ICU conditions: head injury, tetanus, spinal cord injury and neuromuscular disease

1Traumatic head injury

What it is

Brain injury from an external force (road accidents, falls, assault). Primary injury happens at impact (contusion, diffuse axonal injury, extradural or subdural haematoma). Secondary injury follows over hours and days from low oxygen, low BP, raised intracranial pressure (ICP), seizures, fever and high or low blood sugar. The whole ICU plan, including physiotherapy, is built to prevent secondary injury.

What you see in the ICU

• Reduced consciousness; ventilated and sedated; ICP monitor or external ventricular drain; sometimes part of the skull removed (decompressive craniectomy).
• Abnormal posturing: decorticate (arms flexed, legs extended) or decerebrate (arms and legs extended); changing tone; seizures.
• Episodes of fast heart rate, high BP, sweating, fever and posturing (paroxysmal sympathetic hyperactivity).
• Chest problems: aspiration at the time of injury, ventilator-associated pneumonia, collapse; agitation and confusion as the patient wakes.

Medical point that matters for physio

• ICP is treated when it rises above about 22 mmHg; cerebral perfusion pressure (MAP − ICP) is kept at about 60–70 mmHg (Brain Trauma Foundation, 2016).
• Avoid low oxygen and low BP; keep CO₂ normal (high CO₂ widens brain vessels and raises ICP); head up 30°; sedation; drugs such as mannitol or hypertonic saline; surgery for haematomas.

ICF summary

Impairments: reduced consciousness, retained secretions, abnormal tone and posture, weakness, contracture and pressure-sore risk, later cognitive and behaviour changes. Activity: fully dependent. Participation: work, family and study roles, often for months. Context: young adults; family support and access to long-term rehab matter.

Physiotherapy by problem

• Chest: head up 30° with the neck straight; side-lying turns as ICP allows; chest vibrations and compressions on expiration for secretions (in a study of sedated head-injury patients they did not change ICP or cerebral perfusion pressure); suction only when needed, after sedation and pre-oxygenation, with short passes. Suction raised ICP (about 20 to 26 mmHg) but it settled within about 10 minutes, and perfusion pressure was kept.
• Tone and contractures: positioning out of the abnormal posture (for example side-lying with flexed hips and knees for extensor tone), ankle splints, gentle passive range of motion; serial casting later for fixed plantarflexion.
• Mobilisation: once ICP is stable and not being actively treated: sitting up in bed, sitting over the edge, tilt table, standing; watch BP and ICP.
• As the patient wakes: calm, consistent handling for agitation; orientation; family involvement; then neurological rehabilitation (see Neurophysiotherapy).

Precautions

• ICP above target or being actively treated: no active mobilisation; minimal, clustered handling.
• No head-down tilt; avoid neck flexion and rotation, tight tube ties and high-pressure bagging (all raise ICP).
• Craniectomy: no pressure on the side without bone; helmet when mobilising.
• External ventricular drain: clamp or level it as the team instructs before moving the patient.
• Spine not yet cleared: log-roll and spinal precautions; check for other fractures.

Exam points

• GCS grades; ICP 22 and perfusion pressure 60–70; head up 30°; suction raises ICP briefly, so sedate and keep it short; prevent contractures from day one.

2Tetanus

What it is

An illness caused by the toxin of Clostridium tetani, whose spores enter through wounds (puncture wounds, burns, injections, unclean delivery or cord care in newborns). The toxin travels up the nerves and blocks the inhibitory nerve cells in the spinal cord and brainstem, so muscles contract without control and the autonomic nervous system overacts. Symptoms usually start 3–21 days after the injury. It is prevented by vaccination; India was declared free of maternal and neonatal tetanus in 2015, but adult cases still occur after injuries.

What you see in the ICU

• Lockjaw (trismus), a fixed grin (risus sardonicus), stiff neck, back and abdomen; arching of the back (opisthotonus).
• Painful spasms set off by touch, noise, light or moving the patient; the patient stays fully conscious, which is very frightening.
• Spasm of the larynx and a rigid chest wall cause respiratory failure; difficulty swallowing and aspiration.
• Severe cases: unstable BP, fast or irregular heart rate, sweating, fever (autonomic instability).

