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Which Fruit is High In Antioxidants? Food Source

Which Fruit Is High In Antioxidants?/Antioxidants are compounds that inhibit oxidation. Oxidation is a chemical reaction that can produce free radicals, thereby leading to chain reactions that may damage the cells of organisms. Antioxidants such as thiols or ascorbic acid (vitamin C) terminate these chain reactions. To balance the oxidative state, plants and animals maintain complex systems of overlapping antioxidants, such as glutathione and enzymes (e.g., catalase and superoxide dismutase), produced internally, or the dietary antioxidants vitamin A, vitamin C, and vitamin E.

An antioxidant is a molecule stable enough to donate an electron to a rampaging free radical and neutralize it, thus reducing its capacity to damage. These antioxidants delay or inhibit cellular damage mainly through their free radical scavenging property.[] These low-molecular-weight antioxidants can safely interact with free radicals and terminate the chain reaction before vital molecules are damaged. Some of such antioxidants, including glutathione, ubiquinol, and uric acid, are produced during normal metabolism in the body.[] Other lighter antioxidants are found in the diet. Although there are several enzymes system within the body that scavenge free radicals, the principle micronutrient (vitamins) antioxidants are vitamin E (α-tocopherol), vitamin C (ascorbic acid), and B-carotene.[]

Antioxidants are the key to healthy eating. Which foods pack the most nutrients?

Researchers at the University of Oslo wanted to know which foods have the highest concentration of antioxidants, the natural chemicals in food that make it healthy and prevent disease, so they tested 1,113 common foods and drinks, from apples to waffles. Their findings: Ounce for ounce, spices, herbs, nuts, and seeds pack the most nutrients. But if we’re talking typical serving size, berries (five different kinds) also dominate the top ranks. The most surprising find? Chocolate ice cream rated higher than fruits like honeydew and green grapes! Here, the best 10 foods to eat to “anti” up.

Types of Antioxidants

Some compounds contribute to antioxidant defense by chelating transition metals and preventing them from catalyzing the production of free radicals in the cell. Particularly important is the ability to sequester iron, which is the function of iron-binding proteins such as transferrin and ferritin. Selenium and zinc are commonly referred to as antioxidant nutrients, but these chemical elements have no antioxidant action themselves and are instead required for the activity of some antioxidant enzymes, as is discussed below.

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Antioxidant Solubility Concentration in human serum (μM) Concentration in liver tissue (μmol/kg)
Ascorbic acid (vitamin C) Water 50–60 260 (human)
Glutathione Water 4 6,400 (human)
Lipoic acid Water 0.1–0.7 4–5 (rat)
Uric acid Water 200–400 1,600 (human)
Carotenes Lipid β-carotene: 0.5–1retinol (vitamin A): 1–3 5 (human, total carotenoids)
α-Tocopherol (vitamin E) Lipid 10–40 50 (human)
Ubiquinol (coenzyme Q) Lipid 5 200 (human)


Uric acid

Uric acid has the highest concentration of any blood antioxidant and provides over half of the total antioxidant capacity of human serum. Uric acid’s antioxidant activities are also complex, given that it does not react with some oxidants, such as superoxide, but does act against peroxynitrite, peroxides, and hypochlorous acid. Concerns over elevated UA’s contribution to gout must be considered as one of many risk factors. By itself, UA-related risk of gout at high levels (415–530 μmol/L) is only 0.5% per year with an increase to 4.5% per year at UA supersaturation levels (535+ μmol/L). Many of these aforementioned studies determined UA’s antioxidant actions within normal physiological levels, and some found antioxidant activity at levels as high as 285 μmol/L.

Vitamin C

  • Ascorbic acid or “vitamin C” is a monosaccharide oxidation-reduction (redox) catalyst found in both animals and plants. As one of the enzymes needed to make ascorbic acid has been lost by mutation during primate evolution, humans must obtain it from the diet; it is, therefore, a vitamin. Most other animals are able to produce this compound in their bodies and do not require it in their diets.
  • Ascorbic acid is required for the conversion of the procollagen to collagen by oxidizing proline residues to hydroxyproline. In other cells, it is maintained in its reduced form by reaction with glutathione, which can be catalyzed by protein disulfide isomerase and glutaredoxins.


  • The free radical mechanism of lipid peroxidation. Glutathione is a cysteine-containing peptide found in most forms of aerobic life. It is not required in the diet and is instead synthesized in cells from its constituent amino acids. Glutathione has antioxidant properties since the thiol group in its cysteine moiety is a reducing agent and can be reversibly oxidized and reduced.
  • In cells, glutathione is maintained in the reduced form by the enzyme glutathione reductase and in turn reduces other metabolites and enzyme systems, such as ascorbate in the glutathione-ascorbate cycle, glutathione peroxidases, and glutaredoxins, as well as reacting directly with oxidants.
  • Due to its high concentration and its central role in maintaining the cell’s redox state, glutathione is one of the most important cellular antioxidants. In some organisms, glutathione is replaced by other thiols, such as by mycothiol in the Actinomycetes, bacillithiol in some Gram-positive bacteria, or by trypanothione in the Kinetoplastids.

Vitamin E

  • Vitamin E is the collective name for a set of eight related tocopherols and tocotrienols, which are fat-soluble vitamins with antioxidant properties. Of these, α-tocopherol has been most studied as it has the highest bioavailability, with the body preferentially absorbing and metabolizing this form.
  • It has been claimed that the α-tocopherol form is the most important lipid-soluble antioxidant and that it protects membranes from oxidation by reacting with lipid radicals produced in the lipid peroxidation chain reaction. This removes the free radical intermediates and prevents the propagation reaction from continuing. This reaction produces oxidized α-tocopherol radicals that can be recycled back to the active reduced form through reduction by other antioxidants, such as ascorbate, retinol or ubiquinol. This is in line with findings showing that α-tocopherol, but not water-soluble antioxidants, efficiently protects glutathione peroxidase 4 (GPX4)-deficient cells from cell death. GPx4 is the only known enzyme that efficiently reduces lipid-hydroperoxides within biological membranes.
  • Enzymatic antioxidants – benefit you by breaking down and removing free radicals. They can flush out dangerous oxidative products by converting them into hydrogen peroxide, then into the water. This is done through a multi-step process that requires a number of trace metal cofactors, such as zinc, copper, manganese, and iron. Enzymatic antioxidants cannot be found in supplements, but instead, are produced in your body.
  • Superoxide dismutase (SOD) – can break down superoxide into hydrogen peroxide and oxygen, with the help of copper, zinc, manganese, and iron. It is found in almost all aerobic cells and extracellular fluids.
  • Catalase (CAT) – works by converting hydrogen peroxide into water and oxygen, using iron and manganese cofactors. It finishes up the detoxification process started by SOD.
  • Glutathione peroxidase (GSHpx) and glutathione reductase –  are selenium-containing enzymes that help break down hydrogen peroxide and organic peroxides into alcohols. They are most abundant in your liver.
  • Non-enzymatic antioxidants – benefit you by interrupting free radical chain reactions. Some examples are carotenoids, vitamin C, vitamin E, plant polyphenols, and glutathione (GSH). Most antioxidants found in supplements and foods are non-enzymatic, and they provide support to enzymatic antioxidants by doing a “first sweep” and disarming the free radicals. This helps prevent your enzymatic antioxidants from being depleted.
  • Small-molecule antioxidants – work by mopping up or “scavenging” the reactive oxygen species and carrying them away through chemical neutralization. The main players in this category are vitamins C and E, glutathione, lipoic acid, carotenoids, and CoQ10.
  • Large-protein antioxidants– tend to be the enzymatic enzymes outlined above, as well as “sacrificial proteins,” that absorb ROS and stop them from attacking your essential proteins. One example of these sacrificial proteins is albumin, which “take the bullet” for crucial enzymes and DNA.
  • Quercetin –Derived naturally from foods like berries and leafy greens, quercetin seems to be safe for almost everyone and poses little risks. Most studies have found little to no side effects in people eating nutrient-dense diets high in quercetin or taking supplements by mouth short term.
  •  Lutein –Lutein has benefits for the eyes, skin, arteries, heart and immune system, although food sources seem to be generally more effective and safer than supplements. Some evidence shows that people who obtain more lutein from their diets experience lower rates of breast, colon, cervical and lung cancers.
  • Resveratrol – Resveratrol is an active ingredient found in cocoa, red grapes, and dark berries, such as lingonberries, blueberries, mulberries, and bilberries. It’s a polyphonic bioflavonoid antioxidant that’s produced by these plants as a response to stress, injury and fungal infection, helping protect the heart, arteries and more.
  • AstaxanthinAstaxanthin is found in wild-caught salmon and krill and has benefits like reducing age spots, boosting energy levels, supporting joint health and preventing symptoms of ADHD.
  • Selenium – Selenium is a trace mineral found naturally in the soil that also appears in certain foods, and there are even small amounts in water. It supports the adrenal and thyroid glands and helps protect cognition. It may also fight off viruses, defend against heart disease and slow down symptoms correlated with other serious conditions like asthma.
  • Lavender Essential Oil –Lavender oil reduces inflammation and helps the body in many ways, such as producing important antioxidant enzymes – especially glutathione, catalase, and superoxide dismutase.
  • Chlorophyll – Chlorophyll is very helpful for detoxification and linked to natural cancer prevention, blocking carcinogenic effects within the body, and protecting DNA from damage caused by toxins or stress. It’s found in things like spirulina, leafy green veggies, certain powdered green juices, and blue-green algae.
  • Frankincense Essential Oil – Frankincense oil has been clinically shown to be a vital treatment for various forms of cancer, including breast, brain, colon and prostate cancers. Frankincense has the ability to help regulate cellular epigenetic function, which positively influences genes to promote healing. Rub frankincense essential oil on your body (neck area) three times daily, and take three drops internally in eight ounces of water three times daily as part of a natural prevention plan.

Important Benefits of Antioxidants Include

  • Repairing damaged molecules – Some unique types of antioxidants can repair damaged molecules by donating a hydrogen atom. This is very important when the molecule is a critical one, like your DNA.
  • Blocking metal radical production – Some antioxidants have a chelating effect – they can grab toxic metals like mercury and arsenic, which can cause free radical formation, and “hug” them so strongly to prevent any chemical reaction from taking place. Water-soluble chelating agents can also escort toxic metals out of your body through your urine.
  • Stimulating gene expression and endogenous antioxidant production – Some antioxidants can stimulate your body’s genes and increase your natural defenses.
  • Providing a “shield effect” – Antioxidants, such as flavonoids, can act as a virtual shield by attaching to your DNA to protect it from free radicals attacks.
  • Promoting cancer cells to “commit suicide” – Some antioxidants can provide anti-cancer chemicals that halt cancer growth and force some cancer cells to self-destruct (apoptosis).

Antioxidants Foods

  • Allium sulfur compounds – Leeks, onions, garlic
  • Anthocyanins –  Eggplant, grapes, berries
  • Beta carotene – Pumpkin, mangoes, apricots, carrots, spinach, parsley
  • Catechins – Red wine, tea
  • Copper – Seafood, lean meat, milk, nuts, legumes
  • Cryptoxanthins – Red peppers, pumpkin, mangoes
  • Flavonoids – Tea, green tea, red wine, citrus fruits, onion, apples
  • Indoles – Cruciferous vegetables such as broccoli, cabbage, cauliflower
  • Lignans –  Sesame seeds, bran, whole grains, vegetables
  • Lutein – Corn, leafy greens (such as spinach)
  • Lycopene – Tomatoes, pink grapefruit, watermelon
  • Manganese – Seafood, lean meat, milk, nuts
  • Polyphenols – Thyme, oregano
  • Selenium –  Seafood, offal, lean meat, whole grains
  • Vitamin C – Oranges, berries, kiwi fruit, mangoes, broccoli, spinach, peppers
  • Vitamin E – Vegetable oils, nuts, avocados, seeds, whole grains
  • Zinc –  Seafood, lean meat, milk, nuts
  • Zoochemical –  Red meat, offal, fish

Nutrient antioxidants

Antioxidants from our diet play an important role in helping endogenous antioxidants for the neutralization of oxidative stress. Nutrient antioxidant deficiency is one of the causes of numerous chronic and degenerative pathologies. Each nutrient is unique in terms of its structure and antioxidant function (, ).

Vitamin E

  • Vitamin E is a fat-soluble vitamin with high antioxidant potency. Vitamin E is a chiral compound with eight stereoisomers: α, β, γ, δ tocopherol and α, β, γ, δ tocotrienol. Only α-tocopherol is the most bioactive form in humans. Studies in both animals and humans indicate that natural dextrorotary d-α-tocopherol is nearly twice as effective as synthetic racemic dl-α-tocopherol ().
  • Because it is fat-soluble, α-tocopherol safeguards cell membranes from damage by free radicals. Its antioxidant function mainly resides in the protection against lipid peroxidation. Vitamin E has been proposed for the prevention against colon, prostate and breast cancers, some cardiovascular diseases, ischemia, cataract, arthritis, and certain neurological disorders. ().
  • However, a recent trial revealed that daily α-tocopherol doses of 400 IU or more can increase the risk of death and should be avoided. In contrast, there is no increased risk of death with a dose of 200 IU per day or less, and there may even be some benefit (). Although controversial, the use of long-term vitamin E supplementation in high dose should be approached cautiously until further evidence for its safety is available. The dietary sources of vitamin E are vegetable oils, wheat germ oil, whole grains, nuts, cereals, fruits, eggs, poultry, meat (, ). Cooking and storage may destroy natural d-α-tocopherol in foods ().

