a case study on burns

1. Case Study on Burns
By Aishwarya Deepika
M19FN01
Mentor: Dr Geetha Santhosh
I Msc Food science and Nutrition
Mount Carmel College, Bangalore

2. Statistics
• Estimated 1,80,000 deaths annually.
• Almost two thirds occur in the African and South-East Asia regions.
• Burns is currently over 7 times higher in low and middle income
countries.
• Burns are leading cause of DALYs
• In 2004, nearly 11 million people worldwide were burned severely.
Source: https://www.who.int/en/news-room/fact-sheets/detail/burns

3. Introduction
A burn is an injury to the skin or other organic tissue primarily caused
by heat or due to radiation, radioactivity, electricity, friction or contact
with chemicals.
Thermal (heat) burns occur when some or all of the cells in the skin or
other tissues are destroyed by:
• Hot liquids (Scalds)
• Hot solids (Contact burns)
• Flame

4. Pathophysiology
Activation of
inflammatory
Response
Disruption of
cellular
Immunity
Activation of
TNF –
alpha, IL-1, IL-
6
Immune
response
Mast cells and
macrophages
Pro
inflammatory
cytokines
Local skin
barrier
Proinflammatory
process
Leukocytopenia
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3188142/
Active macrophages Predictive marker Sepsis or infection
https://www.ncbi.nlm.nih.gov/pubmed/9115613

5. Metabolic Response to Burns Injury
Ebb Phase (Acute)
• Hypodynamic State
• Cardiac Output
• Metabolic rate
• Hyperglycemia
• Plasma volume
Flow Phase (chronic)
• Hyperdynamic state
• Cardiac Output
• Metabolic Rate
• Hyperglycemia

6. Case Study (Patient Profile)
Name: X
Age: 18 years
Gender : Female
SES: Low Income Group
Reason for admission: History of thermal burns on 25-07-2019

7. Nutritional Assessment
• Anthropometric : Weight- 60kg Height – 5'2" BMI= 26.6kg/m2
• Biochemical parameters: (a) Hematology report
0
10
20
30
40
50
60
70
80
90
WBC Count in
10^3/cumm
Neutrophils in % Lymphocytes in % monocytes in % Eosinophils in % basophils in % Platelet Count in
lakhs/cumm
WBC Counts
patients range normal range

8. (b) Serum Electrolytes
(c) Renal Function Tests
0
20
40
60
80
100
120
140
160
sodium in mmol/l Potassium in
mmol/l
chloride in mmol/l
Serum electrolytes
Patients value normal range
0
5
10
15
20
25
30
35
40
45
Urea in mg/dl creatinine in mg/dl
patients value normal range

9. (d) Liver Function Tests
0
20
40
60
80
100
120
140
Serum total
bilirubin in mg/dl
Direct Bilirubin in
mg/dl
Total protein in g/dl Albumin inG/DL Globulin in g/dl A/G ratio in U/L AST in u/l ALT in u/l
Liver function tests
patients value Normal range

10. Physical Examination:
Pulse: 110/min
Respiratory Rate: SpO2 97%
Blood Pressure: 118/80 mmHg
https://www.ncbi.nlm.nih.gov/pubmed/2335555

11. Rule of 9s 7%
4%
18%
9%9%
12%
0%
12%
Total Body
Surface Area:
71%

12. Dietary intake
Source: Clark, A., Imran, J., Madni, T., & Wolf, S. E. (2017). Nutrition and metabolism in burn patients. Burns & Trauma, 5(1), 11. https://doi.org/10.1186/s41038-017-0076-x

13. By Curreri Formula
• 25(60)+40(71) = 4340 kcal
• High carbohydrate diet consisting of 82% carbohydrate, 3% fat,
and 15% protein.
• 889g of carbs
• 162g of proteins
• 14g of fat
• Dextrose is the main calorie source used
and the recommended carbohydrate 2-7 g/kg/d.
• Protein : 1 g/kg body weight per day to 1.5 to 2 g/kg body weight per
day may be beneficial.