Medical point that matters for physio

• Wound cleaning, human tetanus immunoglobulin, metronidazole; sedation (benzodiazepines); magnesium sulphate reduces spasms and autonomic swings (trial, 2006); paralysing drugs with ventilation and an early tracheostomy in severe cases.
• A dark, quiet room. The illness lasts several weeks. The patient needs vaccination after recovery, because having tetanus does not give immunity.

ICF summary

Impairments: rigidity and spasms, respiratory failure, retained secretions, aspiration, pain, autonomic instability, later weakness and deconditioning. Activity: fully dependent. Participation: off work for weeks to months. Context: often a manual worker with an untreated wound; fear and anxiety.

Physiotherapy by problem

• Plan with the team: treat when sedation is adequate (often just after a dose); keep sessions short; no sudden touch or noise.
• Chest: positioning and regular turns, gentle chest vibrations and shaking, suction with sedation; humidification for a tracheostomy.
• Limbs: positioning and pressure care; slow, gentle passive movement only when spasms are controlled.
• Recovery phase: as sedation and spasms settle: active exercise, jaw-opening exercises, sitting, standing, walking; build strength and endurance after weeks in bed; reassurance.

Precautions

• Any stimulus can trigger spasms and laryngospasm: warn the patient, use firm, slow handling, and stop if spasms start.
• Watch BP and heart rate (autonomic swings); avoid fatigue.
• Strong spasms can fracture vertebrae: report new back pain.

Exam points

• Toxin blocks inhibition; trismus, risus sardonicus, opisthotonus; spasms triggered by stimuli; dark, quiet room; coordinate physiotherapy with sedation.

3Acute spinal cord injury: the respiratory picture

What it is

Damage to the spinal cord, usually from trauma (falls from trees and roofs, road accidents, diving). The higher the level, the more breathing muscles are lost.

What you see in the ICU

• Spinal shock: flaccid paralysis and no reflexes below the level for days to weeks.
• Neurogenic shock (injuries at T6 and above): low BP with a slow heart rate.
• More bronchial secretions (unopposed vagal activity), a weak cough, collapse and pneumonia (the commonest early complications); gut distension that pushes the diaphragm up.
• Vital capacity falls sharply after a cervical injury and often improves over the following weeks to months as spinal shock settles.

Medical point that matters for physio

• The spine is stabilised (collar, traction or surgery); until then strict spinal precautions and log-rolling.
• BP support (a mean arterial pressure of about 85–90 mmHg is often targeted for the first week); ventilation and early tracheostomy in high injuries; DVT prophylaxis.

ICF summary

Impairments: paralysis and sensory loss, low vital capacity, weak cough, secretion retention, low BP, risk of pressure sores, contractures and DVT. Activity: dependent for all mobility and self-care. Participation: work, family and social life for life; major adjustment. Context: home access, carers, funding for equipment.

Physiotherapy by problem

• Weak cough: manually assisted cough (an upward and inward push on the abdomen or lower ribs timed with the cough), cough assist (mechanical insufflation–exsufflation), suction.
• Low lung volume: diaphragmatic breathing; lying flat or semi-reclined when breathless (the abdominal contents support the diaphragm, so vital capacity is often better lying than sitting); an abdominal binder when sitting up; respiratory muscle training (it improves vital capacity and respiratory muscle strength in tetraplegia, Cochrane 2013); manual or ventilator hyperinflation if ventilated.
• Secretions: positioning and turns (log-roll), chest vibrations and shaking, assisted cough.
• Limbs and skin: passive range of motion within spinal limits, positioning and splints, 2–3-hourly turns, pressure care.
• Mobilisation once the spine is stable: sitting up in stages, tilt table for low BP, then wheelchair and rehabilitation.

Precautions

• Spine not yet stable: no active mobilisation; log-roll only.
• Suction or turning can cause severe bradycardia (atropine at hand).
• Autonomic dysreflexia (injuries at T6 and above, after spinal shock): sudden very high BP, pounding headache, flushing and sweating above the level, slow pulse, usually triggered by a full bladder or bowel. Sit the patient up, loosen tight clothing, check the catheter and bowel, call for help.
• Postural hypotension when sitting up; poor temperature control; no assisted cough over a fresh abdominal wound or ileus.