Vitamin C

  • Vitamin C also known as ascorbic acid, is a water-soluble vitamin. It is essential for collagen, carnitine and neurotransmitters biosynthesis (). Health benefits of vitamin C are antioxidant, anti-atherogenic, anti-carcinogenic, immunomodulator.
  • The positive effect of vitamin C resides in reducing the incidence of stomach cancer, and in preventing lung and colorectal cancer. Vitamin C works synergistically with vitamin E to quench free radicals and also regenerates the reduced form of vitamin E.
  • However, the intake of high doses of vitamin C (2000mg or more/day) has been the subject of debate for its eventual pro-oxidant or carcinogen property (). Natural sources of vitamin C are acid fruits, green vegetables, tomatoes. Ascorbic acid is a labile molecule, therefore it may be lost from during cooking ().


  • Beta-carotene is a fat-soluble member of the carotenoids which are considered provitamins because they can be converted to active vitamin A. Beta-carotene is converted to retinol, which is essential for vision. It is a strong antioxidant and is the best quencher of singlet oxygen.
  • However, beta-carotene supplement in doses of 20mg daily for 5-8 years has been associated with an increased risk of lung and prostate cancer and increased total mortality in cigarette smokers (). Beta-carotene 20-30mg daily in smokers may also increase cardiovascular mortality by 12% to 26% (). These adverse effects do not appear to occur in people who eat foods high in beta-carotene content. Beta-carotene is present in many fruits, grains, oil and vegetables (carrots, green plants, squash, spinach) ().


  • Lycopene, a carotenoid, possesses antioxidant and antiproliferative properties in animal and in vitro studies on breast, prostate and lung cell lines, although anticancer activity in humans remains controversial (, , ). Lycopene has been found to be very protective, particularly for prostate cancer ().
  • Several prospective cohort studies have found associations between high intake of lycopene and reduced incidence of prostate cancer, though not all studies have produced consistent results (). The major dietary source of lycopene is tomatoes, with the lycopene in cooked tomatoes, tomato juice and tomato sauce included, being more bioavailable than that in raw tomatoes ().

Selenium (Se)

  • Se is a trace mineral found in soil, water, vegetables (garlic, onion, grains, nuts, soybean), seafood, meat, liver, yeast (). It forms the active site of several antioxidant enzymes including glutathione peroxidase. At low dose, health benefits of Se are antioxidant, anti-carcinogenic and immunomodulator (). Selenium is also necessary for the thyroid function ().
  • Exceeding the Tolerable Upper Intake Level of 400 μg Se/day can lead to selenosis which is a selenium poisoning characterized by gastrointestinal disorders, hair and nail loss, cirrhosis, pulmonary edema and death ().
  • Selenium deficiency can occur in patients on total parenteral nutrition (TPN) and in patients with gastrointestinal disorders. In certain China areas with Se poor soil, people have developed a fatal cardiomyopathy called Keshan disease which was cured with Se supplement (). The role of Se in cancer prevention has been the subject of recent study and debate. Results from clinical and cohort studies about cancer prevention, especially lung, colorectal, and prostate cancers are mixed (, ).


  • Flavonoids are polyphenolic compounds which are present in most plants. According to chemical structure, over 4000 flavonoids have been identified and classified into flavonols, flavanones, flavones, isoflavones, catechins, anthocyanins, proanthocyanidins. Beneficial effects of flavonoids on human health mainly reside in their potent antioxidant activity ().
  • They have been reported to prevent or delay a number of chronic and degenerative ailments such as cancer, cardiovascular diseases, arthritis, aging, cataract, memory loss, stroke, Alzheimer’s disease, inflammation, infection. Every plant contains a unique combination of flavonoids, which is why different herbs, all rich in these substances, have very different effects on the body (). The main natural sources of flavonoids include green tea, grapes (red wine), apple, cocoa (chocolate), ginkgo Biloba, soybean, Curcuma, berries, onion, broccoli, etc.
  • For example, green tea is a rich source of flavonoids, especially flavonols (catechins) and quercetin. Catechin levels are 4-6 times greater in green tea than in black tea. Many health benefits of green tea reside in its antioxidant, anticarcinogenic, antihypercholesterolemic, antibacterial (dental caries), anti-inflammatory activities ().

Omega-3 and omega-6 fatty acids

  • They are essential long-chain polyunsaturated fatty acids because the human body cannot synthesize them. Therefore, they are only derived from food. Omega-3 fatty acids can be found in fat fish (salmon, tuna, halibut, sardines, pollock), krill, algae, walnut, nut oils and flaxseed. However, certain big fishes like tilefish, shark, swordfish are to be avoided because of their high mercury levels ().
  • There are three major dietary types of omega-3 fatty acids: eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA) and alpha-linolenic acid (ALA). EPA and DHA are abundant in fish and are directly used by the body; while ALA is found in nuts and has to be converted to DHA and EPA by the body. Dietary sources of omega-6 fatty acids (linoleic acid) include vegetable oils, nuts, cereals, eggs, poultry.
  • It is important to maintain an appropriate balance of omega-3s and omega-6s in the diet, as these two substances work together to promote health (, ). Omega-3 fatty acids help reduce inflammation, and most omega-6 fatty acids tend to promote inflammation. An inappropriate balance of these essential fatty acids contributes to the development of disease while a proper balance helps maintain and even improve health. A healthy diet should consist of about 2-4 times more omega-6s than omega-3s. In the American diet, omega-6s are 14-25 times more abundant than omega-3s, that explains the rising rate of inflammatory disorders in the USA (). Omega-3s reduce inflammation and prevent chronic ailments such as heart disease, stroke, memory loss, depression, arthritis, cataract, cancer. Omega-6s improve diabetic neuropathy, eczema, psoriasis, osteoporosis, and aid in cancer treatment (, , ).

Antioxidants Home Treatments

What Is The Best Antioxidant?


What Is The Best Antioxidant?

  • One cup of blackberries contains the most antioxidants of all the berries tested, beating out blueberries, strawberries, cranberries, and raspberries. Plus, one cupful provides half your daily recommended intake of vitamin C.
  • Nutrition facts (1 cup): 62 calories, less than 1g fat, 14g carbohydrates, 7.6g fiber, 2g protein


What Is The Best Antioxidant?

  • Just an ounce of walnuts, or 15 to 20 halves, is loaded with antioxidants. They’re also cholesterol-free and low in sodium and sugar. Nuts are laden with calories, though, so be mindful of your intake.
  • Nutrition facts (1 ounce): 185 calories, 18.5g fat (1.7g saturated fat), 4g carbohydrates, 8g fiber, 4g protein


  • What Is The Best Antioxidant?Bursting with fiber and vitamin C (149 percent of your daily recommended intake!), a cup of sliced strawberries is a cup full of healthy benefits.
  • Nutrition facts (1 cup): 49 calories, 0.5g fat, 11.7g carbohydrates, 3g fiber, 1g protein


  • What Is The Best Antioxidant?Add a cup of antioxidant-rich artichoke hearts to your diet.
  • Nutrition facts (1 cup): 70 calories, 0g fat, 11.5g carbohydrates, 4.5g fiber, 2.5g protein


  • One cup of whole cranberries is full of disease-fighting and health-boosting antioxidants.
  • Nutrition facts (1 cup): 51 calories, 0.2g fat, 13.5g carbohydrates, 5g fiber, 1g protein


Do Antioxidants Help You Lose Weight?

  • Your morning cup of joe does more than perk you up — it also boosts your health.
  • Nutrition facts (8 fluid ounces): 18 calories, 2mg sodium


What Is The Best Antioxidant?

  • Another super-healthy berry to add to your diet. One cup is loaded with vitamin C (54 percent of your daily recommended intake) and antioxidants.
  • Nutrition facts (1 cup): 64 calories, 1g fat, 15g carbohydrates, 8g fiber, 1.5g protein


Do Antioxidants Help You Lose Weight?

  • As if you needed any more reason to take a bite out of that pecan pie. One ounce, or 20 jumbo kernels, of pecans is rich in antioxidants.
  • Nutrition facts (1 ounce): 196 calories, 20.5g fat (1.7g saturated), 3.9g carbohydrates, 2.7g fiber, 2.6g protein


What Is The Best Antioxidant?

  • This superfood is good for your health and can help protect your skin from premature aging.
  • Nutrition facts (1 cup): 83 calories, 0.5g fat, 21g carbohydrates, 3.5g fiber, 1.1g protein


What Is The Best Antioxidant?

  • Just a teaspoon of ground cloves can do wonders for your body. Spice up your meals and boost your health at the same time.
  • Nutrition facts (1 tablespoon): 21 calories, 1.3g fat (0.4g saturated), 4g carbohydrates, 2.3g fiber, 0.4g protein


  • Rich in cancer-fighting antioxidants and vitamins, kale is also a good source of beta-carotene and is the top combo of both lutein and zeaxanthin.


  • Spinach is packed with carotenoids—antioxidants that promote healthy eyes and help prevent macular degeneration, the leading cause of blindness in older people.

Brussels Sprouts

What Is The Best Antioxidant?

  • These broccoli cousins have plenty of bitter sulforaphane as well as compounds called isothiocyanates, which detoxify cancer-causing substances in the body before they can do their dirty work. In one Dutch study, guys who ate Brussels sprouts daily for three weeks had 28 percent less genetic damage (gene damage is a root cause of cancer) than those who didn’t eat sprouts.

Alfafa Sprouts

  • This tiny powerhouse is rich in beta-carotene, an antioxidant that protects against lung cancer and helps maintain healthy skin, hair, nails, gums, glands, bones, and teeth. It’s also a good source of vitamin E, which may help prevent heart attacks, strokes, and lower the risk of death from bladder cancer.

Broccoli Flowers

  • Broccoli is full of cancer-fighting antioxidants. One study found men who ate 5 servings or more per week of cruciferous veggies like broccoli were half as likely to develop bladder cancers over a 10-year period as men who rarely ate them.


What Is The Best Antioxidant?

Beets are packed with healthy nutrients, like five essential vitamins, calcium, iron, potassium, and protein.

Red Bell Peppers

  • One medium pepper is light on calories (only 32!) but heavy on vitamin C, providing 150 percent of your recommended daily value and warding off atherosclerosis, which can lead to heart disease.


What Is The Best Antioxidant?

  • You’ll get the most out of this veggie’s cancer-fighting antioxidants by eating it raw; cooking onions at a high heat significantly reduces the benefits of phytochemicals that protect against lung and prostate cancer.


What Is The Best Antioxidant?


  • A study in the Journal of Agricultural Food and Chemistry found that the longer corn was cooked, the higher the level of antioxidants like lutein, which combats blindness in older adults.


What Is The Best Antioxidant?


  • All types of eggplant are rich in bitter chlorogenic acid, which protects against the buildup of heart-threatening plaque in artery walls (and fights cancer, too!), say USDA scientists in Beltsville, Maryland. In lab studies, eggplant lowered cholesterol and helped artery walls relax, which can cut your risk of high blood pressure.

Lifestyle Changes to Maximize Your Antioxidant Intake.

  • Reduce and eventually eliminate sugar (especially fructose) and grains from your diet – According to Dr. Robert Lustig, professor of pediatrics in the Division of Endocrinology at the University of California, San Francisco, fructose undergoes the Maillard reaction with proteins, which leads to superoxide free radicals to form in your body. These damaging free radicals can cause liver inflammation similar to that caused by alcohol. Less sugar and grains (which convert into sugar in your body) in your diet can help decrease your antioxidant stress, meaning you will need to get fewer amounts. Plus, the antioxidants you have will work better and last longer. I also advise against consuming any type of processed foods, especially soda, as these usually contain high amounts of fructose.
  • Exercise – Exercise can boost your body’s antioxidant production but in a paradoxical way, as it actually creates potent oxidative stress. However, if you do it properly and in moderation, it can help improve your body’s capacity to produce antioxidants. This is why I recommend doing short bursts of high-intensity exercises like Peak Fitness, instead of prolonged cardio like marathon running, which puts excessive stress on your heart.
  • Manage your stress – Stress can exacerbate the inflammation and poor immune function caused by free radical formation. Studies have found significant links between acute and/or chronic emotional and psychological stress and numerous health issues. Even the Centers for Disease Control (CDC) acknowledges this link and says that 85 percent of all disease has an emotional element.
  • Avoid smoking – Smoking forms free radicals in your body, which accelerates the aging process. Even being around people who smoke can affect your health by damaging the microcapillaries in your skin, which limits its ability to absorb nutrients, leading to accelerated wrinkling and aging. Smoking also contributes to the pathobiology of various diseases, the most well-known of which is lung cancer.
  • Get enough sleep High-quality sleep is one of the cornerstones of good health, and science has now established that a sleep deficit can have severe far-reaching effects on your health. Six to eight hours of sleep per night seems to be the optimal amount for most adults, and too much or too little can have adverse effects on your wellbeing.
  • Try grounding – Also called “earthing,” grounding has a potent antioxidant effect that helps alleviate inflammation in your body. There is a constant flow of energy between our bodies and the earth, which has a greater negative charge. Walking barefoot on the earth helps you absorb large amounts of negative electrons through the soles of your feet.


