Hormonal & Metabolic Respons of Trauma

download Hormonal & Metabolic Respons of Trauma

of 19

Embed Size (px)

Transcript of Hormonal & Metabolic Respons of Trauma

  • 8/3/2019 Hormonal & Metabolic Respons of Trauma

    1/19

    HORMONAL & METABOLIC RESPONSHORMONAL & METABOLIC RESPONS

    TO TRAUMATO TRAUMA

    RONNY B,drg*,RONNY B,drg*,

    DAVID B. K.drg.SpBM**DAVID B. K.drg.SpBM**

  • 8/3/2019 Hormonal & Metabolic Respons of Trauma

    2/19

    During Trauma ~ TissuesmaybeDuring Trauma ~ Tissuesmaybe

    Injured :Injured :

    Directly by mechanical forces,Directly by mechanical forces,physical factors (extreme heat,coldphysical factors (extreme heat,cold&radiation)&radiation)

    Indirectly by distrurbances of bloodIndirectly by distrurbances of bloodsupplysupply

  • 8/3/2019 Hormonal & Metabolic Respons of Trauma

    3/19

    Physiologic Response to InjuryPhysiologic Response to Injury

    Metabolic response :Metabolic response :

    CUTHBERTSONS TWO PHASECUTHBERTSONS TWO PHASE

    (Ebb phase, Flow phase ( catabolic(Ebb phase, Flow phase ( catabolic& anabolic )& anabolic )

    4 Phase metabolic response4 Phase metabolic response

    shock phaseshock phase resuscitation phaseresuscitation phase

    hyper metabolic phase (post injury)hyper metabolic phase (post injury)-- MODSMODS

  • 8/3/2019 Hormonal & Metabolic Respons of Trauma

    4/19

    * otmar L.T.:AO principles of fracture* otmar L.T.:AO principles of fracturemanagement 2000 Thiememanagement 2000 Thieme--sthgartsthgart

    newyork p 662newyork p 662

    StressStress

    FearFear CortexCortex

    PainPain

    EndotoxinEndotoxin

    TemperatureTemperature HypotHypotPituitaryPituitary

    Blood volumeBlood volume

    fluid shiftsfluid shifts

    HypoxemiaHypoxemia

    Hypercapnea AcidosisHypercapnea Acidosis ReceptorsReceptors

    Brain StemBrain StemAutonomicAutonomic

    Tissue InjuryTissue Injury

    CortexCortex

    HypothalamusHypothalamus PituitaryPituitary

    Brain StemBrain Stem Autonomic CentersAutonomic Centers

  • 8/3/2019 Hormonal & Metabolic Respons of Trauma

    5/19

    Efferent Stimuli :Efferent Stimuli :

    efferent response to re establish homeostasisefferent response to re establish homeostasis

    by restitution of :by restitution of :The effective circulating plasma volumeThe effective circulating plasma volume

    To provide fuelTo provide fuel

    To maintain vital organ functionTo maintain vital organ function

    Autonomic Nervous SystemAutonomic Nervous System catecholamines :catecholamines :

    Non epinephrineNon epinephrine

    EpinephrineEpinephrine

    A1 mediated peripheral vasoconstrictorA1 mediated peripheral vasoconstrictor

    B1 mediated heart rate & contractilityB1 mediated heart rate & contractility

  • 8/3/2019 Hormonal & Metabolic Respons of Trauma

    6/19

    Hormonal response : ant pituitaryHormonal response : ant pituitary

    InsulinInsulinGlucagonGlucagonCorticotropinCorticotropinVasopressin ( antidiuretic hormone)Vasopressin ( antidiuretic hormone)Growth hormoneGrowth hormoneThyroxineThyroxine

    Systemic mediators :Systemic mediators :(mediators release after injury w/ local & systemic effect ,as(mediators release after injury w/ local & systemic effect ,asresult of reperfusion, lead to aplification of the inflammatoryresult of reperfusion, lead to aplification of the inflammatoryresponse)response)

    ComplementComplementOxygen radicalsOxygen radicalsCytokinesCytokinesEicosanoidsEicosanoidsNitrit oxide (NO)Nitrit oxide (NO)

  • 8/3/2019 Hormonal & Metabolic Respons of Trauma

    7/19

    METABOLIC RESPONSEMETABOLIC RESPONSE

    CUTHBERTSONS TWO PHASE :CUTHBERTSONS TWO PHASE :

    EBB PHASE :EBB PHASE :

    Occurs initially after injuryOccurs initially after injury

    Characterized by : physiologic response to restoreCharacterized by : physiologic response to restoretissue perfusion & circulating blood volumetissue perfusion & circulating blood volume

    FLOW PHASE :FLOW PHASE :

