Nutrition, Airways, & Mandibular Fractures - PowerPoint Presentation

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Nutrition, Airways, & Mandibular Fractures

Dr. Hani Al-Sheikh Radhi

Nutrition

Starvation

75 kg reservoir of 200,000 cal. Theoretically sustain the patient for 3-5 months.

Reality below 140,000 cal. Death can occur.

Body attempts to conserve energy resources and cellular function

No exterior source of energy. The body will consume fat and muscles. (1kg of muscles will provide 800 cal, 1kg of fat will provide 7000 cal)

Hepatic and GIT systems will be first affected. Gradually drop in Glucose levels. After depletion the brain will depend on fat as source of energy.

Fat can’t cross the blood brain barrier it will be transformed into ketone acids to pass the barrier and that will create state of acidosis. Which can cause depression of the CNS and its function

Stress related starvation

Stress means trauma, burn, severe infection. Affect physiology of body

Neuroendocrine mediated process. Catabolism Process controlled by hormones (catecholamine, cortisol, and Glucagon) (Interleukins and Cytokines)

Result

HYPERMETABOLIC STATE

Increase temp., Increase in O2 consumption, Overactive circulation, decrease in insulin, decrease in body mass, lipolysis, increase lactate and pyruvate.

Neuroendocrine Starvation State

Peaks 48-72 hrs. Subside 3-4 days, result in severe loss of vitamins and minerals, severe malnutrition develops within days.

Hyper-metabolic state patient treated by metabolic support

Treatment is different than treating real starvation.

Assess Body Mass Index (BMI), Basic Energy Expenditure formula (BEE), Assess Urine Albumin and Nitrogen

Nitrogen in Urine is very important indicator to the levels of protein destruction. Which if positive indicates continuous state of muscular destruction hence continues state of hyper-metabolism.

All food contain hydrogen and oxygen but only proteins contain nitrogen

Treatment

: well nourished patient expected to be back on oral feeding within 1 week we give I.V. 5% Dextrose equivalent to 500 Kcal/day.

Treatment

: Bad nourishment, +/- more than 1 week before oral feeding we need alternative source of feeding.

NON-ORAL METHODS OF NUTRITIONAL THERAPY

NG Tube (Nasogastric feeding)

Tube inserted from the nose into the stomach

We give the patient

metocoplramide

, relax stomach sphincter pylorus

The tube can sustain the patient 4-6 weeks maximum.

Risk: patient with midface and skull base fractures, tracheostomy

NON-ORAL METHODS OF NUTRITIONAL THERAPY

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG)

Old method named Gastrostomy.

No laparotomy, no scar, no peritoneal tearing, less infection risk

Immediate feeding with PEG, less post-op pain

Indication in OMFS,

Cnacer

H&N, Obstruction in pharynx and Larynx

1. Initial assessment: Recognize airway obstruction.

2. Perform airway maneuvers, clear the airway, reposition patient

3. Use artificial airways, and perform bag-valve-mask ventilation

4. Perform endotracheal intubation.

5. Create a surgical airway if unable to intubate.Emergency Airway Management in the Traumatized Patient

Initial Assessment

Look

1- Patients with compromised airways sits up right.

2- Look of terror on their face.

3- Anxiety and agitation are signs of hypoxia.

4- Altered Level of consciousness are signs of hypercarbia.Listen

FeelQuick way: Ask the patient to describe the injury. If he was able to do it then he doesn’t require rapid airway intervention. Obstruction in the upper airway usually cause noisy breathing,

stridor,and

wheezing.

feel for facial fractures, soft tissue swelling, subcutaneous air in the neck, laryngeal tenderness, and dental injuries during the primary assessment

Maintain the patient’s airways

+ to the basic maneuvers

Oropharyngeal & Nasopharyngeal tubes

Temporary until definitive intubation

Oropharyngeal (OPA)Patients with no history no gagging

Determine the proper size and insertion method Nasopharyngeal (NPA)Patients with no history no gaggingDetermine the proper size and insertion method

Oropharyngeal (OPA)

Nasopharyngeal Airway(NPA)

BAG-VALVE-MASK (BVM) VENTILATION

Provides positive pressure

Used usually with other maneuvers

MOANS Difficulty Test (Mask, Obesity/obstruction, Age, No teeth, Stiffness [Asthma, COPD])

Used usually with other maneuvers

ENDOTRACHEAL INTUBATION

placement of a flexible plastic tube into the trachea to maintain an open airway

2 types: 1- Direct

Laryngeoscopy

2-

Nasotracheal IntubationIndications1- Apnea2- Hypoxia less than 90% SPo23- Inadequate Mask seal.

4- No patent airways.5-GCS less than 9.6- Unstable midface fracture.7- Shock BP less than 80 mmHg

Adjunct Medications

Premedication

I.V. Lidocaine (anesthesia)

Opioids (Analgesia)

Atropine (Decrease Secretions)

Etomidate

(Sedation)Succinylcholine (Muscle Relaxing)

SURGICAL AIRWAY