The document discusses the body's metabolic response to trauma on multiple levels. It begins by defining trauma and distinguishing between physical and psychological trauma. It then outlines the neuroendocrine response to trauma, including increased levels of catecholamines, cortisol, aldosterone, and other hormones. This hormonal response leads to catabolic effects on the body as it breaks down tissues to provide energy. The document also discusses mediators of the metabolic response like cytokines and their effects. Finally, it notes implications for therapy focus on supporting the body through the metabolic response phases until recovery.

1. Traumatic
Experiences &
your Health – A
Medical View
Aker Kenneth Ityo, MBBS, FWACS, FAA
Orthopaedic and Trauma Surgeon
Director of Clinical services &
Operations
Nisa Garki Hospital Abuja

2. NisaGarki Hospital Abuja
 1st Hospital built by FCTA in 1986
 Owned by the Federal Capital Territory
Administration (FCTA)
 Closed in 2001
 March 2007, a concession agreement
for the management and operation of
the Garki General Hospital Abuja was
signed between FCTA and Nisa Premier
Hospital

3. NisaGarki Hospital Abuja
• This is in line with the Federal
Government’s Public Private
Partnership (PPP) Policy
• 106 bed hospital

4. NisaGarki Hospital Abuja
• Today it is breaking barriers and
setting the pace in both general
& subsidized specialized services
of all categories including kidney
transplant, open heart surgeries,
invitro fertilization, knee and hip
joint replacements

5. Traumatic Experiences & your Health
Response To Trauma
• Introduction
• Types of Trauma
• The Neuro-endocrine Response to trauma
• Post-traumatic catabolism
• Host mediators of the metabolic response
• Implications for Therapy
• The phase of convalescence
• Conclusion

6. What is Trauma?
 Cellular disruption caused by an
exchange with environmental energy
that is beyond the body’s resilience
 Trauma refers to an event involving a
person who is a victim of or witness to
an atrocity, violence, true horror and/or
the death of another or near death of
ones self

7. What is Trauma?
 Alternate definition of trauma: defined
as physical or emotional injury of any
kind and degree
 It is important to note that almost all
forms of physical trauma affect or lead
to some degree of emotional trauma

8. What is Traumatic Event?
 A traumatic event is an incident that
causes physical, emotional, spiritual, or
psychological harm
 The person experiencing the distressing
event may feel threatened, anxious, or
frightened as a result

9. Traumatic Experiences
 Traumatic experiences/events could be
broadly classified into:
 Acute stress disorder
 Posttraumatic stress disorder

10. Types of Trauma
 Physical trauma
 Psychological Trauma or traumatic
experiences
Response To Trauma

11. Physical trauma
Response To Trauma
• Tissue wound - surgical, traumatic,
burns, fractures, etc
• Volume reduction – haemorrhage,
NGT drainage
• Prolonged starvation
• Infection
• Drugs & Anaesthesia

12. Psychological Trauma
 Death of family member, lover, friend,
teacher, or pet
 Marriage/wedding
 Divorce
 Physical pain or injury (e.g. severe car
accident), terrorism
 serious illness, War, natural disasters
 Emotional stress – pain, fear, anxiety

13. Psychological Trauma
 moving to a new location
 parental abandonment
 witnessing a death
 rape
 domestic abuse
 prison stay

14. Response to Trauma

15. Response to Trauma

16. Body’s Response To Trauma
 The human body responds to
trauma and traumatic experiences
by an integrated sequence of
Endocrine & Biochemical
(adaptive) alterations in regional
and systemic physiology, in the
process of adjustment & recovery
Response To Trauma

17. Human Body’s response to Trauma
 These could largely be encompassed in
the sequence of events in metabolic
responses to trauma
 The response is a challenge-survival
(adaptive) response
Response To Trauma

18. Body’s response to Trauma
 Current understanding based on 2 original
streams of thought:
 Evolutionary Adaptation Charles Darwin (1809-1882)
(survival of the fittest) Individuals with heritable
traits better suited to the environment will survive
 Homeostasis (consistency of milieu
interieur) Claude Bernard (1813-1878) Walter Cannon (1871-1945)
The body maintains a stable internal
environment in the midst of changing
external conditions
Response To Trauma

19. Body’s response to Trauma
 Medical care is based not on the
abrogation of such responses
 But rather on:
 Understanding of the normal adaptation
 Adaptation of treatment to conform to it
 perception of when the response itself is
abnormal or diseased
Response To Trauma

