A thermal burn is an injury caused by exposure to heat sufficient to cause damage to the skin, and possibly deeper tissue. Most thermal burns are caused in one of the following ways, Flame, Hot Liquids, Hot Objects, Flash Injuries and Sunburn.

Definition

The burn wound is a complex and dynamic injury characterized by a zone of coagulation, surrounded by an area of stasis, and bordered by an area of Injury affects the skin and in some cases muscle and bone.

Types of burns according to severity,

· Superficial

· Partial thickness

· Full thickness

Burn severity is detected by:

• Burns >20-25% TBSA require IV fluid resuscitation

• Burns >30-40% TBSA may be fatal without treatment

• In adults: "Rule of Nines" is used as a rough indicator of % TBSA

• In children: Lund-Browder classification and Rule of nine.

Effects of burns on the body

• Extensive inflammatory response

• Rapid fluid shifts and accumulation.

• Hyper metabolic state

• Muscle protein catabolism

• Decrease cardiac output because of increased capillary permeability and vasodilatation.

• Heat loss

• Increased blood glucose levels

• Burn Shock

Hypermetabolism

• Catecholamines, cortisol, and other glucocorticoids are increased

• Epinephrine and norepinephrine increase 10-fold in people with burns greater that 30-40%.

• This lasts 9-12 months after a burn.

Glucose metabolism

• Accelerated gluconeogenesis, glucose oxidation and plasma clearance of glucose

• Blood glucose levels increase due to insulin resistance and breakdown of glycogen stores

• Glucagon excretion by the liver increases initially after the burn and slows down as wound heals

Muscle protein catabolism

• Increased oxidation

• Urea synthesis and

• Protein breakdown

• Protein losses of 260 mg protein/kg/hr.

Treatment

• Initially treat with the principles of Advanced Burn and/or Trauma Life Support-The ABC's (airway, breathing, circulation) of trauma take precedent over caring for the burn

• Search for other signs of trauma

• Airway-All patients with deep burns >35-40% TBSA should be endotracheally intubated

• Breathing-Oxygen administration with ventilator support

• Circulation

• Obtain IV access anywhere possible

• Unburned areas preferred

• Burned areas acceptable

• Central access more reliable if proficient

• Cut-downs are last resort

Resuscitation formulas:

• Parkland formula most commonly used

IV fluid - Lactated Ringer's Solution

Fluid calculation

4 x weight in kg x %TBSA burn

Give 1/2 of that volume in the first 8 hours

Give other 1/2 in next 16 hours.

• Brooke formula

Initial 24 hours: RL solution 1.5 ml/kg/% burn plus colloids 0.5 ml/kg/% burn plus 2000 ml glucose in water

Next 24 hours: RL 0.5 ml/kg/% burn, colloids 0.25 ml/kg/% burn and the same amount of glucose in water as in the first 24 hours.

• Evans formula (1952)

First 24 hours: Crystalloids 1 ml/kg/% burn plus colloids at 1 ml/kg/% burn plus 2000 ml glucose in water

Next 24 hours: Crystalloids at 0.5 ml/kg/% burn, colloids at 0.5 ml/kg/% burn and the same amount of glucose in water as in the first 24 hours

• Modified Brooke, Monafo formula.

• FOR children Shriner’s cincinnati, Galveston are available.

NUTRITIONAL MANAGEMENT

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 hyperglycemia

Minimise hypertriglyceridaemia

Nutrition assessment should include:

Height and pre-burn weight

Details of previous nutritional status

%TBSA of burn and site of injury

Gastrointestinal function

Pain control

Pre-existing medical conditions

Usual diet and any specific dietary needs

Methods of nutrition interventions

• High protein, high calorie diet (including oral nutritional supplements)

• High protein, high calorie diet with supplemental enteral feeding

• Enteral feeding.

• Enteral Feeding Should Be Commenced Early-within 6 to 18 hours.