What Is The Best Antioxidant?


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Low Heart Beat; Causes, Symptoms, Treatment

Low Heart Beat/Bradycardia is defined as a resting heart rate below 60 beats per minute (b.p.m.). A slow heart rate can occur naturally under various circumstances and is not necessarily associated with a medical condition. For example, some highly trained athletes have bradycardia. However, there is also pathological bradycardia, which is caused by conditions that affect the electrical conduction system of the heart, including sick sinus syndrome (SSS) and/or atrioventricular (AV) block. Bradycardia does not necessarily require treatment unless it causes symptoms. People suffering from symptomatic bradycardia can present with dizziness, confusion, palpitations, breathlessness, exercise intolerance and syncope (blackout or fainting). However, bradycardia and symptoms related to it may be intermittent or may be non-specific, particularly in the elderly.

Bradycardia is a condition typically defined wherein an individual has a resting heart rate of under 60 beats per minute (BPM) in adults.[rx] Bradycardia typically does not cause symptoms until the rate drops below 50 BPM. When symptomatic, it may cause fatigue, weakness, dizziness, sweating, and at very low rates, fainting.[rx] During sleep, a slow heartbeat with rates around 40–50 BPM is common and is considered normal. Highly trained athletes may also have athletic heart syndrome, a very slow resting heart rate that occurs as a sport adaptation and helps prevent tachycardia during training.


A heart has numerous pacemaker sites within its conduction system which are independently able to keep the heart beating. And the rate of a heartbeat depends upon the pacemaker site, and as we go down its conduction system, the rate of spontaneous depolarization at pacemaker sites decrease. 

Pacemaker sites and their depolarization rates are listed below

  • Sinoatrial node – 60 to 100 beats per minute
  • Atria – Less than 60 beats per minute
  • Atrioventricular node – 40 to 60 beats per minute
  • Ventricles – 20 to 40 beats per minute

Types of Bradycardia

  • SinusAtrial bradycardias are divided into three types. The first, respiratory sinus arrhythmia, is usually found in young and healthy adults. Heart rate increases during inhalation and decreases during exhalation. This is thought to be caused by changes in the vagal tone during respiration.[rx] If the decrease during exhalation drops the heart rate below 60 bpm on each breath, this type of bradycardia is usually deemed benign and a sign of good autonomic tone.
  • Atrioventricular nodalAtrioventricular nodal bradycardia or AV junction rhythm is usually caused by the absence of the electrical impulse from the sinus node. This usually appears on an EKG with a normal QRS complex accompanied with an inverted P wave either before, during, or after the QRS complex.[rx]An AV junctional escape is a delayed heartbeat originating from an ectopic focus somewhere in the AV junction. It occurs when the rate of depolarization of the SA node falls below the rate of the AV node.[rx] This dysrhythmia also may occur when the electrical impulses from the SA node fail to reach the AV node because of SA or AV block.[rx]
  • VentricularVentricular bradycardia, also known as ventricular escape rhythm or idioventricular rhythm, is a heart rate of less than 50 BPM. This is a safety mechanism when a lack of electrical impulse or stimuli from the atrium occurs.[rx] Impulses originating within or below the bundle of His in the atrioventricular node will produce a wide QRS complex with heart rates between 20 and 40 BPM. Those above the bundle of His, also known as junctional, will typically range between 40 and 60 BPM with a narrow QRS complex.[rx][rx] In a third-degree heart block, about 61% take place at the bundle branch-Purkinje system, 21% at the AV node, and 15% at the bundle of His.[rx] AV block may be ruled out with an EKG indicating “a 1:1 relationship between P waves and QRS complexes.
  • InfantileFor infants, bradycardia is defined as a heart rate less than 100 BPM (normal is around 120–160). Premature babies are more likely than full-term babies to have apnea and bradycardia spells; their cause is not clearly understood. The spells may be related to centers inside the brain that regulate breathing which may not be fully developed. Touching the baby gently or rocking the incubator slightly will almost always get the baby to start breathing again, which increases the heart rate. Medications (theophylline or caffeine) can be used to treat these spells in babies if necessary.

Causes of Bradycardia

Common causes of sinus bradycardia in children include increased vagal tone, hypothyroidism, hypothermia, adrenal insufficiency, and increased intracranial pressure. Inherited arrhythmias and cardiomyopathies may also cause bradycardia. Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a rare inherited disorder.

Pathological causes of sinus bradycardia

  • A congenital defect –or problem you’re born with
  • Thyroid disease –an imbalance of hormones in the body
  • Obstructive sleep apnea when your breathing pauses many times throughout the night
  • Drugs—for example, β blockers, digoxin, amiodarone
  • Problems with the sinoatrial (SA) node – sometimes called the heart’s natural pacemaker
  • Problems in the conduction pathways of the heart that don’t allow electrical impulses to pass properly from the atria to the ventricles
  • Metabolic problems such as hypothyroidism (low thyroid hormone)
  • Damage to the heart from heart disease or heart attack
  • Certain heart medications that can cause bradycardia as a side effect
  • Acute myocardial infarction
  • Obstructive jaundice
  • Raised intracranial pressure
  • Sick sinus syndrome
  • Hypothermia
  • Hypothyroidism

Sinus bradycardia has many intrinsic and extrinsic etiologies].

Inherent Etiologies

  • Chest trauma
  • Ischemic heart disease
  • Acute myocardial infarction
  • Acute and chronic coronary artery disease
  • Repair of congenital heart disease
  • Sick sinus syndrome
  • Radiation therapy
  • Amyloidosis
  • Pericarditis
  • Lyme disease
  • Collagen vascular disease
  • Myocarditis
  • Neuromuscular disorder
  • X-linked muscular dystrophy
  • Familial disorder
  • Inherited channelopathy

Extrinsic Etiologies

  • Vasovagal simulation (endotracheal suctioning)
  • Carotid sinus hypersensitivity
  • Beta-blockers
  • Calcium channel blockers
  • Digoxin
  • Ivabradine
  • Clonidine
  • Reserpine
  • Adenosine
  • Cimetidine
  • Antiarrhythmic Class I to IV
  • Lithium
  • Cannabinoids
  • Hypothyroidism
  • Sleep apnea
  • Hypoxia
  • Intracranial hypertension
  • Hyperkalemia
  • Anorexia nervosa


  • Heart tissue damage related to aging
  • Damage to heart tissues from heart disease or heart attack
  • Heart disorder present at birth (congenital heart defect)
  • Infection of heart tissue (myocarditis)
  • A complication of heart surgery
  • Underactive thyroid gland (hypothyroidism)
  • Imbalance of chemicals in the blood, such as potassium or calcium
  • Repeated disruption of breathing during sleep (obstructive sleep apnea)
  • Inflammatory diseases, such as rheumatic fever or lupus
  • Medications, including some drugs for other heart rhythm disorders, high blood pressure and psychosis
  • Common in sick sinus syndrome
  • Characterized by bursts of atrial tachycardia interspersed with periods of bradycardia
  • Paroxysmal atrial flutter or fibrillation may also occur, and cardioversion may be followed by a severe bradycardia

Symptoms of Bradycardia

  • Fatigue or feeling weak
  • Chest pain, which may signal reduced blood flow to the heart
  • Dizziness or lightheadedness
  • Confusion
  • Fainting (or near-fainting) spells
  • Shortness of breath
  • Difficulty when exercising
  • Cardiac arrest (in extreme cases)
  • Confusion or memory problems
  • Easily tiring during physical activity
  • Heart palpitations or flutters
  • Limited ability to exercise

Diagnosis of Bradycardia

  • Electrocardiogram (ECG or EKG) – An electrocardiogram also called an ECG or EKG, is a primary tool for evaluating bradycardia. Using small sensors (electrodes) attached to your chest and arms, it records electrical signals as they travel through your heart. Because an ECG can’t record bradycardia unless it happens during the test, your doctor might have you use a portable ECG device at home. These devices include:
  • Holter monitor – Carried in your pocket or worn on a belt or shoulder strap, this device records your heart’s activity for 24 to 48 hours. Your doctor will likely ask you to keep a diary during the same 24 hours. You’ll describe any symptoms you experience and record the time they occur.
  • Event recorder – This device monitors your heart activity over a few weeks. You push a button to activate it when you feel symptoms so that it records your heart’s activity during that time.
  • LINQ insertable cardiac monitor: This wireless, powerful, small insertable cardiac monitor is ideal for patients experiencing infrequent symptoms that require long-term monitoring or ongoing management.

Your doctor might use an ECG monitor while performing other tests to understand the impact of bradycardia. These tests include

  • Tilt table test – This test helps your doctor better understand how your bradycardia contributes to fainting spells. You lie flat on a special table, and then the table is tilted as if you were standing up to see if the change in position causes you to faint.
  • Exercise test – Your doctor might monitor your heart rate while you walk on a treadmill or ride a stationary bike to see whether your heart rate increases appropriately in response to physical activity.
  • A stress test – can be helpful in bringing out either sinus node disease or heart block that becomes apparent only during exertion.

Treatment of Bradycardia

The treatment of bradycardia is dependent on whether or not the person is stable or unstable.[rx] If oxygen saturations are low, supplemental oxygen should be provided.

  • Stable – Emergency treatment is not needed if the person is asymptomatic or minimally symptomatic.[rx]
  • Unstable – If a person is unstable, the initial recommended treatment is intravenous atropine.[rx] Doses less than 0.5 mg should not be used, as this may further decrease the rate.[rx] If this is not effective, intravenous inotrope infusion (dopamine, epinephrine) or transcutaneous pacing should be used.[rx] Transvenous pacing may be required if the cause of the bradycardia is not rapidly reversible.[rx]
  • In children – giving oxygen, supporting their breathing, and chest compressions are recommended.[rx][rx]


  • While atropine can be used independently for anti-salivation effects, it most commonly is secondary to anticholinergic or antimuscarinic poisoning which is discussed below. It is not formally recommended for routine use in controlled airways, though can be used off-label for minimizing secretions in the intubated patient.

Anticholinergic Poisoning

  • Acetylcholine works on three different receptors that must be addressed in nerve agent poisonings. Atropine is only useful to counter muscarinic effects (pralidoxime and benzodiazepines address the others). If there are local symptoms to the eyes or respiratory tract, atropine is not indicated.
  • Intravenous (IV) atropine is indicated for patients with hypersalivation, bronchial secretions, or bradycardia. Large doses and repeat doses may be required. Ingestions especially require higher doses (up to 20 mg). Titrate to effect by monitoring the patient’s ability to clear excess secretions. Pupils and heart rate are poor indications of appropriate dosing in these patients.

Rapid Sequence Intubation (RSI) Pretreatment

  • Although not recommended as a routine agent – atropine may be used 3-5min prior to initiation of RSI to prevent bradycardia. In the setting of post-intubation related bradycardia, atropine is indicated. Post induction bradycardia is seen more commonly in the pediatric population due to the predominance of vagal response, even without the use of succinylcholine.
  • Atropine/Diphenoxylate (Lomotil) – is an antimotility agent that can be used in the treatment of diarrhea as second-line therapy. This allows the central acting opioid effect of diphenoxylate and capitalization on its anticholinergic side effect of constipation to slow motility. Subtherapeutic amounts of atropine are included in the dosage form to discourage diphenoxylate abuse. It may potentiate barbiturates, alcohol, or tranquilizers and therefore must be used with caution.
  • Under current ACLS protocols – atropine is indicated for symptomatic bradycardia and not in a pulseless patient. All indications for atropine in the pulseless patient have been removed by the AHA.
  • Atropine is not indicated in beta-blocker-induced bradycardias or hypotension – though its use is unlikely to be harmful. Glucagon is first-line to treat beta-blockade-induced symptoms. Pregnancy Class B: It does cross the placenta and may lead to fetal tachycardia; however, it does not cause fetal abnormalities.


Atropine can be administered by intravenous (IV), subcutaneous, intramuscular, or endotracheal (ET) method; IV is preferred. For ET administration dilute 1 mg to 2 mg in 10 mL of sterile water or normal saline prior to administration. For pediatric ET, double the usual IV dose and dilute in 3 to 5 mL.

  • Antisialagogue/antiviral – 0.5 mg to 1 mg every 1 to 2 hours
  • Organophosphate or muscarinic poisoning – 2 mg to 3 mg every 20 to 30 minutes (may require doses up to 20 mg, titrate to the effect of secretion control, not VS)
  • Bradycardia – 1 mg every 3 to 5 minutes (3 mg max), repeat until desired heart rate is obtained, most effective for sinus and AV nodal disease.
  • Pediatric – 0.01 mg/kg to 0.03 mg/kg every 3 to 5 minutes. Pediatric minimum dose 0.1 mg, maximum dose 0.5 mg (child) and 1.0 mg (adolescent); maximum cumulative dose 1 mg (child) and 2 mg (adolescent).
  • Rapid Sequence Intubation Pretreatment – 0.01 mg/kg IV for adults with bradycardia secondary to repeat dosing of succinylcholine. Pediatric 0.02 mg/kg IV, minimum dose 0.1 mg. Not recommended as a routine.

In general, dosing of atropine can be repeated every 5 minutes until a maximum of 0.04 mg/kg is reached. Dosing in adults to greater than 0.5 mg and slow IV pushes have been associated with paradoxical bradycardia (though likely transient) and ventricular fibrillation (VF).