20. What Are These Responses?
Metabolic Response To Trauma

22. The Neuro-endocrine Response
Response To Trauma
• Catecholamines
• Glucocorticoids (cortisol)
• Aldosterone
• Antidiuretic hormone
• Insulin/Glucagon & Glucose
metabolism
• Others

23. Catecholamines
 Epinephrine & Nor epinephrine
 Trigger: excitement, fear,
apprehension, anger, tissue injury
& vol. reduction
 Most basic of post-traumatic hormonal
response
 Effects on:
 Circulation
 Metabolism
 affect activity of other hormones
Response To Trauma

24. Epinephrine Effects
 Beta receptor stimulant
 Stimulates pituitary gland to produce
ACTH
 Activation of hepatic
glycogenolysis(Liberation of liver
energy stores), with elevation of
blood glucose level
 Inhibition of insulin production
leading to amino acid release from
muscle
Response To Trauma

25. Epinephrine Effects
 Stimulation of glucagon secretion
 Direct stimulation of fat hydrolysis
(Break down of fats)
 Vasodilatation in certain vascular beds
 vasoconstriction in others
Response To Trauma

26. Nor-epinephrine
Response To Trauma
•Alpha-receptor stimulant
•Metabolic effects not as marked as
epinephrine:
•Fat mobilizer (Fat breakdown)
•Vasoconstrictor of all vessels (except
myocardial)
•Inhibits insulin production

27. Norepinephrine
Response To Trauma
•Short biological half-life
•Release/response are short /transient
•Sustained trauma leads to:
•Exhaustion of energy stores
•prolonged vasoconstriction
•Ischaemia of tissues

28. Glucocorticoids (Cortisol)
 Rise in serum level post trauma
 Quickly falls to normal with transient
trauma
 Effects:
 Initiates phase of catabolism (breakdown
of body tissues)
 Release of FFA, glycerol,& aas,
 Directly stimulate gluconeogenesis
(formation of glucose)
Response To Trauma

29. Aldosterone
 Stimuli for secretion:
 Blood loss, or loss of body’s water of
any kind
 Rennin-angiotensin mechanism
activation
 Leads to decrease in Renal Blood
Flow
Response To Trauma

30. Aldosterone
 Decrease in Sodium & increase in
Potassium excretion
 Effects:
 Raises a low BP
 Conserve plasma Na maintaining ECF vol
Response To Trauma

31. Antidiuretic Hormone (Vasopressin)
 Produced from the supra-optic tract,
 Released from the post pit. Gland
 Acts directly on the renal tubules, to
decrease salt & water excretion
Metabolic Response To Trauma

32. Insulin/Glucagon & Glucose Metabolism
 ↑blood glucose →↑insulin production
 ↑ Insulin → combustion of glucose as the
primary fuel
 ↓blood glucose→↓Insulin →utilization
of fat and amino acids as major caloric
source
Response To Trauma

33. Consequences of these elevated
Hormones

34. Post Traumatic Catabolism
 Lysis of cellular protoplasm leading to
loss of body cell mass manifested as
weight loss
 Consequently:
 Negative nitrogen balance
 Loss of intracellular electrolytes K, P04, & S04
 Increased amounts of xanthines:
 Creatine, creatinine, & uric acid
 Epinephrine, glucagon, & cortisol are
the 3 main catabolic hormones
Response To Trauma

35. Change in Energy Source &
Oxidation of Fat
 Shift in energy source from mixed
exogenous diet to endogenous
source (Body no longer uses food eaten by mouth but
prefers to break up tissues-Trust nothing from outside body):
 Oxidation of fat
 Inhibition of insulin production
 Muscle protein for gluconeogenesis
 Transient pseudodiabetic state
 Overall effect is weight loss
Response To Trauma

36. Host Mediators Of The Metabolic Response
Response To Trauma
•Complex series of physiologic events in response to
trauma & infection are aimed at:
•Containment & eradication of invasive
organisms
•Reprioritization of substrates to favour
•immune function
•Haemostasis
•Support of vital organs
•Wound healing.
•Several distinct families of mediators are involved in
these responses

37. Mediators
 Complements
 Cytokines
 Platelet activating factor (PAF), &
 Reactive radicals e.g.. Nitric oxide (NO)
Response To Trauma

38. Metabolic Effects of Cytokines
 Mobilization of peripheral proteins &
fat stores, to be used as substrate
for energy & protein synthesis by
splanchnic & immune cells
 Exaggerated or prolonged production leads
to:
 Shock
 Cachexia (severe weight loss)
 ARDS
 MODS/MOSF
Response To Trauma