Exam points

• Level decides breathing; C3, 4, 5; assisted cough; better vital capacity lying than sitting; abdominal binder; autonomic dysreflexia at T6 and above.

4Neuromuscular disease in the ICU

What it is

Weakness of the breathing and swallowing muscles from disease of the nerves, the neuromuscular junction or the muscles. Guillain–Barré syndrome is worked on the ICU physiotherapy card; the others in this section are:

• Myasthenic crisis: myasthenia gravis (antibodies block acetylcholine receptors) worsening until breathing fails, often triggered by infection, surgery or some drugs.
• Motor neurone disease (ALS): progressive loss of motor neurones; breathing failure is the usual cause of death.
• Muscular dystrophies such as Duchenne: progressive muscle weakness, scoliosis, chest infections and night-time hypoventilation in the teens and twenties.
• Critical illness polyneuropathy and myopathy: weakness that develops during critical illness itself (ICU-acquired weakness; see the bed rest card).
• Neurotoxic snakebite (krait, cobra): see the poisoning section.

Warning signs of breathing failure

• Falling vital capacity (below about 20 mL/kg is a warning sign), a weak cough, choking on food or saliva, a nasal voice (bulbar weakness).
• Rising breathing rate, accessory muscle use, the abdomen moving in on inspiration (diaphragm weakness), breathlessness lying flat.
• Morning headaches, daytime sleepiness and poor sleep (hypoventilation at night).
• A rising PaCO₂ is a late sign; do not wait for it.
• Peak cough flow: below about 270 L/min the cough may fail during a chest infection, so teach cough augmentation; below about 160 L/min the cough is ineffective.

Medical point that matters for physio

• Myasthenic crisis: ventilation, IV immunoglobulin or plasma exchange, steroids. Too much anticholinesterase drug can cause a cholinergic crisis (weakness with excess secretions).
• Motor neurone disease: non-invasive ventilation improves survival and quality of life in patients without severe bulbar weakness (trial, 2006); decisions about invasive ventilation are planned in advance with the patient.
• Muscular dystrophy: night-time NIV, cough assist, scoliosis surgery, heart monitoring.

ICF summary

Impairments: weak breathing and cough muscles, retained secretions, swallowing weakness and aspiration risk, limb weakness, fatigue, contracture risk. Activity: mobility and self-care limited. Participation: depends on the disease course; work and family roles. Context: equipment (NIV, cough assist) at home, carers, advance care planning.

Physiotherapy by problem

• Weak cough: manually assisted cough, cough assist, breath stacking (several breaths in without breathing out, with a bag and one-way valve, to reach a larger volume before coughing), suction when needed.
• Low lung volume and night hypoventilation: support NIV (mask fit, timing); positioning; breath stacking for lung volume.
• Secretions and aspiration: positioning, airway clearance; swallowing assessment by the speech and language therapist.
• Limbs: range of motion and positioning against contractures; gentle, non-fatiguing strengthening in slowly progressive disease; energy conservation.
• Myasthenia: short sessions with rests, timed when the drug is working (often about an hour after a pyridostigmine dose); stop at the first sign of fatigue.

Precautions

• Avoid fatigue: overworked weak muscles get weaker.
• Watch for the warning signs above and report early; aspiration risk with weak swallowing.
• In progressive disease, respect the patient's choices about ventilation and comfort care.

Exam points

• Warning signs of failure; peak cough flow 270 and 160 L/min; cough augmentation and breath stacking; NIV in motor neurone disease; avoid fatigue.

5Exam corner

None of these conditions was asked on its own in the 20 papers from 2016 to 2026. Guillain–Barré syndrome on a ventilator was asked in S23 (15 marks; see the ICU physiotherapy card), and the paper says any syllabus topic can be asked.

Practice questions (not from a paper)

• 7 marks: physiotherapy for a patient with severe head injury on a ventilator, with precautions.
• 7 marks: respiratory management of a patient with C5 tetraplegia.
• 3 marks: three signs of respiratory failure in neuromuscular disease.
• 15 marks: a 24-year-old after a fall from a tree, C5 complete injury, day 3, weak cough, SpO₂ falling. ICF, goals, physiotherapy.