AMPUTEE CARE

1
AMPUTEE CARE

• Michael L. Place, MD
• USAFP
• March 2006

2
(No Transcript)
3
AMPUTEE CARE

• Michael L. Place, MD
• USAFP
• March 2006

4
POST-OPERATIONAL CASUALTY CARE

• Michael L. Place, MD
• USAFP
• March 2006

5
LEARNING OBJECTIVES

• Describe the common challenges of war casualties
  after release from tertiary care
• Explain the role of family physicians in caring
  for this select population
• Discuss the affects of traumatic brain injuries
• Explain the management of amputated limb pain

6
AMPUTEE HISTORICAL PERSPECTIVE

• Civil War nearly 21,000
• WWI over 4,000
• WWII almost 15,000
• Korean Conflict over 1,000 traumatic
  amputations
• Vietnam estimated 6,000 by VA records and
  approximately 3 in the Emergency War Surgery
  Handbook
• Gulf War - 15

7
SCOPE

• 381 patients with major limb amputations
• 59 patients with multiple limbs (15)
• 4 patients with 3 limb involvement
• 10 patients with hip disarticulation
• 104 patients with upper extremity involvement
  (27)
• Amputees comprise 2.2 percent of wounded Soldiers

8
MEDICAL EVACUATION
Follow up at WRAMC or at the local VA or
civilian facility for final prosthetic fitting.
12 BAMC
168 WRAMC 7 BAMC
From LRMC 7 San Diego NMC 1 Camp Lejeune 1
Camp Pendleton 1 Ft Irwin 1 Ft Campbell 2
MAMC
39 to Bethesda 24 to WRAMC 2 to BAMC
OIF 216
LRMC 211 OIF 22 OEF
OEF 22
9
RELEVENCE TO USAFP

• Concerted effort to retain in military
• Multidisciplinary approach required for
  successful management
• PT for general conditioning early and extensive
  involvement in LE amputation
• OT hand/UE injuries including assessment for
  brachial plexus injuries that limit shoulder
  girdle
• Prosthetics specialists
• Neuro consider EMG if clinical evidence of
  weakness or plexopathy
• Physiatry and Pain specialists for pain
  management
• Mental Health concomitant stress reaction,
  survivors remorse, depression, generalized
  anxiety disorder and PTSD common

10
COMMON ISSUES

• Acute concerns (tertiary discharge to 6 months)
• Pain Management
• Traumatic Brain Injuries
• Grieving and Reintegration
• Physical Rehabilitation
• Chronic Concerns (gt 6 months)
• Stump pain
• Phantom Limb Pain
• PTSD

11
PAIN PRIMER

• Neurophysiology of pain
• Transduction peripheral terminals of primary
  afferent nerves result in energy transformation
  into electrical activity
• Transmission electrical activity travels
  through the nervous system
• Modulation process of altering the neural
  activity while in transmission
• Perception the subjective accumulation of all
  input
• 3 Primary receptors (mu, kappa, delta), with mu
  responsible for generalized analgesia
• Mu1 has similar affinity for all opioid peptides
  and results in supraspinal analgesia (euphoria,
  miosis, etc.,)
• Mu2 has greater selectivity for morphine and
  results in sedation, ileus, respiratory
  depression
• Naloxone blocks mu receptors

12
PAIN CONTROL

• Opioids are the drug of choice acutely
• - methadone, fentanyl, long acting morphine and
  oxycodone
• - acts centrally, spinal cord and peripherally
• - select one long acting and one short acting
  med (avoid altering types and routes of admin
  like pca, iv push, oral prn)
• NSAIDs essential in bone pain/amputees
• Gabapentin and TCAs for nerve pain
• Alpha blockers (clonidine) for neuromodulation
• SSRIs and other adjuvants

13
TRAUMATIC BRAIN INJURY

• SGT David Emme

• Injured in IED blast, skull fx requiring
  craniectomy at Balad
• 6 days in WRAMC ICU, sometimes mistaking nurses
  for CIA agents or believing he was back in
  Baghdad.
• On Ward 58, he became alert enough to realize
  that he was having difficulty speaking.
• "I called for the nurse. . . . I kept on just
  trying to say something, but I couldn't really
  say anything," Emme recalled. The nurse asked him
  questions and waited patiently for him to answer.
  Finally, she left to check on other patients.
  About a half hour later, she returned, and Emme
  managed to articulate his message "My head
  hurts."

