Trauma and Nutrition Flashcards
What is the definition of trauma?
an injury or wound to living tissue caused by an extrinsic agent
What are the immediate features of physical trauma?
intravascular fluid loss
extravascular volume
tissue destruction
obstructed/impaired breathing
What are the more delayed features of physical trauma?
Starvation
Infection
Inflammation
What are the 4 most common causes of mortality from major trauma?
Haematological shock
head injury
acute respiratory distress syndrome
multi organ failure
What is interrupted in shock?
supply of substrates into the cell e.g. oxygen, glucose, water etc.
removal of metabolites from the cell e.g. CO2, water, free radicals etc.
What are the 3 phases of mortality from trauma?
Phase 1: clinical shoke
Phase 2: Hypercatabolic state
Phase 3: recovery (anabolic state)
How do you get from phase 1 to phase 2 in mortality from trauma?
spontaneous recovery - physiological adaptation
resuscitation - intervention
What is the duration of phase 1 (shock)?
develops 2-6 hours after injury
lasts 24-48 hours
What is secreted in phase 1 (shock)?
cytokines
catecholamines
cortisol
What are body’s responses in phase 1 (shock)?
tachycardia - increased heart rate increased respiratory rate peripheral vaso-constriction - shut down of vital organs to preserve them hypovolaemia
What are the primary aims in phase 1 (shock)?
stop bleeding
prevent infection
What is the duration of phase 2 (catabolic state)?
2 days after injury
What is secreted in phase 2 (catabolic state)?
Catecholamines
Glucagon
ACTH → Cortisol
What are the primary aims in phase 2 (catabolic state)?
Avoid sepsis
Provide adequate nutrition
What are body’s responses in phase 2 (catabolic state)?
↑ Oxygen consumption ↑ metabolic rate ↑ Negative nitrogen balance ↑ Glycolysis ↑ Lipolysis
What causes negative nitrogen balance?
skeletal muscle breakdown to release amino acids
What is the duration of phase 3 (anabolic state)?
3-8 days after uncomplicated surgery
can be weeks after severe trauma/sepsis
What are body’s responses in phase 3 (anabolic state)?
Gradual restoration of:
body protein synthesis, Normal nitrogen balance, Fat stores, Muscle strength
What are the primary aims in phase 3 (anabolic state)?
Adequate nutrition supply is critical in this phase - beware of risk of Refeeding syndrome risk
What is ‘obesity paradox’?
the fact that after trauma, obese people do better in recovery
What are the 5 steps in the inflammatory response at a trauma site?
- Bacteria and pathogens enter wound
- Platelets release clotting factors
- Mast cells secrete factors that mediate vasodilation - ↑ blood delivery to the injured area
- Neutrophils + macrophages recruited to phagocytose pathogens
- Macrophages secrete cytokines - attract immune cells + proliferate the inflammatory response
What effect does inflammatory mediator release have on the capillaries?
systemic capillary leak - leaks H20, NaCl, albumin and energy substrates
What effect does cytokines IL-1, IL-6 and TNF have on the body?
local effects e.g. vasodilatation catabolic effects B/T cell proliferation anorexia endocrine effects fever fibroblast proliferation repair
What are the 5 cardinal signs of inflammation?
heat redness swelling pain loss of function
What are the endrocrine effects of cytokines? What catabolic hormones are secreted?
↑ ACTH → Cortisol ↑ Glucagon ↑ Catecholamines ↓ growth hormone ↓ insulin
what organ in the body requires a constant supply of glucose?
Brain - has no glycogen store
uses ketones as back up energy substate
What is Glycogenolysis?
Glycogen → Glucose
What is Gluconeogenesis?
amino-acids → Glucose + Lactate production
What is Lipolysis + Ketogenesis?
Free Fatty Acid → acetyl CoA → acetoacetate & hydroxybutyrate
What is the effect of loss of ATP in anaerobic metabolism?
loss of membrane Na/K pump → cellular swelling → Loss of membrane integrity → lysosomal enzyme release
What metabolic processes occur to drive Skeletal muscle
Proteolysis as oppose to Synthesis of
new protein?
↑ Inflammatory modulators and scavengers e.g. CRP
↓ Albumin
↑ Free amino acids
↑ Ammonia
↑ N2 loss (via urinary excretion of urea)
How can protein turnover in trauma cause a patient to develop pneumonia?
Respiratory muscle weakness results → poor cough, retention of secretions = pneumonia
What does excess lactate cause in the body?
tissue hypoxia
What is used as a prognostic marker in trauma?
Lactate
How much nitrogen loss occurs in long bones?
60-70g muscle protein
How much nitrogen loss occurs in Severe burns?
300 g muscle protein
Immobilisation increases losses of which ions?
Calcium
Phosphate
Magnesium
What criteria should nutrition after trauma include?
ambient temperature
Use the gut if possible (nasogastric tubes)
TPN (trace elements, fat soluble vitamins)
What is Primary Malnutrition?
Protein-calorie undernutrition (starvation)
Dietary deficiency of specific nutrients
What is Secondary Malnutrition?
Nutrients present in adequate amounts but:
appetite is suppressed
absorption and utilization are inadequate
Increased demand
What is refeeding syndrome?
Occurs in people who have experienced prolonged malnutrition and then started to eat again
insulin secretion resumes in response to increased blood sugar; resulting in increased glycogen, fat and protein synthesis
What protein is mutated in CF?
Cystic Fibrosis Transmembrane Regulator (CFTR) protein
What is the function of the CFTR protein?
production of thin, watery, free-flowing mucus -
lubricates airways and secretory ducts
protecting the lining of the: airways, digestive system, reproductive system
What does Digestive enzyme deficiencies cause?
Malnutrition
Infection
Persistent inflammatory state
What GI diseases are associated with CF?
Meconium ileus at birth
Severe hepatobiliary disease
Pancreatic cysts, exocrine insufficiency
e.g. decreased insulin
What are the treatment options for the Respiratory diseases in CF?
Physiotherapy Exercise Bronchodilators Antibiotics Steroids Mucolytics
What are the treatment options for the GI diseases in CF?
Pancreatic enzyme replacement (Creon) Nutritional supplements Fat-soluble vitamins High calorie diet Ursodeoxycholic acid - for treatment of primary biliary cirrhosis
