CP11-8 Nutritional Support in Trauma

Question 1

What is the definition of trauma?

Answer 1

An injury or wound to living tissue caused by an extrinsic agent

Question 2

What percentage of global mortality is caused by trauma?

Answer 2

9%

Question 3

What are some potential features of physical trauma?

Answer 3

Bleeding (intravascular fluid loss)
Extra vascular volume increases
Tissue destruction
Obstructed/impaired breathing
Infection
Inflammation
Starvation due to metabolic changes

Question 4

What changes due to trauma can cause shock?

Answer 4

Blood loss
Poor blood flow
Low O2 supply

Question 5

What are the three phases of metabolic change following trauma?

Answer 5

Shock
Hypercatabolism
Anabolic phase

Question 6

What is involved in the hypercatabolism phase after trauma?

Answer 6

Increase in basal metabolic rate
Increase in anaerobic metabolism
Excessive metabolic breakdown of fat and protein

Question 7

What is involved in the anabolic phase following trauma?

Answer 7

Macromolecule synthesis
Onset of recovery including improved appetite and diuretics.

Question 8

What most commonly causes immediate death after trauma?

Answer 8

Haematological shock
Brain injury

Question 9

What most commonly causes early death after trauma?

Answer 9

Haemorrhage
CNS injury

Question 10

What most commonly causes late death after trauma?

Answer 10

Infection
Multi-organ failure

Question 11

How does loss of circulating volume affect the body?

Answer 11

Decrease in red cells = decrease in O2 causing cellular hypoxia, anaerobic metabolism and lactate accumulation
Decrease in white cells and immune response
Decrease in cardiac output, BP and organ perfusion
Decrease in energy substrate deliver to cells and tissues

Question 12

After trauma what are the endocrine effects of pro inflammatory cytokines (IL-1 and TNF-alpha)?

Answer 12

Increase in catabolic hormones include ACTH (cortisol) and catecholamines (e.g. glucagon)

Decrease in anabolic hormone secretion including growth hormone and insulin

This decreases appetite

Question 13

After trauma, how long can glucose stores in the body last without eating?

Answer 13

24 hours

Question 14

What happens to the brain in states of stress?

Answer 14

It has no glycogen store so has to use ketones in place as an energy substrate

Question 15

What is a danger in the catabolic phase?

Answer 15

Stress-induced hyperglycaemia and increased blood lactate - both reduce prognosis

Question 16

What are some catabolic responses to trauma?

Answer 16

Glycogenolysis
Lipolysis and ketogenesis
Proteolysis and gluconeogenesis

Question 17

How much glucose can be gained from a 1kg of muscle when the body is in a state of proteolysis?

Answer 17

Only 120g

Question 18

How much nitrogen is lost on average per day when the body is in a state of proteolysis?

Answer 18

60-70 g/day

Question 19

What are some qualitative protein changes after trauma?

Answer 19

Increase in inflammatory modulators and scavengers
Increased CRP
Increase haptoglobin
Increase in clotting factors
Decrease in albumin

Question 20

What are some quantitative protein changes that can occur as a result of trauma?

Answer 20

Decrease in synthesis of protein
Decrease in skeletal protein
Decrease in structural protein
Decrease in secreted protein

Question 21

How can unchecked proteolysis lead to death?

Answer 21

Causes life-threatening damage to essential structural and secreted proteins so can no longer prevent the development of infections like pneumonia for examples as can no longer cough to expel infection so retains secretions leading to inflammation.

Question 22

How long does the anabolic phase after trauma usually last?

Answer 22

3-8 days

Question 23

When does the anabolic phase after trauma happen?

Answer 23

Sometimes not until several weeks after severe trauma and coincides with beginning of dieuresis and request for oral intake.

Question 24

What is a risk during the anabolic phase?

Answer 24

Reseeding syndrome risk

Question 25

What is the obesity paradox?

Answer 25

People who are obese tend to do better after trauma as have more energy reserves

Question 26

What is restored in the anabolic phase after trauma?

Answer 26

Body proteins Nitrogen balance Fat stores Muscle strength

Question 27

True or false - provision of adequate nutrition can reverse a hypercatabolic state?

Answer 27

False - strongly catabolic patients cannot achieve a positive nitrogen balance by nutritional intervention until the peak of the catabolic drive has passed, instead it is important to support vital functions, maintain electrolyt and fluid balance.

Question 28

What is important to consider in nutritional support following trauma?

Answer 28

Timing Route - enteral/parental Constituents Monitoring

Question 29

When determining the constituents of nutritional support following trauma, what should be considered?

Answer 29

The demands of the hypermetabolic phase Pre-trauma nutritional state The amount of nitrogen lost What will be lost by immobilisation Refeeding syndrome

Question 30

What is refeeding syndrome?

Answer 30

When a patient has been deprived of nutrition for so long that they are in starvation mode so upon refeeding will cause rapid uptake of glucose.

Question 31

What are some consequences of malnutrition?

Answer 31

Negative nitrogen balance Muscle wasting Widespread cellular dysfunction - including infection, poor wound healing, changes in drug metabolism, prolonged hospitalisation and increased mortality.

Question 32

What is the incidence of malnutrition in hospitalised patients?

Answer 32

50%

Question 33

How do you nutritionally treat patients with CF?

Answer 33

With pancreatic enzyme replacement (Creon) Nutritional supplements Fat-soluble vitamins High calorie diet Ursodeoxycholic acid

Question 34

What is the aim of nutritional treatment in CF patients?

Answer 34

Maintain body weight Avoid catabolic state Introduce peritoneal nutrition early when get sick

Question 35

What is Wernicke’s-Korsakoff syndrome?

Answer 35

A thiamine (B1) deficiency affecting glycolysis, the citric acid cycle, synthesis of nucleic acids, neurotransmitters, formation of gluathione and steroids.

Question 36

What drugs increase breakdown of thiamine?

Answer 36

Anti neoplastic drugs Contraceptives Diuretics

Question 37

What is a consequence of acute B1 (thiamine) deficiency?

Answer 37

Wernicke encephalopathy

Question 38

What is the classic triad that characterises Wernicke’s encephalopathy present in 17% of affected patients?

Answer 38

Encephalopathy, occulomotor dysfunction and gait ataxia

Question 39

What is korsakoff syndrome?

Answer 39

Chronic B1 deficiency

Question 40

What criteria is used to diagnose Wernicke’s encephalopathy?

Question 41

What are symptoms of Wernicke’s encephalopathy?

Question 42

What are symptoms of korsakoff syndrome?

Question 43

How do you treat Wernicke’s encephalopathy?

Question 44

What are risk factors for thiamine deficiency?

Answer 44

Alcohol dependency Cancer chemotherapy Anorexia nervosa Bariatric surgery Refeeding syndrome

Question 45

What modulates the metabolic response to trauma?

Answer 45

Catecholamines Hormones Cytokines