  • If damage to the heart’s electrical system causes your heart to beat too slowly, you will probably need to have a pacemaker. A pacemaker is an implanted device that helps correct the slow heart rate.
  • If another medical problem, such as hypothyroidism or an electrolyte imbalance, is causing a slow heart rate, treating that problem may cure the bradycardia.
  • If a medicine is causing your heart to beat too slowly, your doctor may adjust the dose or prescribe a different medicine.


The most effective way to prevent bradycardia is to reduce your risk of developing heart disease. If you already have heart disease, monitor it and follow your treatment plan to lower your risk of bradycardia.

Prevent heart disease

Treat or eliminate risk factors that may lead to heart disease. Take the following steps

  • Exercise and eat a healthy diet – Live a heart-healthy lifestyle by exercising regularly and eating a healthy, low-fat, low-salt, low-sugar diet that’s rich in fruits, vegetables, and whole grains. Having a heart-healthy eating plan that includes vegetables, fruits, nuts, beans, lean meat, fish, and whole grains. Limit alcohol, sodium, and sugar.
  • Maintain a healthy weight –Being overweight increases your risk of developing heart disease.
  • Keep blood pressure and cholesterol under control – Make lifestyle changes and take medications as prescribed to correct high blood pressure (hypertension) or high cholesterol.
  • Don’t smoke – If you smoke and can’t quit on your own, talk to your doctor about strategies or programs to help you break a smoking habit.
  • If you drink, do so in moderation – For healthy adults, that means up to one drink a day for women of all ages and men older than age 65, and up to two drinks a day for men age 65 and younger. Ask your doctor if your condition means you should avoid alcohol. If you can’t control your alcohol use, talk to your doctor about a program to quit drinking and manage other behaviors related to alcohol abuse.
  • Don’t use recreational drugs –  If you’re using drugs, talk to your physician about treatment programs.
  • Exercise and eat healthy – Get regular physical activity and eat a low-fat diet rich in fruits, vegetables and whole grains.
  • Get regular checkups – Have regular physicals and, if you experience new or changing symptoms, see your physician.
  • Keep blood pressure and cholesterol under control – Make the lifestyle changes listed above and take medications as prescribed.
  • Monitor and treat existing heart disease – Understand your treatment plan. Take medications as directed. And report new or worsening symptoms immediately.
  • Manage stress – Avoid unnecessary stress and learn coping techniques to handle normal stress in a healthy way.
  • Being active on most – if not all, days of the week. Your doctor can tell you what level of exercise is safe for you.
  • Losing weight if you need to – and staying at a healthy weight.
  • Managing other health problems – such as high blood pressure, high cholesterol, and diabetes.
  • Go to scheduled checkups – Have regular physical exams and report signs or symptoms to your doctor.

Monitor and treat existing heart disease

If you already have heart disease, there are steps you can take to lower your risk of developing bradycardia or another heart rhythm disorder:

  • Follow the plan – Be sure you understand your treatment plan and take all medications as prescribed.
  • Report changes immediately – If your symptoms change or worsen or you develop new symptoms, tell your doctor immediately.

Risk Factors

Risk factors that could contribute to bradycardia include:

  • Age – Men and women age 65 and older are most likely to develop a slow heart rate that needs treatment.
  • Congenital heart defect – Problems with the structure or function of the heart present at birth can cause a slow heart rate.
  • Electrolyte imbalance – Any abnormality in the body’s mineral balance – including calcium, chloride, magnesium, phosphate, potassium, and sodium can lead to a slow or irregular heart rate.
  • Infection of the heart – Certain bacteria, viruses, and parasites can infect the heart muscle, causing inflammation and damage leading to an irregular heart rate.
  • Previous heart attacks – Heart attacks can weaken the heart muscle or cause problems with its electrical system.
  • Low thyroid – An abnormally low level of thyroid hormones can cause a slow heart rate.
  • Medications for other heart problems – Some medications for treating high blood pressure or other heart conditions like beta-blockers, antiarrhythmics and digoxin (for heart failure) can cause bradycardia.


Is Slow Heart Rate Good or Bad For You


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Water Retention Symptoms, Diagnosis, Treatment

Water Retention Symptoms/Water retention (also known as fluid retention) or hydrops, hydropsy, edema, signifies an abnormal accumulation of clear, watery fluid in the tissues or cavities of the body. Water is found both inside and outside the body’s cells. It forms part of the blood, helping to carry the blood cells around the body and keeping oxygen and important nutrients in solution so that they can be taken up by tissues such as glands, bone, and muscle. Even the organs and muscles are mostly water.

The body uses a complex system of hormones and hormone-like substances called prostaglandins to keep its volume of fluid at a constant level. If one were to intake an excessive amount of fluid in one day, the amount of fluid would not be affected in the long term. This is because the kidneys quickly excrete the excess in the form of urine. Likewise, if one did not get enough to drink, the body would hold on to its fluids and urinate less than usual. Imbalances in this system can lead to water retention, which can range from mild and unnoticeable to symptomatic with swelling.

Causes of Water Retention

Where water retention occurs

  • Fluid rich with oxygen, vitamins and other nutrients passes all the time from the capillaries (the smallest blood vessels) into the surrounding tissues, where it is known as tissue fluid or interstitial fluid. This fluid nourishes the cells and eventually should return to the capillaries.
  • Water retention is said to occur as a result of changes in the pressure inside the capillaries, or changes that make the capillary walls too leaky (see edema and vascular permeability). If the pressure is wrong, or the capillaries are too leaky, then too much fluid will be released into the tissue spaces between the cells. Sometimes so much fluid is released that it cannot all return to the capillaries and remains in the tissues, where it causes the swelling and waterlogging which is experienced as water retention.
  • Another set of vessels known as the lymphatic system acts like an “overflow” and can return a lot of excess fluid back to the bloodstream. But even the lymphatic system can be overwhelmed, and if there is simply too much fluid, or if the lymphatic system is congested, then the fluid will remain in the tissues, causing swellings in legs, ankles, feet, abdomen or any other part of the body.

The Heart

  • The pumping force of the heart should help to keep normal pressure within the blood vessels. But if the heart begins to fail (a condition is known as congestive heart failure) the pressure changes can cause very severe water retention. In this condition, water retention is mostly visible in the legs, feet, and ankles, but also collects in the lungs, where it causes a chronic cough. This condition is usually treated with diuretics, otherwise, the water retention may cause breathing problems and additional stress on the heart.

The Kidneys

  • Another cause of severe water retention is kidney failure, where the kidneys are no longer able to filter fluid out of the blood and turn it into the urine. Kidney disease often starts with inflammation, for instance in the case of diseases such as nephrotic syndrome or lupus. Once again, this type of water retention is usually visible in the form of swollen legs and ankles.

Other Causes of Swollen legs

  • Swollen legs, feet, and ankles are common in late pregnancy. The problem is partly caused by the weight of the uterus on the major veins of the pelvis. It usually clears up after delivery of the baby, and is mostly not a cause for concern, though it should always be reported to a doctor.
  • Lack of exercise is another common cause of water retention in the legs. Exercise helps the leg veins work against gravity to return blood to the heart. If blood travels too slowly and starts to pool in the leg veins, the pressure can force too much fluid out of the leg capillaries into the tissue spaces. The capillaries may break, leaving small blood marks under the skin. The veins themselves can become swollen, painful and distorted – a condition known as varicose veins.
  • Lack of exercise is a common cause of water retention because muscle action is needed not only to keep blood flowing through the veins but also to stimulate the lymphatic system to fulfill its “overflow” function. Long-haul flights, lengthy bed-rest, immobility caused by disability and so on, are all potential causes of water retention. Even very small exercises such as rotating ankles and wiggling toes can help to reduce it.


  • Protein attracts water and plays an important role in water balance. In cases of severe protein deficiency, the blood may not contain enough protein to attract water from the tissue spaces back into the capillaries. This is why starvation often shows an enlarged abdomen. The abdomen is swollen with edema or water retention caused by the lack of protein in their diet.
  • When the capillary walls are too permeable, protein can leak out of the blood and settle in the tissue spaces. It will then act like a magnet for water, continuously attracting more water from the blood to accumulate in the tissue spaces.

Other factors

  • Certain medications are prone to causing water retention. These include estrogens, thereby including drugs for hormone replacement therapy or the combined oral contraceptive pill, as well as non-steroidal anti-inflammatory drugs and beta-blockers. Premenstrual water retention, causing bloating and breast tenderness, is common and may be related to hormone imbalances promoted by a lack of nutrients such as B vitamins or magnesium.

Medication-caused water retention

Some medications can cause water retention, including

  • Drugs that contain estrogen – These can reduce water retention. Examples include birth control pills or hormone replacement therapy (HRT).
  • Non-steroidal anti-inflammatory drugs (NSAIDs) – These are medications with pain-reducing, fever-reducing effects. In high doses, they are actually effective in reducing inflammation. Examples include aspirin, ibuprofen, and naproxen.
  • Beta-blockers – These are used to treat abnormal heart rhythms and prevent tachycardias.

Premenstrual water retention

This can cause bloating and breast tenderness. Experts say this is due to hormone imbalances and some nutritional factors, including:

  • Malnutrition and bad diet – A poor diet low in protein result in low levels of albumin, which may also play a part in developing water retention.
  • Salt, or sodium – sodium-rich foods may cause water retention.
  • Allergies – Some foods and insect bites may cause edema in susceptible people.
  • Thyroid disease – People with a disorder of the thyroid gland commonly experience water retention.

Symptoms of Water Retention

Diagnosis of Water Retention


For most people with widespread water retention, blood tests are done to evaluate the function of the heart, kidneys, and liver. Urinalysis is usually also done to check for large amounts of protein, which can indicate nephrotic syndrome or, in pregnant women, preeclampsia. Other tests are done based on the suspected cause. For example, in people with isolated leg swelling, doctors may do ultrasonography to look for blockage of a vein in the leg.

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Causes water retention

Common Features


Some times itching or tight sensation

water retention that does not remain indented after being pressed

Only a doctor’s examination

A blood clot in a deep-lying vein in a leg (typically), an arm, or the pelvis (deep vein thrombosis)

Sudden swelling

Usually pain, redness, warmth, and/or tenderness in the affected area

If the clot travels and blocks an artery to the lung (pulmonary embolism), usually shortness of breath and sometimes coughing up blood

Sometimes in people who have risk factors for blood clots, such as recent surgery, an injury, bed rest, a cast on a leg, hormone therapy, cancer, or a period of immobility such as a long airplane flight


Chronic venous insufficiency (causing blood to pool in the legs)

Swelling in one or both ankles or legs

Chronic mild discomfort, aching, or cramps in the legs but no pain

Sometimes reddish brown, leathery areas on the skin and shallow sores on the lower legs

Often varicose veins

Only a doctor’s examination

Drugs (such as minoxidil, nonsteroidal anti-inflammatory drugs, estrogens, fludrocortisone, and some calcium channel blockers)

Painless swelling in both legs and feet

Only a doctor’s examination

Painless swelling in both legs and feet

Often shortness of breath during exertion or while lying down and during sleep

Often in people known to have heart disease and/or high blood pressure


Usually echocardiography

Infection of the skin (cellulitis)

An irregular area of redness, warmth, and tenderness on part of one limb

Water retention

Sometimes fever

Only a doctor’s examination

Infection deep under the skin or in the muscles (rare)

Deep, constant pain in one limb

Redness, warmth, tenderness and swelling that feels tight

Signs of severe illness (such as fever, confusion, and a rapid heart rate)

Sometimes a foul discharge, blisters, or areas of blackened, dead skin

Blood and tissue cultures


Sometimes MRI

Kidney disease (mainly nephrotic syndrome)

Widespread, painless swelling

Often fluid within the abdomen (ascites)

Sometimes puffiness around the eyes or frothy urine

Measurement of protein in a urine specimen

Liver disease if chronic

Widespread, painless swelling

Often fluid within the abdomen (ascites)

Causes that are often apparent based on history (such as alcohol abuse or hepatitis)

Sometimes small spiderlike blood vessels that are visible in the skin (spider angiomas), reddening of the palms and, in men, breast enlargement and a decrease in the size of the testes

Measurement of albumin in the blood

Other blood tests to evaluate liver function

Lymphatic vessel obstruction due to surgery or radiation therapy for cancer

Painless swelling of one limb

A cause (surgery or radiation therapy) that is apparent based on history

Only a doctor’s examination

Lymphatic filariasis (a lymph vessel infection due to certain parasitic worms)

Painless swelling of one limb and sometimes the genitals

In people who have been in a developing country where filariasis is common

Examination of a blood sample under a microscope

Normal swelling

A small amount of swelling of both feet and/or ankles that occurs at the end of the day and resolves by morning

No pain, redness, or other symptoms

Only a doctor’s examination

Pregnancy or a normal premenstrual symptom

Painless swelling in both legs and feet

Usually relieved to some extent by rest and leg elevation

In women known to be pregnant or about to have a menstrual period

Only a doctor’s examination

Pregnancy, with preeclampsia

Painless swelling in both legs and feet and sometimes hands

High blood pressure (often new)

Usually occurring during the 3rd trimester of pregnancy

Measurement of protein in urine

Pressure on a vein (for example, by a tumor, pregnancy, or extreme abdominal obesity)

Painless swelling that develops slowly

Ultrasonography or CT if a tumor is suspected

*Features include symptoms and the results of the doctor’s examination. Features mentioned are typical but not always present.