39. Metabolic Effects Of Nitric Oxide (NO)
 Discovered to be similar to
endothelial derived relaxing factor
(EDRF)
 produced by vascular endothelial cells
 Has important effects on vascular tone
 Exhibits inhibitory effects on platelet
aggregation.
Response To Trauma

40. Gross Effect on the Human Body

41. Remedy & Implication

42. Implications For Therapy
 Challenge of treatment of physical trauma,
and largely psychological trauma is shifted
from
 Early & effective resuscitation to
treatment of the host response to
injury/trauma
 Most treatment is to maintain tissue energy
supply & removal of wastes while stoping the
body from injuring itself
Response To Trauma

43. Implications For Therapy
• These therapies will eventually fail if the
microvasculature ceases to function as
a result of widespread & uncontrolled
cytokine activity which is what these
cytokine aim to do
Response To Trauma

44. Implications For Therapy
• No successful intervention yet for these
cytokines
• Successful treatment is by maintaining
the blood flow and ensuring the toxic
metabolites are washed out while the
body recovers by itself
• Therapy allows a patient to flow
through these predictable phases to
recovery
Response To Trauma

45. Response To Trauma
IMPLICATIONS FOR THERAPY
(MANAGEMENT OF THE RESPONSE TO INJURY)
Injury
Emergency Care
Cardiopulmonary support Wound care General care Nutritional support Other potentially
useful modalities
Resuscitate (Oxygen and volume)
Control hemorrhage
Debride necrotic tissue
Drain pus
Restore tissue intergrity
Maintain intravascular volume
Maintain hyperdynamic
Cardiovascular performance
Ventilatory support as reqired
Debride
Drain pus
Control bacterial
Colonization
Close wound
Provide substrate
for repair
Keep warm
Control pain, anxiety
Pulmonary toilet
Catheter care
Exercise and
mobility
Treat established
infections
Institute early
increased calories
and protein
Use gut as much as
possible
Use mixed fuels
(carbohydrate and fat)
Control blood glucose
Oxygen radical scavengers
Antiendotoxin antibodies
Regional anesthesia
Adrenergic bloodade
Glutamine
Growth hormone

46. The Phases Of Convalescence
 Acute Injury Phase
 Turning Point
 Anabolic Phase
 Fat Gain Phase
Response To Trauma

47. Acute Injury Phase
 Already discussed above
 Phase of release of all the hormones
mentioned in the foregoing following
injury, that results in post-traumatic
catabolism
 Magnitude & duration proportional to
the extent & severity of initiating injury
Response To Trauma

48. Acute Injury Phase
 Treatment is aimed at shortening
this phase and allow the next phase
start
 If treatment is successful
Catecholamine responses will cease
 If this occurs, within 2-5 days the
patient begins to look clinically
brighter
 Vital signs will improve

49. The Turning Point Phase
• And the patient enters the turning
point
 Organ/system specific recovery indices
like Return of peristalsis, flatus, etc
 Return of appetite with a strong desire
for food
 Diuresis
Response To Trauma

50. The Turning Point Phase
 A renewed interest in surroundings
 A desire to see visitors, to read & to
return to living
 The young woman now seeks to restore
her cosmetics (“positive lipstick sign”)
Response To Trauma

51. The Anabolic Phase
 Increase in levels of anabolic hormones
mainly GH & insulin
 Increasing strength, appetite, & food
intake
 Normal absorption
Response To Trauma

52. The Fat Gain Phase
 Nitrogen metabolism has returned to
zero balance
 Patient continues to gain fat almost
exclusively
 Normal stores of body fat are regained
 Weight gain through fat accumulation
 Patient’s clothes again begin to fit
normally
Response To Trauma

53. Time is of essence in all these

54. Conclusion

55. Conclusion
 The interlocking events of physio-
biology, though complicated is also
fascinating
 The medical practitioner is privileged to
witness, at times to assist, but rarely to
modify these responses
Response To Trauma

56. Conclusion
 At best the medical practitioner
appreciates these processes & assists
them and at the very least he must
understand them if he is to be effective
in his service to the sick
Response To Trauma

57. Conclusion
 If his treatment is ideal, appropriate
operation and intervention well
conceived & executed, they will impose
a minimal catabolic change in the
patient’s body composition
Response To Trauma

58. Conclusion
 As the surgeons reward,
 There is no more gratifying experience in all of
medicine than to see a critically ill patient
 Pass through the deep valley of challenge &
combustion
 Finally to emerge, climb the mountain of
anabolism,
 And return to the peak of normal living with his
wound healed, & his body composition
restored!!
Response To Trauma

59. Thank you all