14
TRAUMATIC BRAIN INJURY

• 22 of OIF casualties per Joint Theater Trauma
  Registry (vice 12 from Vietnam)
• Over 450 diagnosed JAN03-FEB05
• 56 of admitted blast casualties suffering TBI
• Severity based on GCS, length of loss of
  consciousness and post traumatic amnesia (PTA)

15
DIAGNOSTIC CRITERIA
Pathophysiology - postulated as axonal damage
without disruption leading to impaired axonal
transport - potential role of release of
excitatory neurotransmitters and free radicals
with secondary injury Potential increased risk
with previous TBI
16
TRAUMATIC BRAIN INJURY

• Clinical manifestations may emerge over time
• - mood changes (depression, anxiety,
  impulsiveness, emotional outbursts)
• - cognitive disturbances (memory, problem
  solving, language and attention),
• - headaches
• - personality changes
• - sleep disturbances
• - photophbia and phonophobia
• Seizures generally early (commonly in first
  hours) and increase risk of post-traumatic
  epilepsy to more than 25
• Recommend tailoring of treatment (amitriptyline
  or propranolol for HA, donepezil for cognitive
  impairments, SSRIs for irritability and outburst,
  valproate for migraines and behavioral issues)
• Unaware of any published data on long term risk
  of post-concussive syndrome in this population,
  although civilian models of mild TBI (GCS 13-15)
  range from 30-80 w/ PCS

17
POST-CONCUSSIVE SYNDROME
Consider use of standardized instrument for
documentation Postconcussion Symptom Checklist
(Gouvier, Cubic, et al., 1992) or Kennedy-Johnson
Post-Concussive Scale (Cicerone and Kalmar, 1995)
18
(No Transcript)
19
(No Transcript)
20
(No Transcript)
21
(No Transcript)
22
OTHER ACUTECONCERNS

• Normal grief process exacerbated by TBI and
  psychosocial factors
• Oftentimes limited support systems and coping
  techniques
• Depression common and should be routinely
  screened
• Rehabilitation requires significant patience and
  dedication necessitating celebrating incremental
  goals

23
CHRONIC CONCERNS

• Stump pain
• peripherally mediated
• evaluate for skin breakdown due to prosthesis or
  neuroma
• Phantom limb pain
• perceived pain in missing extremity
• centrally mediated
• PTSD
• No data to date on Chronic Regional Pains
  Syndrome (RSD) or contractures
• Evaluate for hearing damage (1 cause of medical
  boards post combat)

24
PHANTOM LIMB PAIN

• Up to 50-80 of all amputees experience
• Little quality data no comparative data of
  treatment modalities for traumatic amputees
• Modalities to attempt include
• - regional nerve blocks
• - TENS
• - salmon calcitonin
• - massage
• - narcotics
• - topicals (DMSO, capsaicin, lidocaine, etc.,)
• Must rule out poorly fitting prosthetics, bone
  spur/heterotopic ossification

25
HETEROTOPIC OSSIFICATION

• Primary cause of stump pain is poorly fitting
  prosthesis
• R/O heterotopic ossification, osteomyelitis

26
EXTREME MAKEOVERHOME EDITION
27
RESOURCES

• Military Severely Injured Center
• Military One Source
• www.painfoundation.org

28
RETURN TO DUTY
http//www.defenselink.mil/news/Apr2005/20050412_5
76.html