In most people with water retention, doctors do a complete blood count, other blood tests, and urinalysis (to check for protein in the urine).



Treatment of Water Retention


In the acute, or early phase, remember PRICE

  • P = Protection from further damage
  • R = Rest to avoid prolonging irritation
  • = Ice (cold) for controlling pain, bleeding, and edema
  • C = Compression for support and controlling swelling
  • E = Elevation for decreasing bleeding and edema
  • Protection can mean immobilization with a brace, or a wrap, or even just staying off the body part.
  • Rest means not moving the body part in a painful way. Movement is good and can increase healing, but it should be pain-free at this stage.
  • Ice for the first 72 hours – 20 minutes out of every hour. Leaving ice on longer actually reverses the effect it has, and may increase swelling. Chemical icepacks should never be applied directly to the skin, or frostbite can occur. Do not use heat for the first 72 hours; heat will increase the swelling.
  • Compression – with an ace wrap. Your athletic trainer or doctor can show you how to wrap the body part to minimize swelling.
  • Elevation – or resting with the injury above heart level, to encourage swelling to return towards the body, instead of collecting in the extremities where it is difficult to get rid of.

Medicine of Water Retention

Talk to your child’s doctor before switching back and forth between doses of acetaminophen and ibuprofen. When you switch between two medicines, there is a chance your child will get too much medicine

  • Elevate your feet as often as possible. (Either sitting in a chair with your feet on a stool with a pillow or in the bed or couch with feet up on two pillows)
  • Do not stand for long periods of time.
  • Avoid tight clothing (shoes, girdles, etc).
  • Do not cross your legs.
  • Reduce your salt intake if swelling is present. Avoid foods such as bouillon, potato chips, tomato juice, bacon, ham, canned soups, soy sauce, and table salt, for example.
  • Try to eat a balanced diet (see eating well section).
  • If your swelling is severe, consider wearing Jobst stockings or TED hose.
  • Weigh yourself daily. Notify your doctor or health care provider if you have gained 5 pounds or more in a week.
  • Take your medications exactly as prescribed.

Home Remedies of Water Retention


  • Dandelions are very high in potassium that can act as a natural diuretic. A big reason why many of us suffer from water retention is that we eat a diet that is too high in sodium and too low in potassium. While sodium makes your body hold on to water, potassium encourages it to release excess fluids. Drinking dandelion tea can make you pee more often and reduce water retention. But the most effective way to use dandelion as a diuretic is to take concentrated dandelion supplements.


  • Asparagus has been used as a natural diuretic for centuries. This plant contains an amino acid called asparagine which is especially effective in treating water retention due to menstrual cycles and rheumatism. After eating asparagus, you might notice that your pee smells funny. This is because after you eat asparagus, it gets broken down into sulfur compounds that cleanse your body of toxins and makes you pee more frequently.


  • Parsley is a popular medicinal herb and had extensive uses in traditional medicine. A herbal tea made by steeping fresh parsley leaves in boiling water was often used as a natural remedy to treat water retention. Studies on the diuretic effects of parsley conducted on rats did find that rats urinated more frequently after ingesting parsley. While studies on humans haven’t been conducted yet, there’s plenty of anecdotal evidence to support parsley’s diuretic powers.


  • Caraway seeds are small, brown seeds that look very much like cumin. In Eastern traditional medicine, caraway seeds were often used to soothe digestive issues and reduce water retention. Studies conducted on rats found that after being fed caraway extracts, rats urinated a lot more frequently than usual. The lack of studies on humans, however, means that we don’t know just how much caraway is required to reduce water retention. You can start using caraway seeds by adding it as a spice to your meals or boiling it with water and drinking the tea along with the seeds.


  • Both green and black tea have strong diuretic properties that can help reduce water retention. However, it’s important that you drink it black and with no sugar as dairy and white sugar can aggravate water retention. Interestingly, studies have shown that tea is most effective as a diuretic when a person doesn’t drink it on a regular basis. Drinking tea everyday can make you develop a tolerance for it which can affect its diuretic properties. So if you’re a coffee drinker, it’s best you switch to tea on days when you feel extra puffy.


  • Horsetail is one of the most powerful natural diuretics known to us and is available in the form of a tea and as a supplement. One study found that taking horsetail supplements were as effective as certain commercial diuretics. But while horsetail can dramatically reduce water retention in the short run, it can cause harmful side effects if you use it for too long. Horsetail can also be dangerous if you already have kidney disease or diabetes.


  • Cucumbers are almost entirely water themselves, so it isn’t surprising that eating them will make you pee more. Cucumbers contain sulfur and silicon which can help your kidneys function better and remove excess uric acid from them. They are also very high in potassium which helps your body release water. You can even use cucumbers topically to reduce symptoms of water retention. If your eyes get puffy when you have water retention, placing cool slices of cucumber over them can reduce the swelling.



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Child Rheumatic Fever, Symptoms, Diagnosis, Treatment

Child Rheumatic Fever/Rheumatic fever (RF) is an autoimmune, multiorgan inflammatory disease that occurs as a result of group A β-hemolytic streptococcal infection in genetically syusceptible individuals [].

Rheumatic fever is an immunologically mediated inflammatory disease, that occurs as a delayed sequel to group A streptococcal throat infection, in genetically susceptible individuals. Chronic rheumatic heart disease remains an important public health problem in developing countries. Aetiopathogenesis and guidelines for the diagnosis, prevention and treatment of acute rheumatic fever are reviewed.


Although epidemiological and immunological studies have clearly identified group A β-hemolytic streptococcus (GAS) as the etiologic agent triggering ARF in a susceptible host, the molecular pathways linking GAS to ARF are still poorly understood. Molecular mimicry and autoimmunity probably play a pivotal role in the pathogenesis of ARF and carditis [] since it was shown that the streptococcal M protein shares an α-helical coiled structure with cardiac proteins such as myosin and that antibodies isolated from ARF patients cross-react with both M protein and heart tissue. Elevated in patients with valvular involvement, these antibodies are significantly reduced after surgical removal of inflamed valves and they correlate with poor prognosis []. Moreover, heart-M protein cross-reactive T cells have been isolated from the myocardium and the valves of RHD patients suggesting their involvement in the pathophysiology of the disease [, ]. However, the role of collagen should not be underestimated, as shown by recent studies demonstrating pathological findings in subendothelial and perivascular connective tissue in ARF [].

Causes of Rheumatic Fever

  • Rheumatic fever – may develop after strep throat or scarlet fever infections that are not treated properly. Bacteria called group A Streptococcus or group A strep cause strep throat and scarlet fever. It usually takes about 1 to 5 weeks after strep throat or scarlet fever for rheumatic fever to develop. Rheumatic fever is thought to be caused by a response of the body’s defense system — the immune system. The immune system responds to the earlier strep throat or scarlet fever infection and causes a generalized inflammatory response.
  • Rheumatic fever – is an inflammatory condition that may develop approximately 14-28 days after infection with group A Streptococcus bacteria, such as strep throat or scarlet fever. About 5% of those with untreated strep infection will develop rheumatic fever. Although group A Streptococcus bacterial infections are highly contagious, rheumatic fever is not spread from person to person.
  • Bacteria called group –  A Streptococcus (group A strep) can cause many different infections. These infections range from minor illnesses to very serious and deadly diseases. Learn more below about some of these infections, including symptoms, risk factors, treatment options, and how to prevent them.
  • Strep Throat – When is a sore throat “strep throat”? Your doctor can do a quick test to see if you or your child has strep throat.
  • Scarlet Fever – Have a sore throat and rash? It could be scarlet fever. Your doctor can do a quick test to find out…
  • Necrotizing Fasciitis – Sometimes called “flesh-eating” disease, this infection is not common. Good hygiene, proper wound care, and quick recognition and treatment are important.
  • Rheumatic Fever – This disease affects the heart and other organs. It is not common but can happen if strep throat or scarlet fever aren’t treated properly
  • Post-Streptococcal Glomerulonephritis – This disease affects the kidneys and is not common but can happen after strep throat or impetigo

Symptoms of Rheumatic Fever

Symptoms of rheumatic fever include

  • Joint swelling and pain This may include redness and warmth, mainly of the larger joints like the knees, ankles, wrists and elbows
  • Fever Hot and cold fevers which may feel like symptoms of a cold or flu
  • Sydenham’s Chorea – Jerky, uncontrollable movements called chorea
  • Erythema marginatum – A rare skin rash, mainly found on the trunk of the body (this is a very a rare symptom)
  • Subcutaneous nodules – Round, painless nodules over the elbows, wrists, knees, ankles and areas near the spine (also very rare)
  • Heart problems – Swelling of the heart may cause chest pain, and if severe there may be signs of heart failure (breathlessness, swollen legs and face).
  • Painful – tender joints (arthritis), most commonly in the knees, ankles, elbows, and wrists
  • Symptoms of congestive heart failure – including chest pain, shortness of breath, fast heartbeat
  • Jerky uncontrollable body movements (called chorea)
  • Painless lumps (nodules) under the skin near joints.
  • Rash that appears as pink rings with a clear center.
  • Red raised, lattice-like rash, usually on the chest, back, and abdomen.
  • Uncontrolled movements of arms, legs, or facial muscles
  • Swollen, tender, red and extremely painful joints
  • Weakness and shortness of breath
  • Nodules over swollen joints
  • Stomach pains
  • Weight loss
  • Fatigue
  • Fever

Diagnosis of Rheumatic Fever

The diagnostic tests can be considered as those meant for (i) diagnosis of RF, (ii) presence of active vs. inactive RF in recurrences, and (iii) identification of carditis and valve damage in RHD.

Diagnosis of RF

The diagnosis of RF is dependent on some laboratory tests included as minor criteria and consist of the following:

  • (i)Acute phase reactants (leukocytosis, elevated sedimentation rate and presence of C reactive protein CRP).
  • (ii)Prolonged PR interval in the electrocardiogram.
The diagnosis requires presence of essential criteria in the form of evidence for recent GAS infection and consists of:
  • (i) elevated antistreptococcal antibodies,
  • (ii) positive throat culture for GAS, and
  • (iii) evidence for recent scarlet fever- rare in India.

Diagnostic criteria for rheumatic fever – modified 1992 Jones criteria []

Major criteria Minor criteria
Erythema marginatum
Subcutaneous nodules
Arthralgia, without other signs of inflammation
Laboratory indicators of acute phase:
Prolonged PR interval in ECG
And evidence of antecedent streptococcal infection
– Throat swab culture or rapid antigen test
– Elevated/increasing anti-streptococcal antibody titer in serum

ESR – erythrocyte sedimentation rate; CRP – C-reactive protein; ECG – electrocardiography

Major criteria

  • Polyarthritis – [rx] A temporary migrating inflammation of the large joints, usually starting in the legs and migrating upwards.
  • Carditis – Inflammation of the heart muscle (myocarditis) which can manifest as congestive heart failure with shortness of breath, pericarditiswith a rub, or a new heart murmur.
  • Subcutaneous nodules – Painless, firm collections of collagen fibers over bones or tendons. They commonly appear on the back of the wrist, the outside elbow, and the front of the knees.
  • Erythema marginatum – A long-lasting reddish rash that begins on the trunk or arms as macules, which spread outward and clear in the middle to form rings, which continue to spread and coalesce with other rings, ultimately taking on a snake-like appearance. This rash typically spares the face and is made worse with heat.
  • Sydenham’s chorea (St. Vitus’ dance) – A characteristic series of involuntary rapid movements of the face and arms. This can occur very late in the disease for at least three months from onset of infection.

Minor criteria

  • Fever of 38.2–38.9 °C (100.8–102.0 °F)
  • Arthralgia – Joint pain without swelling (Cannot be included if polyarthritis is present as a major symptom)
  • Raised erythrocyte sedimentation rate or C reactive protein
  • Leukocytosis
  • ECG showing features of heart block, such as a prolonged PR interval[rx][rx] (Cannot be included if carditis is present as a major symptom)
  • Previous episode of rheumatic fever or inactive heart disease


Diagnostic criteria for rheumatic fever – modified 2015 Jones criteria []

Major criteria
Low risk population High risk population
Carditis (clinical or subclinical)
Arthritis – only polyarthritis
Erythema marginatum
Subcutaneous nodules
Carditis (clinical or subclinical)
Arthritis – monoarthritis or polyarthritis
Erythema marginatum
Subcutaneous nodules
Minor criteria
Low risk population High risk population
Hyperpyrexia (≥ 38.5ºC)
ESR ≥ 60 mm/h and/or CRP ≥ 3.0 mg/dl
Prolonged PR interval (after taking into account the differences related to age; if there is no carditis as a major criterion)
Hyperpyrexia (≥ 38.0ºC)
ESR ≥ 30 mm/h and/or CRP ≥ 3.0 mg/dl
Prolonged PR interval (after taking into account the differences related to age; if there is no carditis as a major criterion)

ESR – erythrocyte sedimentation rate; CRP – C-reactive protein


The modifications introduced in 2015 in the Jones criteria are as follows

In the major criteria

  • Low risk population – clinical and/or subclinical carditis. AHA recommends that all the patients with suspected RF undergo Doppler echocardiographic examination, even if no clinical signs of carditis are present []. In doubtful cases it is recommended that echocardiography is repeated.
  • Medium and high risk population – also clinical and/or subclinical carditis and arthritis – monoarthritis or polyarthritis, possibly also with polyarthralgia [, ].