    Begins once the patient is successfullyBegins once the patient is successfullyresuscitatedresuscitated

    Sub divided :2 phasesSub divided :2 phases

    * CATABOLIC PHASE:* CATABOLIC PHASE:

    -- From daysFrom days weekweek-- Characterized by : hyperdynamic response toCharacterized by : hyperdynamic response totraumatrauma

    * ANABOLIC PHASE :* ANABOLIC PHASE :

    -- begins after wounds have closedbegins after wounds have closed

    -- characterized by return of normal homeostasischaracterized by return of normal homeostasis

  • 8/3/2019 Hormonal & Metabolic Respons of Trauma

    8/19

    4 PHASE METABOLIC RESPONSE :4 PHASE METABOLIC RESPONSE :

    1.1. Shock phase : characterized by hypoperrfusion secondary toShock phase : characterized by hypoperrfusion secondary tohemorrhage & tissue injuryhemorrhage & tissue injury

    2.2. Resuscitation phase :Resuscitation phase :Is seen w/ active vol. resuscitation &Is seen w/ active vol. resuscitation &operation to control hemorrhageoperation to control hemorrhage

    Characterized by : elaboration of many inflammatory mediators.Characterized by : elaboration of many inflammatory mediators.

    3.3. Hyper metabolic phaseHyper metabolic phase (post injury) :(post injury) :Similar to catabolic phaseSimilar to catabolic phaseCharacterized byCharacterized by sympathetic & adrenal responsesympathetic & adrenal responseAcutely , this serves to protect the individualAcutely , this serves to protect the individualProlonged & sustained this phaseProlonged & sustained this phase SIRSSIRSMODSMODS

    4.4. MODS :MODS :Over expression of injuryOver expression of injury induced inflammatory mediators orinduced inflammatory mediators ordevelopment of infections complicationsdevelopment of infections complicationsmost cause of late death in trauma ICUmost cause of late death in trauma ICU

  • 8/3/2019 Hormonal & Metabolic Respons of Trauma

    9/19

    The Journal of Bone & Joint., JBJS.ORGThe Journal of Bone & Joint., JBJS.ORGVol 87A,No2 Feb 05Vol 87A,No2 Feb 05

  • 8/3/2019 Hormonal & Metabolic Respons of Trauma

    10/19

    Diagnosa :Diagnosa :

    Two or more following clinical findingTwo or more following clinical finding

    1.1. Body themperature > 38Body themperature > 38 00 C or < 36C or < 36 00 CC

    2.2. Tachycardia ( HR >90 beats/min)Tachycardia ( HR >90 beats/min)

    3.3. Tachypnea ( RR>20/min)Tachypnea ( RR>20/min)

    ( Pa CO( Pa CO22 12.000 cell/mm33

    5.5. Leucopenia ( WBC 4000 cells/mmLeucopenia ( WBC 4000 cells/mm33 ))

    or significant bondemia>10% immatureor significant bondemia>10% immatureneutrophil Sepsisneutrophil Sepsis SIRS + this result ofSIRS + this result of

    confirmed infection process.confirmed infection process.

  • 8/3/2019 Hormonal & Metabolic Respons of Trauma

    11/19

    FOLLOWING TRAUMA :FOLLOWING TRAUMA :

    Px anegicPx anegic post traumaticpost traumaticsepsissepsis

    ( Immunosepsis effect of( Immunosepsis effect of

    trauma )trauma )

    Prod.ofimmunoglobulinProd.ofimmunoglobulin

    NeutrophilchemotaxisNeutrophilchemotaxis

    PhagocytosisPhagocytosis

    LysosomalenzymecontentLysosomalenzymecontent

  • 8/3/2019 Hormonal & Metabolic Respons of Trauma

    12/19

    CYTOKINES THAT ARE IMPORTANTCYTOKINES THAT ARE IMPORTANT

    INFLAMATORY MEDIATORSINFLAMATORY MEDIATORS

    Interleukin(IL)Interleukin(IL) ---------- ILIL11, IL, IL22, IL, IL33, IL, IL44, IL, IL55, IL, IL66, IL, IL77, IL, IL88, IL, IL99, IL, IL1010,,ILIL1111, IL, IL1212, IL, IL1313, IL, IL1818

    Tumor Necrosis Factors (TNF)Tumor Necrosis Factors (TNF)------TNFTNF,Lymphotoxin (LT),Lymphotoxin (LT)

    Interferon (IFN)Interferon (IFN)------------------ IFNIFN , IFN, IFN , IFN, IFN

    Colony Stimulating Factors (CSF)Colony Stimulating Factors (CSF)------GCSF,MCSF,GM,CSFGCSF,MCSF,GM,CSF