14. Role of Glutamine & Arginine
Glutamine
• Transport and supply energy to liver
cells and helps in wound healing
• Glutamine directly provides fuel for
lymphocytes and enterocytes.
• Administration of 25 g/kg/day of
glutamine.
Arginine
• It stimulates T lymphocytes, augments
natural killer cell performance, and
accelerates nitric oxide synthesis.
• Improves immune responsiveness.
• Administration of 0.5 g/kg of
Arginine.

15. Immune Enhancing Diets
IED enhanced with omega-
3 fatty acids, arginine, and
RNA are used.
Feedings were begun within
48 hours of injury.
Reduction hospitalization.
Frequency of the acquired
infections were low
https://journals.lww.com/ccmjournal/Abstract/2000/03000/An_immune_enhancing_enteral_diet_reduces_mort
ality.7.aspx

16. Fluid Management
• By Parklands Formula (1st – 24hrs )
• Adults: 4(BW)*TBSA in ml (RL)
4(60)*71= 17 Litres
Maintenance Fluid
Adults: 24*BW+1.3(TBSA +25)
24*60+1.3(71+25)
1.5litres
1 litre DNS 0.5 litre RL

17. Overfeeding
• The overfeeding of severely burned patients can lead to major complications.
Excess CHO
• Increased O2 Production
• Hyperglycemia
• Fatty Liver
Excess
Protein
• Uremia
• Dehydration
• Metabolic acidosis
Excess Fat
• Hypertriglyceridemia
• Compromised immunity

18. EN Or PN?
• PN alone or in conjunction with EN, is associated with overfeeding,
liver dysfunction, decreased immune response, and three-fold
increased mortality.
• PN also appears to increase the secretion of proinflammatory
mediators, including TNF.
• Mechanical and infectious complications of catheters.
Enteral Nutrition
• The presence of nutrients within the lumen of the bowel promotes
function of the intestinal cells.
• Decreases hyperglycemia and hyperosmolarity as it has a “first-
pass” hepatic delivery of nutrients.
Reference: http://www.iapen.co.in/espen-endorsed-recommendations-burns.pdf

19. Current And Emerging Therapeutic Treatments
• Vitamin C
• N-acetylcysteine (NAC)
• Insulin
• Ghrelin
• Ulinastatin
• Endogenous catecholamines
Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5214064/#R59

20. References :
• Arturson, G. (1980). Pathophysiology of the burn wound. Annales Chirurgiae Et
Gynaecologiae, 69(5), 178–190.
• Clark, A., Imran, J., Madni, T., & Wolf, S. E. (2017). Nutrition and metabolism in burn
patients. Burns & Trauma, 5(1), 11. https://doi.org/10.1186/s41038-017-0076-x
• H014373854.pdf. (n.d.). Retrieved from http://www.iosrjournals.org/iosr-jdms/papers/Vol14-
issue3/Version-7/H014373854.pdf
• Ja et al. - 2017—Burns Definition, Classification, Pathophysiology.pdf. (n.d.). Retrieved
from https://www.longdom.org/open-access/burns-definition-classification-pathophysiology-and-
initial-approach-2327-5146-1000298.pdf
• Ja, G.-E., Vb, A.-A., Eh, O.-V., & Ra, G.-M. (2017). Burns: Definition, Classification,
Pathophysiology and Initial Approach. Los Angeles, 5(5), 5.
• Nevarez—2014—Burn Care Management 2015.pdf. (n.d.). Retrieved
from http://www.vdh.virginia.gov/content/uploads/sites/23/2016/05/TRA-1705.pdf
• Nielson, C. B., Duethman, N. C., Howard, J. M., Moncure, M., & Wood, J. G. (2017). Burns:
Pathophysiology of Systemic Complications and Current Management. Journal of Burn Care &
Research, 38(1), e469–e481. https://doi.org/10.1097/BCR.0000000000000355

21. • Rousseau, A.-F., Losser, M.-R., Ichai, C., & Berger, M. M. (2013). ESPEN endorsed
recommendations: Nutritional therapy in major burns. Clinical Nutrition, 32(4), 497–
502. https://doi.org/10.1016/j.clnu.2013.02.012
• WHO | Burns. (n.d.). Retrieved July 30, 2019, from WHO
website: http://www.who.int/violence_injury_prevention/other_injury/burns/en/