Nutritional Management of BURNS

Presented By:Qurrot Ulain Taher

The skin has an important role to play in the fluid and temperature regulation of the body. If enough skin area is injured, the

ability to maintain that control can be lost. The skin also acts as a protective barrier

against the bacteria and viruses that inhabit the world outside the body.

There are three layers:1.Epidermis, the outer layer of the skin.

2.Dermis, made up of collagen and elastic fibers and where nerves, blood vessels, sweat glands, and hair follicles reside.

3.Hypodermis or subcutaneous tissue, where larger blood vessels and nerves are located. This is the layer of tissue that is most important in temperature regulation.

• Burns are a result of the effects of thermal injury on the skin and other tissues

• Human skin can tolerate temperatures up to 42-440 C (107-1110 F) but above these, the higher the temperature the more severe the tissue destruction

• Below 450 C (1130 F), resulting changes are reversible but >450 C, protein damage exceeds the capacity of the cell to repair

Classification According to Depth• First-degree Burns (mild): epidermis

Pain, erythema & slight swelling, no blisters Tissue damage usually minimal, no scarring Pain resolves in 48-72 hours

• Superficial Second-degree Burns: entire epidermis & variable dermis

Vesicles and blisters characteristic Extremely painful due to exposed nerve

endings Heal in 7-14 days if without infection

• Midlevel to Deep Second-degree Burns: Few dermal appendages left There are some fluid & metabolic effects

• Full-thickness or Third-Degree: entire epidermis and dermis, no residual epidermis

Painless, extensive fluid & metabolic deficits Heal only by wound contraction, if small, or if

big, by skin grafting or coverage by a skin flap

BURNS

Mild Burn

2nd degree Burn 1 hr

2nd degree Burn 1 day

2nd degree Burn 2 days

• Burns are measured as a percentage of total body area affected. The"rule of nines“ , is a measurement adjusted for infants and children.

• This calculation is based upon the fact that the surface area of the following parts of an adult body each correspond to approximately 9% of total (and the total body area of 100% is achieved):

• Head = 9%• Chest (front) = 9%• Abdomen (front) = 9%• Upper/mid/low back and buttocks = 18%• Each arm = 9%• Each palm = 1%• Groin = 1%• Each leg = 18% total (front = 9%, back = 9%)• As an example, if both legs (18% x 2 = 36%),

the groin (1%) and the front chest and abdomen were burned, this would involve 55% of the body.

• Rule of Nines• Rule of Palms• Lund & Browders chart• Baux Score = Age + % of Burn

Classification According to Extent

• Mild: 10%• Moderate:

10-30%• Severe: > 30%

• Hospitalization for > 10% of body surface area

Anatomic structure

Surface area

Head 18%

Anterior Torso 18%

Posterior Torso 18%

Each Leg 14%

Each Arm 9%

Perineum 1%

Infant Rule of Nines (for quick assessment of total body surface

area affected by burns)

• Scald Burn: most frequent in home injuries; hot water, liquids and foods are most common causes; above 65o C, cell death

• Flame Burn: due to gasoline, kerosene, liquified petroleum gas (LPG) or burning houses

• Chemical Burn: common in industries and laboratories but may also occur at home; acid is more common than alkali

• Electrical Burn: worse than the other types; with entrance and exit wounds; may stop the heart and depress the respiratory center; may cause thrombosis and cataracts

• Radiation Burn: from X-ray, radioactive radiation and nuclear bomb explosions

Scald Burns Flame Burns

Chemical (Acid) Burns

Radiation (Flash) Burns

Electrical Burns Entrance Wounds

Electrical Burns Exit Wounds

Entrance wound of electrical burns from an overheated tool

Severe swellingpeaks 24-72 hrs after

Electrical burns mummified1st 2 fingers later removed

COMPLICATIONS OF BURNS• Burn Shock• Pulmonary complications due to

inhalation injury• Acute Renal Failure• Infections and Sepsis• Curling’s ulcer in large burns over

30% usually after 9th day• Extensive and disabling scarring• Psychological trauma• Cancer called Marjolin’s ulcer, may

take 21 years to develop

• Typically, biphasic response• The initial period of hypofunction manifests as: • (a) Hypotension, • (b) Low cardiac output, • (c) Metabolic acidosis, • (d) Ileus, • (e) Hypoventilation,• (f) Hyperglycemia, • (g) Low oxygen consumption and • (h) Inability to thermoregulate

Nutritional care for a patient in burns is adjusted to individual needs and is given in three stages:

This ebb phase/ Shock Period occurs usually in the first 24 hours and responds to fluid resuscitation

The flow/ Recovery phase, resuscitation, follows and is characterized by gradual increases in (a) Cardiac output, (b) Heart rate, (c) Oxygen consumption and (d) Supranormal increases of temperature

The Anabolic Phase/ hypermetabolic hyperdynamic response peaks in 10-14 days after the injury after which condition slowly recedes to normal as the burn wounds heal naturally or surgically closed by applying skin grafting

GOALS OF NUTRITIONAL MANAGEMENT

•To promote optimal wound healing and rapid recovery from burn injuries.

