Question

A person was admitted to hospital for a car accident and sustained a fracture in his right arm and left leg with burns of total burn surface area of 68% and injury in his head and neck due to accident but with no fracture in them. He stayed in coma for 3 days to control his situation and the severity of brain injury is measured by the Glasgow Coma Scale and found to be 14. The patient had no previous medical or nutritional problems. The patient had a surgery for his leg (installation for hip joint), but all other problem were solved with no surgeries. An inflammation happened to his hip after the surgery where the physician delayed his discharge from the hospital. The patient weight upon his admission to hospital is 109 Kg and his height is 188 cm.

1-Discuss the metabolic response in this case describing phases, hormonal state, regulations? (Please notice that your answer not to exceed 300 words, and list the reference you have used).

2-If you are working in this hospital as a dietitian, explain the nutrition plan you will follow for this case, in each stage of his medical treatment plan, from his admission, ICU, before surgery, after surgery, at home, mention all nutrients to concentrate on, or to supply and method of feeding to use in each stage? (Please notice that your answer not to exceed 1 word page, with single space between lines, and no need for references).

-How to assess thyroid disorders medically and nutritionally?

(Please notice that your answer not to exceed 150 words for each point, and list the reference you have used).

Answer 1

Answers :

1. Metabolic phase.

The metabolic response to trauma and sepsis involves an increased loss of protiens.In skeletal muscle the rate of proteolysis is accelarated graetley. The rate of protein synthesis also may be increased but not enough to match the increese in degradation. Intramauscular glutamine concentration is decreased because of increased efflux and possibly decreased de novo synthesis. In the liver the rate of synthesis of selected proteins ( albumin, prealbumin, transferrin, retinol binding protein, and fibronectin) is decreased where as acute phase protein synthesis is accelarated. Increase stress hormone ( cortisol and glucagon ) and cytokine secretion, as well as intracellular glutamine depletion, are potential mediaters of altered protein metabolism in trauma and sepsis.  

Phases :

• emergency or immediate resusciative phase ( onset of injury to completion of fluid resuscitation)

On the scene care ( ABC , initial wound care, injury )

management of fluid loss and shock.

• Acute or intermediate phase ( begenning of diuresis to near completion of wound closure)

Maintanance of respiratory and circulatory status, fluid and electrolyte balance , gastro intestinal functions

Infection prevention , wound care, pain management, and nutritional support

• Rehabilitation phase ( wound closure to optimal level )

Wound healing restoring maximal functional activity, alterations in self image and life style.

Hormonal state

After burn trauma very marked hormonal stae are occur. Mainly the changes in various hormone levels are described, as well as the possible role of the acute phase response after burn trauma and the communications between the endocrine and immune system. Some of the hormons are very sensitive indicators of the burn stress, eg. the T3 levels ( very low ) , testosterone in males ( very low ), dehydroepiandrosterone ( DHEA ) and dehydroepiandrosterone sulfate ( DHEA-S ) ( very low ), ADH, catecholamines , renin and angiotensin II , cortisol ( high ) , 17-beta-estradiol in males ( usually elevated) . Other hormones are usually elevated, but not always ( ACTH, aldosterone, prolactin, glucagon, immunoreactive insulin, beta-endorphin, rT3 , 11-betahydroxyandrostenendion), but there are hormones that are usually low( T4, FSH, androstenendion, progesterone- the later especially in females). Calcitonin , parathyroid hormone, growth hormones are sometimes elevated. TSH is usually normal, the biologically LH is low.

2. Nutrional statement

On admission :

• No oral route can administer because the patient in coma. Early nutrition should started as proactive approach in preventing starvation rather than treating it later.
• Nasogastric tube feeding can providing the extensive calorie requirment. This effectively prevent upper GI tract ulcer formation.

In ICU

• Start rylestube feeding
• Bsal energy expenditure with incremental energy input is calculated based on body weight and burn size is used to calculate nutritional requirment.
• The calorie balance is maintained with 1500 to 2100 cal / day.

Before Surgery

• Corrects proteins and haemoglobin deficiency if any, before undergoing surgery.
• As more protein losses occured during burning and proteins are needed for the repair of tissues.
• if serum albumin level is below 3.5 g/dl it leads to edema formation in body.which affects the healing of burn wounds.so correct it with the iv human albumin.

After surgery

• If the albumin level low correct it with parenteral route. In order to prevent development of gastritis , stress ulcer and to maintain the function of intestinal tract administer 100 ml of milk or other fluids along with protein powder can be given every two hourly.
• Include food containing more anti oxidants and vitamin C, zinc.
• IV infusion of other amino acids can be given alone.
• Add multi vitamins along with iv fluids.
• Maintaining the blood volume using appropriate fluids along with nutritional support is very important for rapid healing of burn wounds.

At home.

Advise the patient to take well balanced diet.

• Pritein rich foods such as, beans, nuts, milk, yogut, and cheese
• Advise to take other nutrients essential to wound healing such as vitamin A , copper and zinc and diet with extra vitamin C.