l a c tiv ity a n d t h a t is a v e ry im p o r ta n t p a r t o f th e to ta l h e a d in ju r y tre a tm e n t, a n d o n e c a n n o t b e g in to o e a rly . F in d o u t th r o u g h a r e la tiv e w h a t th e p a tie n t’s h o m e la n g u a g e is, b e c a u s e ev en if he c o u ld s p e a k se v e ra l la n g u a g e s p re v io u s ly , h e w ill re s p o n d b e s t a t first to h is n a tiv e to n g u e . I n c e rta in p a r ts o f th e w o rld , th is c a n in v o lv e th e p h y s io th e r a ­ p ist in c o n s id e ra b le lin g u istic d ifficulties, b u t it is a lw ay s w o r th th e a tte m p t! A C K N O W L E D G E M E N T S I w o u ld lik e to th a n k P r o fe s s o r 3. C . d e V illiers, C h ie f C o n s u lta n t, N e u r o -S u r g ic a l U n it, G r o o te S c h u u r H o s p ita l, v e r y m u c h for. h is h e lp in p re p a rin g th is a rticle, a n d f o r th e le n d o f h is p h o to g r a p h s . I n a d d itio n , th a n k s g o to M is s H e b le r f o r th e ty p in g o f th is article. THE TREATMENT OF PENETRATING STAB WOUNDS OF THE CHEST by J. M . H a y se -G r e g so n , D ip . P h y s . (U .C .T .) P h y s io th e ra p ist, B a ra g w a n a th H o s p ita l. Those o f us w h o h a v e h a d to tr e a t p a tie n ts w ith penetrating s ta b w o u n d s o f th e c h e s t, w ill a p p re c ia te that p h y sio th e ra p y p la y s a v ita l ro le in th e m a n a g e ­ ment of th e s e p a tie n ts . A t B a ra g w a n a th H o s p ita l C'proxim ately o n e t h o u s a n d five h u n d re d N o n - E u r o p e a n itients w ith s ta b b e d c h e s ts a re a d m itte d y e a rly . In addition th e s e p a tie n ts m ig h t p re se n t w ith a s ta b b e d abdomen re q u irin g a la p a ro to m y , w h ile n o t in fre q u e n tly , patients a re a d m itte d w ith a p e n e tra tin g s ta b in to th e heart, n e cessitating a th o ra c o to m y . H o w e v e r, fo r th e purpose o f th is a rtic le th e tre a tm e n t o f p a tie n ts w ith penetrating s ta b w o u n d s o f th e c h e s t re q u irin g in te r­ costal d ra in a g e o n ly , is discussed. Mechanism o f Injury The in tra p le u ra l p re s s u re w ith in th e c h e s t is less th a n atmospheric p re ssu re , v a ry in g fro m a p p r o x im a te ly m in u s nine to m inus tw elve c e n tim e tre s o f w a te r in in s p ira tio n , and from m in u s th r e e t o m in u s six c e n tim e tre s o f w a te r on expiration. T h u s e x p a n s io n o f t h e lu n g s is p a ssiv e ly maintained b y a p a r tia l v a c u u m w ith in th e p le u ra . W h e n a stab w ound is in flic te d w h ic h p e n e tra te s th e p le u ra l cavity, allow ing a ir t o e n te r, th e n e g a tiv e p re s s u re within the p le u ra l sp a c e is e lim in a te d , r e s u ltin g in collapse o f th e lu n g , t h e d e g re e o f c o lla p s e b e ing p r o ­ portional to th e a m o u n t o f a ir in th e p le u ra l sp a c e. Pressure w ithin th e p le u r a l sp a c e m a y in c re a s e p r o ­ gressively u n til it ex ceed s a tm o s p h e ric p re ssu re , c on- •tituting a severe te n s io n -p n e u m o th o ra x . T h is m a y a rise w h e n th e la c e ra tio n to th e c h e s t w a ll, tra c h e a , b ro n c h u s o r s m a lle r b r o n c h io le p re s e n ts a s a ‘flap v a lv e ’ w h ic h a llo w s t h e fre e p a ssa g e o f a ir in to t h e p le u r a l sp a c e o n in s p ira tio n , b u t tr a p s th e a ir w ith in t h e p le u r a o n e x p ira tio n . T h is in c re a s in g p re s s u re w ith in th e p le u ra l sp a c e w ill n o t o n ly to ta lly c o lla p s e th e lu n g o n the a ffe c te d sid e , b u t w ill c a u s e th e m e d ia s tin u m to s h if t to th e o p p o s ite sid e , w h ic h in tu rn w ill p r o d u c e c o m p re s ­ s io n o f th e g o o d lu n g . M e d ia s tin a l s h if t a n d d e v ia tio n o f th e tr a c h e a c a n b e c le a rly se e n o n X -R a y . T h is s ta te o f a ffa irs w ill n o t re v e rse u n til a n in te rc o s ta l d ra in is in s e rte d , w h ic h w ill a llo w t h e a ir w ith in t h e p le u ra l sp a c e to e sc ap e . T h e r a te a t w h ic h th e lu n g e x p a n d s is n o t p r o p o r tio n a l t o th e e x te n t o f t h e p n e u m o th o ra x , b u t d e p e n d s o n h o w q u ic k ly th e d a m a g e d lu n g tis su e seals itself. P le u r a l th ic k e n in g a n d th e p re se n c e o f o th e r p a th o lo g y in th e lu n g w ill r e ta r d e x p a n s io n . C lin ic a l signs o f p n e u m o th o r a x a re: (i) D e c re a s e d a ir e n try . (ii) H y p e r - r e s o n a n c e o n p e rc u ss io n . (iii) D e v ia tio n o f t h e tra c h e a a w a y fro m th e a ffected side. (S ee F ig . 1.) W hein th e lu n g tis su e o r th e in te rc o s ta l vessels a r e la c e ra te d , th e p a tie n t p re s e n ts w ith a h a e m o th o ra x . L a c e r a tio n o f lu n g tis s u e is th e m o s t c o m m o n c a u s e o f a h a e m o th o ra x , w h e n th e c lo ttin g o f v essels is u su a lly ra p id a n d e ffective, th u s r e n d e rin g s e c o n d a ry h a e m o r r ­ h a g e o r a p ro g re s siv e ly in c re a s in g h a e m o th o ra x a n u n ­ u s u a l o c c u rre n c e . N e v e rth e le s s a se c o n d X -R a y w ill fre - 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. )