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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...
There are three
layers:
1.Epidermis, the outer
layer of the skin.
2.Dermis, made up
of collagen and elastic
fibers and whe...
• Burns are a result of the effects of thermal
injury on the skin and other tissues
• Human skin can tolerate temperatures...
Classification According to Depth
• First-degree Burns (mild): epidermis
 Pain, erythema & slight swelling, no blisters
...
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
infan...
• 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 surf...
• Scald Burn: most frequent in home injuries; hot
water, liquids and foods are most common causes;
above 65o
C, cell death...
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
S...
COMPLICATIONS OF
BURNS
• Burn Shock
• Pulmonary complications due to
inhalation injury
• Acute Renal Failure
• Infections ...
• Typically, biphasic response
• The initial period of hypofunction manifests as:
• (a) Hypotension,
• (b) Low cardiac out...
Nutritional care for a patient in burns is adjusted to
individual needs and is given in three stages:
This ebb phase/ Shoc...
GOALS OF NUTRITIONAL
MANAGEMENT
•To promote optimal wound healing and rapid recovery
from burn injuries.
•To minimise risk...
OBJECTIVES OF
NUTRITIONAL
MANAGEMENT
•Provide nutrition via enteral route within 6 - 18
hours post burn injury
•Maintain w...
NUTRITIONAL MANAGEMENT
Enteral Feeding Should Be Commenced Early
Aggressive Nutritional Support is Often
Required
Energ...
Enteral nutrition support with a high–protein, high–carbohydrate
diet is recommended, and timing may be critical.
Feedings...
ENERGY AND
MACRONUTRIENT SUPPORT
Significant weight loss is preventable with nutritional support.
Recommended daily energy...
•High–carbohydrate, low–fat diets for burn patients result in less
proteolysis and more improvement in lean body mass, com...
FIRST AID MEASURES IN
BURNS
1. Extinguish flames by rolling in the ground, cover
child with blanket, coat or carpet
2. Aft...
NON DIETARY MANAGEMENT
For 1st
and 2nd
degree burns less than
10% BSA
• Blisters should be left intact and
dressed with si...
INITIAL PROCEDURES
• Fluid infusion must be started immediately
• NGT insertion to prevent gastric dilatation,
vomiting an...
Fluid Resuscitation
• For most, Parkland formula a suitable starting
guide (4 ml Ringer’s Lactate/kg body weight/%
BSA bur...
Inhalation Injury
• Three syndromes:
1. Early CO poisoning, airway obstruction &
pulmonary edema major concerns
2. ARDS us...
Infection Control
• Tetanus prophylaxis: 250-500 IU or 3000 units
equine ATS ANST IM; Toxoid
• Antibiotic of choice is one...
Pain Relief and Adjustment
• Important to provide adequate
analgesia, anxiolytics and
psychological support to:
a) Reduce ...
Pathophysiology, Nutritional Management of BURNS
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Pathophysiology, Nutritional Management of BURNS

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Burns, Introduction, Classification, Pathophysiology, Nutritional Management, Macro nutrient Support, Enteral Nutrition, Nutrition, Energy, Proteins, Calories, Fats, Fluids, Rule Of Nines, Complications, Pathophysiological Response, Nutrition Care, EBB Phase, Anabolic Phase,

Veröffentlicht in: Gesundheit & Medizin
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Pathophysiology, Nutritional Management of BURNS

  1. 1. Nutritional Management of BURNS Presented By: Qurrot Ulain Taher
  2. 2. 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.
  3. 3. 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.
  4. 4. • 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
  5. 5. 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
  6. 6. BURNS Mild Burn 2nd degree Burn 1 hr 2nd degree Burn 1 day 2nd degree Burn 2 days
  7. 7. • 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.
  8. 8. • Rule of Nines • Rule of Palms • Lund & Browders chart • Baux Score = Age + % of Burn
  9. 9. 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)
  10. 10. • 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
  11. 11. Scald Burns Flame Burns
  12. 12. Chemical (Acid) Burns Radiation (Flash) Burns
  13. 13. Electrical Burns Entrance Wounds Electrical Burns Exit Wounds Entrance wound of electrical burns from an overheated tool Severe swelling peaks 24-72 hrs after Electrical burns mummified 1st 2 fingers later removed
  14. 14. 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
  15. 15. • 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
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. 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.
  21. 21. 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
  22. 22. •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
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. Inhalation Injury • Three syndromes: 1. Early CO poisoning, airway obstruction & pulmonary edema major concerns 2. ARDS usually at 24-48 hrs or much later 3. 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 oxygenation 2. Aggressive pulmonary toilet and chest physiotherapy
  28. 28. 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
  29. 29. Pain Relief and Adjustment • Important to provide adequate analgesia, anxiolytics and psychological support to: a) Reduce early metabolic stress b) Decrease potential for posttraumatic stress syndrome c) Allow future stabilization and rehabilitation • Family support patient through grieving process and help accept long-term changes in appearance

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