•To minimise risk of complications, including infections during the treatment period

•To attain and maintain normal nutritional status

•To minimise metabolic disturbances during the treatment process

OBJECTIVES OF NUTRITIONAL MANAGEMENT

•Provide nutrition via enteral route within 6 - 18 hours post burn injury•Maintain weight within 5 % - 10 % of pre-burn weight•Prevent signs and symptoms of micronutrient deficiency•Minimise hyperglycaemia•Minimise hypertriglyceridaemia

NUTRITIONAL MANAGEMENT

Enteral Feeding Should Be Commenced Early

Aggressive Nutritional Support is Often Required

Energy Requirements are Elevated by the Burn Injury

Protein Requirements are Substantially Increased

An Increased Requirement Exists for Nutrients Associated with Healing and Immune Function

Enteral nutrition support with a high–protein, high–carbohydrate diet is recommended, and timing may be critical. Feedings started within ~ 4 to 36 hours following injury appear to have advantages over delayed (> 48 hours) feedings.

Enteral support can reduce the burn–related increase in secretion of catabolic hormones and help maintain gut mucosal integrity. The duodenal route is better tolerated than gastric feeding, due to an 18% failure rate in the latter from regurgitation.

Total parenteral nutrition (TPN) is not recommended, due to its ineffectiveness in preventing the catabolic response to burns.TPN also impairs immunity and liver function and increases mortality, when compared with enteral nutrition.

ENERGY AND MACRONUTRIENT SUPPORT

Significant weight loss is preventable with nutritional support. Recommended daily energy intake is as follows: for adults, 25 calories per kilogram plus 40 calories per each percent of burn area for children, 1,800 calories plus 2,200 calories per m2 of burn area. Individualized nutrition assessment is recommended for patients with burns on >20% of TBSA

•High–carbohydrate, low–fat diets for burn patients result in less proteolysis and more improvement in lean body mass, compared with high–fat diets,and may reduce infectious morbidity and shorten hospitalization time, when compared with a high–fat regimen.

•However, the benefit of a high–carbohydrate formula must be balanced against the risk for hyperglycemia, which can negatively influence the outcome of critically ill patients. Nearly all burn patients experience insulin resistance as part of their hypermetabolic response and will need to be placed on an insulin drip to maintain tight control of their blood glucose level.

•Protein and fluid needs must also be considered carefully. Protein oxidation rates are 50% higher in burn patients, and protein needs are ~1.5 to 2.0 grams/kg. Water loss can be as much as 4 liters/m2/day, and a range of 30 to 50 ml/hour is given depending on urine output

FIRST AID MEASURES IN BURNS

1. Extinguish flames by rolling in the ground, cover child with blanket, coat or carpet

2. After determining airway is patent, remove smoldering clothes and constricting accessories during edema phase in the 1st 24-72 hours after

3. Brush off remaining chemical if powdered or solid then wash or irrigate abundantly with water

4. Cover burn wounds with clean, dry sheet and apply cold (not iced) wet compresses to small injuries; significant burns (>15-20% BSA) decreases body temperature which contraindicates use of cold compress dressings

5. If burn caused by hot tar, mineral oil to remove it

NON DIETARY MANAGEMENT

For 1st and 2nd degree burns less than 10% BSA

• Blisters should be left intact and dressed with silver sulfadiazine cream

• Dressings should be changed daily washing with lukewarm water to remove any cream left

INITIAL PROCEDURES

• Fluid infusion must be started immediately• NGT insertion to prevent gastric dilatation,

vomiting and aspiration• Urinary catheter to measure urine output• Weight important and has to be taken daily• Local treatment delayed till respiratory

distress and shock controlled• Hematocrit and bacterial cultures

necessary

Fluid Resuscitation• For most, Parkland formula a suitable starting

guide (4 ml Ringer’s Lactate/kg body weight/% BSA burned), ½ to be given over 1st 8 hr from time of onset while remaining over the next 16 hr

• During 2nd 24 hr, ½ of 1st day fluid requirement to be infused as D5LR

• Oral supplementation may start 48 hr after as homogenized milk or soy-based products given by bolus or constant infusion via NGT

• Albumin 5% may be used to maintain serum albumin levels at 2 g/dl

• Packed RBC recommended if hematocrit falls below 24% (Hgb <8 g/dl)

• Sodium supplementation may be needed if burns greater than 20% BSA

Inhalation Injury• Three syndromes:

1. Early CO poisoning, airway obstruction & pulmonary edema major concerns

2. ARDS usually at 24-48 hrs or much later3. Pneumonia and pulmonary emboli as late

complications (days to weeks)• Assessment:

1. Observation (swelling or carbonaceous material in nasal passages

2. Laboratory determination of carboxyhemoglobin and ABGs

• Treatment:1. Maintain patient airway by early ET intubation,

adequate ventilation and oxygenation2. Aggressive pulmonary toilet and chest

physiotherapy

Infection Control

• Tetanus prophylaxis: 250-500 IU or 3000 units equine ATS ANST IM; Toxoid

• Antibiotic of choice is one that will include Pseudomonas in its spectrum; most frequent pathogens in burns are Staphylococcus aureus, Pseudomonas aeruginosa and the Klebsiella-Enterobacter species

• Topical therapy: 0.5% Silver nitrate dressing Mafenide acetate or Sulfacetamide acetate

cream Silver sulfadiazine cream Povidone-iodine ointment Gentamicin cream or ointment

Pain Relief and Adjustment

• Important to provide adequate analgesia, anxiolytics and psychological support to:a) Reduce early metabolic stressb) Decrease potential for

posttraumatic stress syndromec) Allow future stabilization and

rehabilitation• Family support patient through

grieving process and help accept long-term changes in appearance