In the minor criteria

  • Low risk population – the parameters of inflammation and the level of fever were defined precisely.
  • Medium and high risk population – monoarthralgia, also with defined parameters of inflammation and the level of fever.

The diagnosis of RF in the whole population with evidence of antecedent group A β-hemolytic streptococcal infection requires a confirmation of two major criteria or one major and two minor criteria – the first episode of the disease. The echocardiographic criteria developed by AHA in 2012 are as follows [, ]

Echocardiographic (Doppler) criteria: Pathological mitral regurgitation – 4 criteria (all must be met)

  • Visible at least in 2 projections.
  • Regurgitation jet length ≥ 2 cm at least in 1 projection.
  • Regurgitation peak velocity > 3 m/s.
  • Regurgitation pansystolic.

Pathological aortic regurgitation – 4 criteria (all must be met)

  • Visible at least in 2 projections.
  • Regurgitation jet length ≥ 1 cm at least in 1 projection.
  • Regurgitation peak velocity > 3 m/s.
  • Regurgitation pandiastolic.

Echocardiographic (morphological) criteria: In acute mitral valve involvement

  • Dilatation of mitral annulus.
  • Elongation of chordae tendineae.
  • Rupture of chorda tendinea with acute mitral regurgitation.
  • Prolapse of anterior (less often posterior) leaflet.
  • Nodular lesions on leaflets.

In chronic mitral valve involvement (invisible in acute involvement)

  • Thickening of leaflets.
  • Thickening of chordae tendinea, with their fusion.
  • Limited mobility of leaflets.
  • Calcifications.

Lesions in acute and chronic aortic valve involvement

  • Symmetrical or focal thickening of leaflets.
  • Disturbed leaflet coaptation (leaflet closing during systole).
  • Limited mobility of leaflets.
  • Prolapse of leaflets.

Presence of GAS in throat culture with low values of ASLO suggests a carrier state. As such a positive throat culture for GAS cannot be taken as recent infection unless the antibody titres are elevated.

  • Echocardiogram (echo) – This test uses sound waves to check the heart’s chambers and valves. The echo sound waves create a picture on a screen as an ultrasound transducer is passed over the skin overlying the heart. Echo can show damage to the valve flaps, backflow of blood through a leaky valve, fluid around the heart, and heart enlargement. It’s the most useful test for diagnosing heart valve problems.
  • Electrocardiogram (ECG) – This test records the strength and timing of the electrical activity of the heart. It shows abnormal rhythms (arrhythmias or dysrhythmias) and can sometimes detect heart muscle damage. Small sensors are taped to your skin to pick up the electrical activity.
  • Chest X-ray – An X-ray may be done to check your lungs and see if your heart is enlarged.
  • Cardiac MRI – This is an imaging test that takes detailed pictures of the heart. It may be used to get a more precise look at the heart valves and heart muscle.
  • Blood tests – Certain blood tests may be used to look for infection and inflammation.

Presence of active vs. inactive RF in recurrences Two investigations have been tried to assess the presence or absence of active RF in patients with recurrences besides ESR, CRP and evidence for recent GAS infection.

  • Induced subcutaneous nodules (SCN) Massell et al tried inducing SCN by injecting five dl autologous blood drawn from a vein and injecting over the olecranon process of one elbow and saline in the other elbow. Frictional pressure was applied to the injected sites. Appearance of a SCN in 5 to 10 days was accepted as indicating active RF. Vasan modified this test and used concentrated leukocyte injection instead of whole blood with 86 per cent sensitivity and 94 per cent specifically to identify active RF. The test offers the advantage of being cheap and easily available everywhere. The potential utility of the test lies in identifying active RF. However, additional validation studies are perhaps needed.
  • Myocardial biopsy A study of myocardial histology to identify active vs. inactive RF was utilized in patients of RF. Myocardial biopsies were performed in 89 patients of active RF and chronic RHD to identify active carditis Myocardial biopsies failed to improve on clinically assessed presence of active RF. Myocardial biopsy was felt to be insensitive for identifying presence of active carditis.

Treatment of Rheumatic Fever

Antibiotics used in primary prevention and treatment of group A streptococcal throat infection (World Health Organization guidelines)

Antibiotic Route of administration and dosage Dose
Benzathine benzylpenicillin Intramuscular injection; childen should be kept under observation for 30 minutes Single dose 1.2 million U; <27 kg, 600 000 U
Phenoxymethylpenicillin (penicillin V) Oral, 2-4 times daily for 10 days Children 250 mg twice or three times daily, adolescents or adults 250 mg three or four times daily or 500 mg twice daily
Amoxicillin Oral, 2-3 times daily for 10 days 25-50 mg/kg/d in three doses; total adult dose 750-1500 mg/d
First generation cephalosporins Oral, 2-3 times daily for 10 days Varies with formulation
Erythromycin if allergic to penicillin Oral, 4 times daily for 10 days Varies with formulation


Antibiotic Dose Duration
Penicillin V 250 mg by mouth 2 to 3 times daily (≤27 kg) or 500 mg by mouth 2 to 3 times daily (>27 kg) 10 days
Benzathine penicillin G 600,000 units intramuscular (≤27 kg) or
1,200,000 units intramuscular (>27 kg)
Amoxicillin 50 mg/kg by mouth daily 10 days
Cephalosporin (first generation) Drug-dependent 10 days
Clindamycin 20 mg/kg/day divided in 3 doses by mouth 10 days
Clarithromycin 15 mg/kg/day divided in 2 doses by mouth 10 days
Azithromycin 12 mg/kg by mouth daily 5 days

Rheumatic fever treatment has not changed for many years. It covers:

  • anti-streptococcal treatment (primary and secondary prevention),

  • anti-inflammatory treatment.

Anti-Streptococcal Treatment

Primary prevention relies on the proper treatment of streptococcal pharyngitis, that is, prevention of the first RF episode.

  • The drug of choice is still phenoxymethylpenicillin orally at the following doses – adults and children with a body weight > 40 kg – 2–3 MIU/day in 2 divided doses every 12 hours for 10 days, children with a body weight < 40 kg – 100,000 to 200,000 IU/kg/day in 2 divided doses every 12 hours for 10 days.
  • Benzylpenicillin – administered intramuscularly at a single dose (only in hospital settings), is acceptable, for adults and children with a body weight > 40 kg – 1.2 MIU, children with a body weight < 40 kg – 600,000 IU. In patients with hypersensitivity to penicillin (except for immediate-type reactions), first-generation cephalosporins (cefadroxil or cefalexin) are used.
  • Cefadroxil – adults and children with a body weight > 40 kg – 1 g, children with a body weight < 40 kg – 30 mg/kg, in a single dose for 10 days.
  • Cefalexin – adults 500 mg twice per day, children 25–50 mg/kg/day in 2 doses for 10 days. Macrolides should only be administered in patients with immediate-type hypersensitivity to beta-lactam antibiotics. The following can be used: erythromycin, clarithromycin and azithromycin.
  • Erythromycin – adults and children with a body weight > 40 kg – 0.2–0.4 γ every 6–8 hours, children with a body weight < 40 kg – 30–50 mg/kg/day in 3–4 doses, for 10 days.
  • Clarithromycin – adults and children with a body weight > 40 kg – 250–500 mg every 12 hours, children with a body weight < 40 kg – 15 mg/kg/day in 2 doses, for 10 days.
  • Azithromycin – adults and children with a body weight > 40 kg – 500 mg on the first day, then 250 mg for three consecutive days, children with a body weight < 40 kg – a single daily dose of 12 mg/kg/day for 5 days or 20 mg/kg/day for 3 days [].
  • Secondary prevention is the prevention of subsequent rheumatic fever relapses through the chronic anti-streptococcal treatment – phenoxymethylpenicillin or benzathine benzylpenicillin or possibly macrolides. The duration of secondary prevention must be determined individually, depending on whether the patient has developed carditis and complications in the form of chronic valvular heart disease. Secondary prevention should be administered from 5 to 10 years from the last RF relapse, or up to 21 years of age (whichever is longer) [, ]. In RF cases with carditis leading to chronic valvular heart disease, the prevention should be administered for 10 years or until 40 years of age (whichever is longer) []. Secondary prevention makes use of benzathine benzylpenicillin, intramuscularly in adults and children with a body weight > 20 kg – 1.2 MIU, in children with a body weight < 20 kg – 600,000 IU every 4 weeks []. Phenoxymethylpenicillin is administered orally at a dose of 2 × 250 mg (i.e. 2 × 400,000 IU).
  • Anti-inflammatory drugs – Naproxen, for example, may help to reduce pain, inflammation, and fever.
  • Corticosteroids – Prednisone may be given if the patient does not respond to first-line anti-inflammatory medications, or if there is inflammation of the heart.
  • Aspirin – This is not usually recommended for children aged under 16 years because of the risk of developing Reye’s syndrome, which can cause liver and brain damage, and even death, but an exception is usually made in cases of RA because the benefits are greater than the risks.
  • Anticonvulsant medications – These can treat severe chorea symptoms. Examples include valproic acid, carbamazepine, haloperidol and risperidone.


Child Rheumatic Fever


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Avulsions Wound, Causes, Diagnosis, Treatment

Avulsions Wound/Wounds are defined as a disruption of the normal structure and function of skin and underlying soft tissue that is caused by trauma or chronic mechanical stress (e.g., decubitus ulcers). Wounds can be broken down into acute or chronic, and open or closed. Wound treatment is performed according to pathology, the extent, and circumstances of the lesions. To heal, the wound needs to have a vascular supply, be free of necrotic tissue, clear of infection, and moist. General wound treatment includes surgical wound closure, open wound treatment, and plastic reconstruction of skin defects. In addition, infectious or concomitant disease prevention should be considered (e.g., antibiotic therapy, vaccines for tetanus and rabies, diabetes control).

A wound is damaged or disruption to the skin and, before treatment, the exact cause, location, and type of wound must be assessed to provide appropriate treatment. Each clinician will have widely differing and distinct opinions and understanding of wound care depending on their prior experience. The reason for this because of the widely differing and distinct types of wounds, each with their etiology. An ostomy nurse will have a completely different approach to wound care that will require an orthopedic surgeon who deals with trauma and both will be far different from a dermatologist who treats burn victims. Nevertheless, each of these healthcare providers is performing wound care. How do professionals then approach wound assessment when the causes are so diverse? Below are some basic questions to ask during a wound assessment to best classify and treat a wound presenting in a clinical setting.

Normal Healthy Skin of Wounds

As the interface between the environment and body, the skin has several distinct functions. It protects the underlying tissues from abrasions, the entry of microbes, unwanted water loss, and ultraviolet light damage. Tactile sensations of touch, pressure, and vibration, thermal sensations of heat and cold, and pain sensations all originate in the skin’s nervous system. The body’s thermoregulation relies on the skin’s ability to sweat and to control the flow of blood to the skin to increase or decrease heat loss. The skin’s functions are performed by three distinct tissue layers: a thin outer layer of cells called the epidermis, a thicker middle layer of connective tissue called the dermis, and an inner, subcutaneous layer. The outer layers of the epidermis are composed of flattened, cornified dead keratinocytes that form a barrier to water loss and microbe entry. These cells are derived from a basal layer of constantly dividing keratinocytes that lies next to the dermis. The epidermis does not contain nerves or blood vessels and obtains water and nutrients through diffusion from the dermis. The dermis is composed mostly of collagen fibers and some elastic fibers both produced by fibroblasts and, along with water and large proteoglycan molecules, makes up the extracellular matrix. This layer of the skin provides mechanical strength and a substrate for water and nutrient diffusion; it contains blood vessels, nerves, and cells involved in immune function, growth, and repair. The dermis also contains sweat glands, oil glands, and hair follicles. The subcutaneous layer is composed of adipocytes that form a thick layer of adipose tissue.

Types of Wounds

 Each of the potential underlying causes must be addressed for the wound to heal. Before determining the underlying cause, it is important to determine what type of wound the patient has. These subclassifications can be acute or chronic.

1. According to the severity, a wound can be classified as


Clinicians assess acute wounds by the method of injury and damage to the soft tissues and bony structures. In crush or high impact injuries, there is an area of demarcation which is not fully recognized until sometimes as much as a week or 2 later. For this reason, it is important to determine the method of injury and to keep in mind that the wound seen is not necessarily the entirety of the wound which will be present in a week. In these cases, the patient and their family should be educated on this progression to prevent frustration and misunderstanding.

For all acute types of wounds, it is important to determine the length of time since injury (days or hours), the involvement of neurovascular supply, muscle, tendon, ligament, and bony involvement, and the likelihood of contaminants in the wound. Also of importance is when the patient had their last tetanus shot. CLinicians should start antibiotics if the wound is severely contaminated or if it is longer than 3 hours since the injury. All underlying tissue should be repaired if possible, and the wound should be irrigated to remove contaminants and bacteria.