  • 8/3/2019 Hormonal & Metabolic Respons of Trauma

    13/19

    the Journal of Bone & Jointthe Journal of Bone & Joint

    .,.JBJS.ORG,Vol 87A,No2,Feb 05.,.JBJS.ORG,Vol 87A,No2,Feb 05

  • 8/3/2019 Hormonal & Metabolic Respons of Trauma

    14/19

    During the StruggleDuring the Struggle Lethal TriadLethal Triad

    for surgical controlfor surgical control -- metabolic acidosismetabolic acidosisofof -- bleedingbleeding -- hypothermiahypothermia

    -- repeated bouts ofrepeated bouts of -- coagulopathycoagulopathy

    hypotensionhypotension

    -- physiologic instabilityphysiologic instability

    ICU for physiologicICU for physiologic

    restorationrestoration

    Level ILevel I

    Trauma CenterTrauma Center

    Late definitive repairLate definitive repair

    DamageDamageControlControl

  • 8/3/2019 Hormonal & Metabolic Respons of Trauma

    15/19

    Damage Control : 3 distinct phaseDamage Control : 3 distinct phase

    1.1. Abbreviated Surgical Control ofAbbreviated Surgical Control ofhemorrhage and contaminationhemorrhage and contamination

    2.2. Continued and complexContinued and complexresuscitation in the ICUresuscitation in the ICU

    3.3. Definitive repair and reconstructionDefinitive repair and reconstruction

  • 8/3/2019 Hormonal & Metabolic Respons of Trauma

    16/19

    Technical ConsiderationofDamage ControlTechnical ConsiderationofDamage Control

    Phase I : Establishing control & knowing when to stopPhase I : Establishing control & knowing when to stop

    1.1. Hemorrhage control ( vascular clamps, suture ligature, temporaryHemorrhage control ( vascular clamps, suture ligature, temporaryvascular shunting, Avoid complex repair of bleeding solid injuries,vascular shunting, Avoid complex repair of bleeding solid injuries,interventional radiology for complex bleeding.interventional radiology for complex bleeding.

    2.2. Contamination ControlContamination ControlControl bellow viscus injuries for ligamentControl bellow viscus injuries for ligamentSimple repairSimple repairGastro story or jejunostomy tubesGastro story or jejunostomy tubesDebridemant open fractures.Debridemant open fractures.

    3.3. PackingPackingApply laparotomy pads over all dissected surfaces and any solid organ injuries (overApply laparotomy pads over all dissected surfaces and any solid organ injuries (overpack off abd.carity)pack off abd.carity)

    4.4. Abdominal ClosureAbdominal ClosureTowel clip closure, continuous sutureTowel clip closure, continuous sutureBogota bagsBogota bags

  • 8/3/2019 Hormonal & Metabolic Respons of Trauma

    17/19

    Phase II Secondary Resuscitation : Breaking thePhase II Secondary Resuscitation : Breaking thevicious cyclevicious cycle

    1.1. Maximization of hemodynamicsMaximization of hemodynamics

    2.2. Core Re warningCore Re warning

    3.3. Coagulopathy correctionCoagulopathy correction

    Phase III : second operationPhase III : second operation

    Re inspection and reconstructionRe inspection and reconstruction

    Damage control :Damage control :

    require exquisite surgical judgmentrequire exquisite surgical judgmentWhen attempting to resuscitate PX in ICU :When attempting to resuscitate PX in ICU :

    Recognition of failed surgical control of bleedingRecognition of failed surgical control of bleedingand the need for re exploration is essentialand the need for re exploration is essential

  • 8/3/2019 Hormonal & Metabolic Respons of Trauma

    18/19

    Prioritiesand TimingofSurgeryDependingonPrioritiesand TimingofSurgeryDependingon

    Physiological StatusPhysiological Status

    Physiological StatusPhysiological Status Surgical InterventionSurgical Intervention TimingTiming

    Responds toResponds toResuscitationResuscitation

    ((--))live saving surgerylive saving surgery

    (?)(?)DAMAGEDAMAGE

    CONTROLCONTROL(+)(+) DelayedDelayed

    Primary SurgeryPrimary Surgery

    Day IDay I

    Hyper inflammationHyper inflammation Second look onlySecond look only Day 2Day 2--33

    Window of OpportunityWindow of Opportunity Scheduled definitiveScheduled definitivesurgerysurgery

    Day 5Day 5--1010

    ImmunosuppressionImmunosuppression No Surgery !No Surgery !

    RecoveryRecovery Secondary reconstructiveSecondary reconstructive

    surgerysurgery

    Week 3Week 3

  • 8/3/2019 Hormonal & Metabolic Respons of Trauma

    19/19