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,

1. Nutritional Management of BURNS
Presented By:
Qurrot Ulain Taher

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. 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. • 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. 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. BURNS
Mild Burn
2nd
degree Burn 1 hr
2nd
degree Burn 1 day
2nd
degree Burn 2 days

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

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. • 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. Scald Burns Flame Burns

12. Chemical (Acid) Burns
Radiation (Flash) Burns

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. 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. • 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. 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. 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. 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. 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. 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. 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. •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. 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. 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. 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. 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. 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. 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. 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