Download - Hormonal & Metabolic Respons of Trauma

8/3/2019 Hormonal & Metabolic Respons of Trauma

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HORMONAL & METABOLIC RESPONSHORMONAL & METABOLIC RESPONS

TO TRAUMATO TRAUMA

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

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


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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


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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


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* 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


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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


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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)


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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


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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


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


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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.


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FOLLOWING TRAUMA :FOLLOWING TRAUMA :

Px anegicPx anegic post traumaticpost traumaticsepsissepsis

( Immunosepsis effect of( Immunosepsis effect of

trauma )trauma )

Prod.ofimmunoglobulinProd.ofimmunoglobulin

NeutrophilchemotaxisNeutrophilchemotaxis

PhagocytosisPhagocytosis

LysosomalenzymecontentLysosomalenzymecontent


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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


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the Journal of Bone & Jointthe Journal of Bone & Joint

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


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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


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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


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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


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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


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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


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