CASE STUDY ON BURNS

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  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3188142/ 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)

7. Nutritional Assessment  Anthropometric : Weight- 60kg Height – 5'2" BMI= 26.6kg/m2 Biochemical parameters:  (a) Hematology report 

8. (b) Serum Electrolytes  (c) Renal Function Tests

9. (d) Liver Function Tests

10. Physical Examination: 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   https://journals.lww.com/ccmjournal/Abstract/2000/03000/An_immune_enhancing_enteral_diet_reduces_mortality.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.

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/