• Aggressive Nutritional Support is Often Required-oral nutrition with naso-gastric feeding

• Energy Requirements are Elevated by the Burn Injury-indirect calorimetry.

• Protein Requirements are Substantially Increased-20 % of calories

• An Increased Requirement Exists for Nutrients Associated with Healing and Immune Function-vitamins A, C, E, some B vitamins and zinc, is especially important.

Energy requirement

• Indirect calorimetry is considered most reliable method for assessing energy expenditure

• Caloric goal should be calculated at 120-130% of measured REE

• Adult burn patients who received more than 30 kcal/kg/day had less mortality, less pneumonia and sepsis, and fewer treatment days

• Energy-2400 kilocalories, carbohydrate-390 grams ,protein-90grams ,fat-53grams are needed.

Vitamin C- Needed for edema prevention, Involved in collagen synthesis for wound healing, Aid in immune functioning

Vitamin A- Needed for immune function, Epithelialization, 5000 IU of Vitamin A per 1000 cal of enteral feeding is recommended

Vitamin D and calcium-Burns cause an impairment in the metabolism of Vitamin D, Burn patients are more susceptible to fractures so calcium and vitamin D should be administered, Calcium- 1000 mg daily, Vitamin D- 200-400 IU daily, Maintain serum 25-hydroxy vitamin D level of 30-60 ng/Ml

Zinc and copper-Tissue breakdown and urinary excretion causes deficiency, Supplementation is recommended for patients

• Cereals, Bananas, Cauliflower, Chicken, Eggs, Fish, Milk, Onion, Oysters, Radish, Spinach, Sunflower seeds, Tomatoes are rich in zinc.

• Sea foods, egg yolk, spices and herbs, vegetables, fruits and pulses are rich in copper.

Complications

Refeeding Syndrome in entral feeding

Non-obstructive Bowel Necrosis

Steatorrhoea

Tube blockages

Aspiration

Vomiting

Constipation

Dehydration

Inadequate Nutrition Delivery

Mechanical Complications- pneumo- or haemo-thorax, air embolism, or misplacement.

Metabolic Complications- electrolyte imbalance, glucose intolerance, and respiratory effects.

Infectious Complications.- hepatic dysfunction and hypertriglyceridaemia.

CONCLUSION:

Nutrition therapy is a cornerstone of burn care from the early resuscitation phase until the end of rehabilitation. Thus, the goal of nutrition support in the burn patient is to ameliorate- and hopefully optimize- the deranged metabolism resulting from burn injury and permit successful closure of the burn wound and resolution of the hyper metabolic state.

REFERENCES:

1. Herndon DN, Tompkins RG. Support of the metabolic response to burn injury. Lancet 2004; 363: 1895-902.

2. Dickerson RN, Gervasio JM, Riley ML, Scott BJ, Daugherty SA, Koh YO. Accuracy of predictive methods to estimate resting energy expenditure of thermally-injured patients. JPEN J Parenter Enteral Nutr 2002; 26: 17-29

3. Schulman CI, Ivascu FA. Nutritional and Metabolic Consequences in the Pediatric Burn Patient. The J Craniofacial Surg 2008; 19: 891-4.

4. Liusuwan RA, Palmieri TL, Kinoshita L, Greenhalgh DG. Comparison of measured resting energy expenditure versus predictive equations in pediatric burn patients. J Burn Care Rehabil 2005; 26: 464-70.

5. Passos JC. Os experimentos de Joule e a primeira lei da termodinâmica. Rev Bras Ens Fisic 2009; 31: 3602-9.

6. Suman OE, Mlcak RP, Chinkes DL, Herndon DN. Resting energy expenditure in severely burned children: analysis of agreement between indirect calorimetry and prediction equations using the Bland-Altman method. Burns 2006; 32: 335- 42.

Received on 09.01.2015 Modified on 26.02.2015

Int. J. Adv. Nur. Management 3(2): April- June, 2015; Page 170-172