ملخص المحاضرتين pptx

METABOLIC RESPONSE

3. RESUSCITATION , surgical intervention and critical care can return the severly injured patients to asituation in which homeostasis become possible once again .
1. HOMEOSTASIS is the foundation of normal physiology
2.As a result of modern understanding of homeostasis minimizing the response by MINIMALACCESS SURGERY & STRESS FREE PERIOPERALINE CARE .
4. THE GRADED NATURE of injury response , (the more sever the injury the greater the response

5.MEDIATERS of the metabolic response to injury :-

A.NEUROENDOCRINE RESPONSE TO INJURY \ CRITICAL ILLNESS IS BIPHASIC :
2
* ACUTE PHASE :characterised by actively secreating pituitary & elevated counter – regulatory hormones (cortisol , glutagon , adrenaline ) .
*CHORONIC PHASE : associated by hypothalamic suppression & low serum levels of the respective target organ hormones . Change contribute to chronic wasting .

B.Systemic inflammatery response syndrome following major injury

* is driven initially by proinflammatory cytokines (e.g IL1 , IL6 interleukin -1 and TNF and tumor necrosis factor alpha )
3
* Is followed rapidly by increased plasma levels of cytokine antagenists and soluble receptors (IL1Ra,TNF-SR interleukin -1reseptor antagonist & TNF soluble reseptors )
*if prolonged or excession may evshe into acounter – inflammatory syndrome .


Important note on metabolic response :-
1 . Homeostasis : in emergency surgery cause amarked disturbance in homeostasis
4
2. Stress response , spinal cord , thalamus , hypothalamus & pituitary all form apart of the neuroendocrine pathaway .
3. Fluid & Electrolyte conservation :
conservation of sodium & water at renal tubule

4 .Stress response depends upon

Severity of injury
5

Types of injury

To get speedy resolution avoid

*secondary in sulits l3 is (ischemia , infection , in adequate oxygen .hypoxia.

*ongoing trauma e.g (compartment syndrome DVT (dap.v.thralz)

Ongoing complation & secondary recovery ...

Hypothalamus
6
TRAUMA spesis major operation


CRF

Anterior pituatory

ACTH

Adrenals

cortisol
Releaze of cortisole

5. The interplay of neuro , endocrine & infammatory factors :

Catechoamine – mediater .. fightor flight .. response
7

Adrenal medulla

adrenaline

Hypothalamus

Nor-adrenaline from perpher neuro

Neuro hormonal response

Cortisol relazing hormone (CRH)

AP (anterior – pituatory)

ACTH

Cortisol & glucocorhiods

Cytokines

Inflammatory response

6 .It is hyperglycemia & not hypoglycemia that occurs in stress response .
7.IN Ebb (early) phase
8
Inflammatory mediaters and hormone mediators accumelate
Hypovolemic


Hypotension

Anaerobic metabolism

Lactic acid ↑ base deficit ↑

BMR ↓ HR ↓ C:O ↓ O2 ↓ Bp ↓ urine ↓ temp ↓

A

9
Hormone regulating ebb phase

Catecolamine cortisole aldosterone

Ebb (early) phase

Purpose is to conserve circulating volume & energy store for recovery & repair

Achirenin of renin – angiostensin system
The ebb phase (holding pattern)
B

10
Wounds healing
1. Normal wound healing :
Inflammatory phase of wound healing lasts for 2-3 days . Proliferative phase last from 3 days to 3 weeks ,remoeling phase last from end of 3 weeks to years
INFLAMMATORY PHASE
Also called exudate phase
1. Has no tonsile strength to the wound
2. It consist of vascular , cellular & enzymatic process


Platlet stick to damage new endothalmic

ADP + cytokines +sorozonin + protoglyandine + histamine

releazing

Causing vasolar permeability in migration of inflammatory cells & macrophages .

Fibringen fibrine frame for fibroblastic

11
Prolifrative phase

Fibroblast activting , collagen proucte , & new capillaries .

Remodelling phase

Re-arrangement of collagen fibers .

2 . Compatment syndrome
Occurs usually in the lower limb , following closed injury , circumferenite burns & crush – injury . The patients complains of sever pain assosiated with sensory disturbance , & late stage absent periphere phase . In crush injuries , presentation maybe late , delayed may be dangerous . Then in become lymoglobin releaze from dead muscle result in myoglobinan → crush syndrome → acute renal failure )vndn such circumstance , ampulzine may be safer .

12
3 . Contrac → scars across joint .
4. Hypertrophic scar
5. Keleiod → exuberant scar
6 . Leg ulcer . Merjohns ulcer .
7. Necrotising soft tissue infection causative organisms are ;
Gram +ve (staph. Aerus )+gram –anaerobic (Ecoli .psudomans ,clostridium , bacctremia )& B- hemolytic streptoccoi . The two main type are (clostridial gass gangrine and streptoccoci orisin )
8 . Pressase sore → are bony prominme → ischemic → ulcer