In cases of open fracture the most used classification is Gustillo-Anderson

  • Type 1 – Clean wound, less than one cm with minimal soft tissue damage, adequate soft tissue coverage of bone, and no periosteal stripping
  • Type 2 – Wound with moderate contamination, greater than one cm with moderate soft tissue damage, adequate soft tissue coverage of bone, and no periosteal stripping
  • Type 3A – Wound with significant contamination, with significant soft tissue damage, adequate soft tissue coverage of bone, and periosteal stripping is present
  • Type 3B – Wound with significant contamination, with significant soft tissue damage, unable to cover bone with soft tissue (requiring graft), and periosteal stripping
  • Type 3C – Similar to type A or B, however with Arterial damage requiring repair


If a wound becomes arrested in progression through the normal stages of inflammation and wound healing and remains open, then this becomes a chronic wound. While there is no consensus as to when a wound becomes chronic, a study by Sheehan et. al determined that in diabetic wounds, the degree of healing at 4 weeks is a strong predictor of 12 week healing, suggesting that those wounds which have not healed approximately 50% in 4 weeks are likely to have an arrested healing process, and therefore are chronic.

In the chronic setting, the main goal is to identify why the wound is not healing and to fix this obstacle or obstacles.

There are a limited number of reasons a wound becomes chronic; however, once these reasons are rectified, the wound resumes its natural course of healing.

  • Arterial – Is there enough blood flow? Generally speaking, an ABI of less than 50 mm Hg, or an absolute toe pressure less than 30 mm Hg (or less than 50 mm Hg for persons with diabetes) indicates critical limb ischemia and predicts failure of wounds to heal.
  • Venous – Pressure-induced changes in blood vessel wall permeability then lead to leakage of fibrin and other plasma components into the perivascular space. Accumulation of fibrin has direct and negative effects on wound healing as it down-regulates collagen synthesis.
  • Infection – Underlying infectious processes including cellulitic and osteomyelitis processes will inhibit wound healing. Culturing for aerobic, anaerobic, and fungal pathogens is recommended.
  • Pressure – Increased pressure to the area of concern will destroy new tissue growth and prevent proper perfusion of blood to the wound site. These areas need to be offloaded to avoid pressure in the area.
  • Oncologic – Always biopsy areas of concern in nonhealing wounds, as this can be an atypical presentation of some types of malignancies.
  • Systemic – There are multiple systemic diseases which inhibit wound healing, with diabetes being the most common culprit. It has been determined that uncontrolled blood glucose levels suppresses the body’s normal inflammatory response, as well as causing microvascular disease which limits healing.
  • Nutrition – While serum albumin has not been found to be a good predictor of wound healing, there is some evidence that protein malnutrition, as well as insufficient levels of certain vitamins and minerals, will limit the body’s ability to heal chronic wounds.
  • Pharmacological – Hydroxyurea has been reported in multiple instances to cause nonhealing ulcerations.
  • Self-inflicted/psychosocial – There are instances where a patient is causing the ulceration, either on purpose or as a result of noncompliance. This is often the hardest factor to spot and overcome, but must always be a consideration.

2. According to level of contamination, a wound can be classified as

  • Clean wound – made under sterile conditions where there are no organisms present, and the skin is likely to heal without complications.
  • Contaminated wound – usually resulting from accidental injury; there are pathogenic organisms and foreign bodies in the wound.
  • Infected wound – the wound has pathogenic organisms present and multiplying, exhibiting clinical signs of infection (yellow appearance, soreness, redness, oozing pus).
  • Colonized wound – a chronic situation, containing pathogenic organisms, difficult to heal (i.e. bedsore).


Open wounds can be classified according to the object that caused the wound

  • Incisions or incised wounds – caused by a clean, sharp-edged object such as a knife, razor, or glass splinter.
  • Lacerations – irregular tear-like wounds caused by some blunt trauma. Lacerations and incisions may appear linear (regular) or stellate (irregular). The term laceration is commonly misused in reference to incisions.[rx]
  • Abrasions (grazes) – superficial wounds in which the topmost layer of the skin (the epidermis) is scraped off. Abrasions are often caused by a sliding fall onto a rough surface such as asphalt, tree bark or concrete.
  • Avulsions – injuries in which a body structure is forcibly detached from its normal point of insertion. A type of amputation where the extremity is pulled off rather than cut off. When used in reference to skin avulsions, the term ‘degloving’ is also sometimes used as a synonym.
  • Puncture wounds – caused by an object puncturing the skin, such as a splinter, nail or needle.
  • Penetration wounds – caused by an object such as a knife entering and coming out from the skin.
  • Gunshot wounds – caused by a bullet or similar projectile driving into or through the body. There may be two wounds, one at the site of entry and one at the site of exit, generally referred to as a “through-and-through.”


Closed wounds have fewer categories, but are just as dangerous as open wounds:

  • Hematomas (or blood tumor) – caused by damage to a blood vessel that in turn causes blood to collect under the skin.
    • Hematomas that originate from internal blood vessel pathology are petechiae, purpura, and ecchymosis. The different classifications are based on size.
    • Hematomas that originate from an external source of trauma are contusions, also commonly called bruises.
  • Crush injury – caused by a great or extreme amount of force applied over a long period of time.

3. According to the Visuality, a wound can be classified as

Internal Wounds

Disturbance of the different regulating systems of the human body can lead to wound formation, and may include the following:

  • Impaired circulation – This can be from either ischemia or stasis. Ischemia is the result of reduced blood supply caused by the narrowing or blockage of blood vessels, which leads to poor circulation. Stasis is caused by immobilization (or difficulty moving) for long periods or failure of the regulating valves in the veins, which leads to blood pooling and failing to flow normally to the heart.
  • Neuropathy – This is seen mostly in cases of prolonged uncontrolled diabetes mellitus, where high blood sugars, derivative proteins and metabolites accumulate and damage the nervous system. The patients are usually unaware of any trauma or wounds, mainly due to loss of sensation in the affected area.
  • Medical illness – When chronic and uncontrolled for long periods (such as hypertension, hyperlipidemia, arthrosclerosis, diabetes mellitus, AIDS, malignancy, morbid obesity, hepatitis C virus, etc.), medical illnesses can lead to impairment of the immune system functions, diminishing the circulation and damaging other organs and systems.

External Wounds

External wounds can either be open or closed. In cases of closed wounds, the skin is intact and the underlying tissue is affected but not directly exposed to the outside environment. The following are the most common types of closed wounds:

  • Contusions – These are a common type of sports injury, where a direct blunt trauma can damage the small blood vessels and capillaries, muscles and underlying tissue, as well the internal organs or bone. Contusions present as a painful bruise with reddish to bluish discoloration that spreads over the injured area of skin.
  • Hematomas – These include any injury that damages the small blood vessels and capillaries resulting in blood collecting and pooling in a limited space. Hematomas typically present as a painful, spongy rubbery lump-like lesion. Depending on the severity and site of the trauama, hematomas can be small or large, deep inside the body or just under the skin.
  • Crush injuries – These are usually caused by an external high-pressure force that squeezes part of the body between two surfaces. The degree of injury can range from a minor bruise to a complete destruction of the crushed area of the body, depending on the site, size, duration and power of the trauma.

Causes of Wound

  • Sudden forceful  fall down
  • Road traffic accident
  • Burn and injured suddenly
  • Falls – Falling onto an outstretched hand is one of the most common causes of wound.
  • Sports injuries – Many sports injury occur during contact sports or sports in which you might fall onto an outstretched hand — such as in-line skating or snowboarding.
  • Motor vehicle crashes – Motor vehicle crashes can cause wound. Sometimes into many pieces, and often require surgical repair.
  • Have osteoporosis –  a disease that weakens your bones.
  • Eave low muscle mass or poor muscle strength – or lack agility and have poor balance (these conditions make you more likely to fall)
  • Walk or do other activities in snow or on the ice – or do activities that require a lot of forwarding momenta, such as in-line skating and skiing
  • Wave an inadequate intake of calcium or vitamin D
  • Football or soccer, especially on artificial turf
  • Rugby
  • Horseback riding
  • Hockey
  • Skiing
  • Snowboarding
  • In-line skating
  • Jumping on a trampoline

Symptoms of Wound

General signs and symptoms of a wound infection include

  • Redness or discoloration
  • Swelling
  • Warmth
  • Pain, tenderness
  • Scaling, itching
  • Pustules, pus drainage
  • Increased pain around the wound bed
  • Redness or warmth
  • Fever /chills or other flu-like symptoms
  • Pus draining from the wound bed
  • Increasing odor from the wound
  • Increased firmness of skin or swelling around the wound bed
  • Increasing drainage from the wound bed
  • Delayed wound healing
  • Discoloration of the wound bed with it turning darker in color
  • Foul odor
  • Increased fragility of the wound bed
  • Wound breakdown /enlargement

The skin may harden or tighten in the area and red streaks may radiate from the wound. Wound infections may also cause fevers, especially when they spread to the blood.

Diagnosis of Wound

Clinicians perform wound assessment as a means for determining the appropriate treatment for an extremely diverse grouping of disease processes. Just as hypertension is not treated the same as diabetes, each of the underlying etiologies of the given wound must be identified and treated as if it were its own disease, not a blanket classification of “wound.”

The initial assessment should begin with the following:

  • How – How was the wound created and, if chronic, why is it still open? (underlying etiology)
  • Where –  Where on the body is it located? Is it in an area which is difficult to offload, or to keep clean? Is it in an area of high skin tension? Is it near any vital structures such as a major artery?
  • When – How long has this wound been present? (eg., chronic or acute)
  • What – What anatomy does it extend? (e.g., epidermis, dermis, subcutaneous tissue, fascia, muscle, tendon, bone, arteries, nerves)
  • What – What co-morbidities or social factors does the patient have which might affect which might affect their ability to heal the wound?
  • Is it life threatening?

All of these factors significantly affect the treatment plan moving forward. While there are many excellent biologics, skin grafts, and other options available, without the appropriate understanding of the nature of the wound the chances of healing decline significantly.

Issues of Concern

While some wounds are simple, the majority of wounds many clinicians encounter are caused by or complicated by some other issue. These are a few of the possible complications from different wound types:

  • A chronic wound will have a different makeup than that of an acute wound, requiring conversion for healing.
  • An underlying infection will prevent wound healing even if the infection is subacute.
  • A damaged or constricted arterial supply will prevent appropriate blood flow to the wound.
  • A damaged venous supply will cause venous stasis.
  • Physical pressure on chronic ulceration will cause repeated damage, preventing healing.


Many minor and superficial skin and wound infections are diagnosed by a healthcare practitioner based on a physical examination, sign and symptoms, and experience. A clinical evaluation cannot, however, definitively tell the healthcare practitioner which microbe is causing a wound infection or what treatment is likely to be effective. For that, laboratory testing is required.

Laboratory Tests
Examples of common tests include

  • Bacterial culture – This is the primary test used to diagnose a bacterial infection. Results are usually available within 24-48 hours.
  • Gram stain – This is usually performed in conjunction with the wound culture. It is a special staining procedure that allows bacteria to be evaluated under the microscope. The results are usually available the same day and provide preliminary information about the microbe that may be causing the infection.
  • Antimicrobial susceptibility – A follow-up test to a positive wound culture, this is used to determine the bacteria’s likely susceptibility to certain drugs and helps the healthcare practitioner select appropriate antibiotics for treatment. Results are typically available in about 24 hours. This testing can identify resistant bacteria such as MRSA.

Other tests may include

  • KOH prep – This is a rapid test performed to detect fungi in a sample. The sample is treated with a special solution, placed on a slide, and examined under a microscope.
  • Fungal culture – This is ordered when a fungal infection is suspected. Many fungi are slow-growing and may take several weeks to identify.
  • AFB testing – This is ordered when a mycobacterial infection is suspected. Most AFB are slow-growing and may take several weeks to identify.
  • Blood culture – This is ordered when infection from a wound may have spread to the blood.
  • Molecular testing  – to detect genetic material of a specific microbe
  • Basic metabolic panel (BMP) or Comprehensive metabolic panel (CMP) – This may be ordered to detect underlying conditions that can affect wound healing, such as a glucose test to detect diabetes.
  • Complete blood count (CBC) – An elevated white blood cell (WBC) count may be a sign of infection.

Treatment of Wound

Emergency Management

Pain control

  • Intravenous opiates are often used as patients typically in severe pain
    • Highly effective for management of pain 
    • Lower side effect profile than systemic analgesia
    • Always calculate your toxic dose of local anesthetic to avoid local anesthetic systemic toxicity
  • Closed the wounds should be placed in long leg splint and can also be placed in traction
  • If open Fractures should receive antibiotics and should proceed to OR for irrigation/debridement.
  • Cleaning to remove dirt and debris from a fresh wound. This is done very gently and often in the shower.
  • Vaccinating for tetanus may be recommended in some cases of traumatic injury.
  • Exploring a deep wound surgically may be necessary. Local anaesthetic will be given before the examination.
  • Removing dead skin surgically. Local anaesthetic will be given.
  • Closing large wounds with stitches or staples.
  • Dressing the wound – The dressing chosen by your doctor depends on the type and severity of the wound. In most cases of chronic wounds, the doctor will recommend a moist dressing.
  • Relieving pain with medications – Pain can cause the blood vessels to constrict, which slows healing. If your wound is causing discomfort, tell your doctor. The doctor may suggest that you take over-the-counter drugs such as paracetamol or may prescribe stronger pain-killing medication.
  • Treating signs of infection including pain – pus and fever. The doctor will prescribe antibiotics and antimicrobial dressings if necessary. Take as directed.
  • Skin Traction (Hare or Thomas) if needed
    • May improve wound alignment, blood flow, and pain
    • Skin traction splint can cause complications if a patient with a significant  injury (i.e. multi ligamentous knee injury)
    • Hare Splint Video(link)
    • Thomas Splint Video (link)


Here we review only the commonly used medications that have a significant impact on healing, including glucocorticoid steroids, non-steroidal anti-inflammatory drugs, and chemotherapeutic drugs.

  • Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema. Antibiotics and tetanus vaccination may be used if the bone breaks through the skin creating an open fracture.
  • NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and KetorolacAceclofenacNaproxen, Etoricoxib.
  • Glucocorticoid Steroids – Systemic glucocorticoids (GC), which are frequently used as anti-inflammatory agents, are well-known to inhibit wound repair via global anti-inflammatory effects and suppression of cellular wound responses, including fibroblast proliferation and collagen synthesis. Systemic steroids cause wounds to heal with incomplete granulation tissue and reduced wound contraction [. Glucocorticoids also inhibit production of hypoxia-inducible factor-1 (HIF-1), a key transcriptional factor in healing wounds [.
  • Non-steroidal Anti-inflammatory Drugs – Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are widely used for the treatment of inflammation and rheumatoid arthritis and for pain management. Low-dosage aspirin, due to its anti-platelet function, is commonly used as a preventive therapeutic for cardiovascular disease, but not as an anti-inflammatory drug [. There are few data to suggest that short-term NSAIDs have a negative impact on healing.
  • Muscle Relaxants –  These medications provide relief from associated muscle spasms or injury
  • Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
  • Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
  • Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
  • Calcium & vitamin D3 – To improve bones health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
  • Glucosamine & DiacereinChondroitin sulfate – can be used to tightening the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament.
  • Dietary supplement -to remove general weakness & improved health.
  • Vitamin C – It help to cure the wounds
  • Chemotherapeutic Drugs – Most chemotherapeutic drugs are designed to inhibit cellular metabolism, rapid cell division, and angiogenesis and thus inhibit many of the pathways that are critical to appropriate wound repair. These medications inhibit DNA, RNA, or protein synthesis, resulting in decreased fibroplasia and neovascularization of wounds [.
  • Nutrition – For more than 100 years, nutrition has been recognized as a very important factor that affects wound healing. Most obvious is that malnutrition or specific nutrient deficiencies can have a profound impact on wound healing after trauma and surgery. Patients with chronic or non-healing wounds and experiencing nutrition deficiency often require special nutrients. Energy, carbohydrate, protein, fat, vitamin, and mineral metabolism all can affect the healing process [.
  • Carbohydrates, Protein, and Amino Acids – Together with fats, carbohydrates are the primary source of energy in the wound-healing process. Glucose is the major source of fuel used to create the cellular ATP that provides energy for angiogenesis and deposition of the new tissues [. The use of glucose as a source for ATP synthesis is essential in preventing the depletion of other amino acid and protein substrates [.
  • Protein – is one of the most important nutrient factors affecting wound healing. A deficiency of protein can impair capillary formation, fibroblast proliferation, proteoglycan synthesis, collagen synthesis, and wound remodeling. A deficiency of protein also affects the immune system, with resultant decreased leukocyte phagocytosis and increased susceptibility to infection [. Collagen is the major protein component of connective tissue and is composed primarily of glycine, proline, and hydroxyproline. Collagen synthesis requires hydroxylation of lysine and proline, and co-factors such as ferrous iron and vitamin C. Impaired wound healing results from deficiencies in any of these co-factors [.
  • Arginine – is a semi-essential amino acid that is required during periods of maximal growth, severe stress, and injury. Arginine has many effects in the body, including modulation of immune function, wound healing, hormone secretion, vascular tone, and endothelial function. Arginine is also a precursor to proline, and, as such, sufficient arginine levels are needed to support collagen deposition, angiogenesis, and wound contraction [. Arginine improves immune function, and stimulates wound healing in healthy and ill individuals [. Under psychological stress situations, the metabolic demand of arginine increases, and its supplementation has been shown to be an effective adjuvant therapy in wound healing [.
  • Glutamine – is the most abundant amino acid in plasma and is a major source of metabolic energy for rapidly proliferating cells such as fibroblasts, lymphocytes, epithelial cells, and macrophages [. The serum concentration of glutamine is reduced after major surgery, trauma, and sepsis, and supplementation of this amino acid improves nitrogen balance and diminishes immunosuppression [. Glutamine has a crucial role in stimulating the inflammatory immune response occurring early in wound healing [. Oral glutamine supplementation has been shown to improve wound breaking strength and to increase levels of mature collagen [.
  • Fatty Acids – Lipids are used as nutritional support for surgical or critically ill patients to help meet energy demands and provide essential building blocks for wound healing and tissue repair. Polyunsaturated fatty acids (PUFAs), which cannot be synthesized de novo by mammals, consist mainly of two families, n-6 (omega-6, found in soybean oil) and n-3 (omega-3, found in fish oil). Fish oil has been widely touted for the health benefits of omega-3 fatty acids such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). The effects of omega-3 fatty acids on wound healing are not conclusive. They have been reported to affect pro-inflammatory cytokine production, cell metabolism, gene expression, and angiogenesis in wound sites [. The true benefit of omega-3 fatty acids may be in their ability to improve the systemic immune function of the host, thus reducing infectious complications and improving survival [.
  • Vitamins, Micronutrients, and Trace Elements – Vitamins C (L-ascorbic acid), A (retinol), and E (tocopherol) show potent anti-oxidant and anti-inflammatory effects. Vitamin C has many roles in wound healing, and a deficiency in this vitamin has multiple effects on tissue repair. Vitamin C deficiencies result in impaired healing, and have been linked to decreased collagen synthesis and fibroblast proliferation, decreased angiogenesis, and increased capillary fragility. Also, vitamin C deficiency leads to an impaired immune response and increased susceptibility to wound infection [;. Similarly, vitamin A deficiency leads to impaired wound healing. The biological properties of vitamin A include anti-oxidant activity, increased fibroblast proliferation, modulation of cellular differentiation and proliferation, increased collagen and hyaluronate synthesis, and decreased MMP-mediated extracellular matrix degradation [.
  • Vitamin E, an anti-oxidant – maintains and stabilizes cellular membrane integrity by providing protection against destruction by oxidation. Vitamin E also has anti-inflammatory properties and has been suggested to have a role in decreasing excess scar formation in chronic wounds. Animal experiments have indicated that vitamin E supplementation is beneficial to wound healing [; and topical vitamin E has been widely promoted as an anti-scarring agent. However, clinical studies have not yet proved a role for topical vitamin E treatment in improving healing outcomes [.
  • Several micronutrients – have been shown to be important for optimal repair. Magnesium functions as a co-factor for many enzymes involved in protein and collagen synthesis, while copper is a required co-factor for cytochrome oxidase, for cytosolic anti-oxidant superoxide dismutase, and for the optimal cross-linking of collagen. Zinc is a co-factor for both RNA and DNA polymerase, and a zinc deficiency causes a significant impairment in wound healing. Iron is required for the hydroxylation of proline and lysine, and, as a result, severe iron deficiency can result in impaired collagen production [;; .

Normal Wound-healing Process

Phase Cellular and Bio-physiologic Events
  • vascular constriction

  • platelet aggregation, degranulation, and fibrin formation (thrombus)

  • neutrophil infiltration

  • monocyte infiltration and differentiation to macrophage

  • lymphocyte infiltration

  • re-epithelialization

  • angiogenesis

  • collagen synthesis

  • ECM formation

  • collagen remodeling

  • vascular maturation and regression


Some of the unique features of each are described below.

The following dressings may be used on chronic or acute wounds depending on the nature of the wound.

  • Low or nonadherent dressings – are inexpensive and allow wound exudate to pass through into a secondary dressing while helping to maintain a moist wound environment. These dressings are specially designed to reduce adherence to the wound bed. Non adherent dressings are made from open weave cloth soaked in paraffin, textiles, or multilayered or perforated plastic films. This type of dressing is suitable for flat, shallow wounds with low exudate such as a venous leg ulcer.
  • Hydrocolloid dressings – are composed of adhesive, absorbent, and elastomeric components. Carboxymethylcellulose is the most common absorptive ingredient. They are permeable to moisture vapor, but not to water. Additionally, they facilitate autolytic débridement, are self-adhesive, mold well, provide light-to-moderate exudate absorption, and can be left in place for several days, minimizing skin trauma and disruption of the healing process. They are intended for use on light-to-moderate exuding, acute or chronic partial- or full-thickness wounds but are not intended for use on infected wounds. Upon sustained contact with wound fluid, the hydrocolloid forms a gel.
  • Foam dressings – vary widely in composition and construction. They consist of a polymer, often polyurethane, with small, open cells that are able to hold fluids. Some varieties of foam dressings have a waterproof film covering the top surface and may or may not have an adhesive coating on the wound contact side or border. Foams are permeable to water and gas, and are able to absorb light to heavy exudate. This type of dressing is frequently used under compression stockings in patients with venous leg ulcers.
  • Film dressings consist of a single – thin transparent sheet of polyurethane coated on one side with an adhesive. The sheet is permeable to gases and water vapor but impermeable to wound fluids. Film dressings retain moisture, are impermeable to bacteria and other contaminants, allow wound observation, and do not require a secondary dressing. Excessive fluid buildup may break the adhesive seal and allow leakage. Film dressings are intended for superficial wounds with little exudate and are commonly used as a secondary dressing to attach a primary absorbent dressing. The dressing may remain in place for up to seven days if excessive fluid does not accumulate. Film dressings have been used extensively to treat split-thickness graft donor sites.
  • Alginate dressings – are made from calcium or calcium-sodium salts of natural polysaccharides derived from brown seaweed. When the alginate material comes into contact with sodium-rich wound exudates, an ion exchange takes place and produces a hydrophilic gel. This hydrophilic gel is capable of absorbing up to 20 times its weight and does not adhere to the wound. This dressing can remain in place for about seven days if enough exudate is present to prevent drying. This category of dressing is best suited for moist, moderate-to-heavy exuding wounds. Alginate dressings require a secondary dressing, such as a film dressing, to hold them in place and to prevent the alginate from drying out.
  • Hydrofiber dressing –  is composed of sodium carboxymethylcellulose fibers. The fibers maintain a moist wound environment by absorbing large amounts of exudate and forming a gel. This dressing is not intended for lightly exuding wounds. A secondary dressing is required.
  • Hydrogel sheets  – are three-dimensional networks of cross-linked hydrophilic polymers. Their high water content provides moisture to the wound, but these dressings can absorb small-to-large amounts of fluid, depending on their composition. Depending on wound exudate levels, hydrogels may require more frequent dressing changes, every 1–3 days, compared with other synthetic dressings. Hydrogel sheets can be used on most wound types but may not be effective on heavily exuding wounds. The gel may also contain additional ingredients such as collagens, alginate, or complex carbohydrates. Amorphous hydrogels can donate moisture to a dry wound with eschar and facilitate autolytic débridement in necrotic wounds. A second dressing may be used to retain the gel in shallow wounds.
  • Polymer-based dressing – Transforming methacrylate (TMD) was compared to carboxymethylcellulose (CMC-Ag) in one study of 34 patients. The study showed that TMD, compared to CMC-Ag, was associated with lower pain scores and better patient satisfaction, but the two dressings did not differ in terms of number of dressing changes and the time to complete healing.Suprathel (a polymer-based dressing) was evaluated in a study of 72 patients, and it was compared to a polyurethane dressings (Biatain-Ibu) and a silicone dressing (Mepitel). The three dressings had similar time to re-epithelialization, but Suprathel had a significantly lower number of dressing changes compared to the two other dressings.
  • Crystalline cellulose dressings – Results for the comparison between CMC-Ag and TMD are presented above.Veloderm was compared to Vaseline gauze in 96 patients. The study showed that Veloderm was associated with lower time to complete healing and number of dressing changes. The two dressings did not differ in terms of incidence of exudate, peri-lesional erythema or pain intensity.Rayon dressing was compared to Veloderm in a study of 14 patients and 28 skin graft donor sites. Rayon dressing showed lower dressing adherence to wound and lower 1st day pain score; the two dressings did not differ in terms of pain beyond day 14, hyperemia, edema and pruritus.
  • Alginate dressings – The study evaluated the dressing materials in terms of time to healing, pain scores, clinical infections and hypergranulation. Results showed that the six types of dressings did not differ with statistical significance except in the following cases: first, the semi-permeable films (Tegaderm or Opsite) were associated with lower pain scores than any other dressing type; second, the hydrocolloid dressing (DuoDerm E) required lower time (seven days difference) to healing than all other dressings; finally, the gauze dressings (Adaptic or Jelonet) were associated with the highest incidence of clinical infections.
  • Alginate-based dressings – were also evaluated in three other trials; the first one compared Algisite to a keratin dressing (Keramatrix).The trial showed that Algisite was associated with higher rate of epithelialization seven days after the operation than Keramatrix in patients older than 50 years; for younger patients, the rate of epithelialization did not significantly differ. Ding et al. compared time to healing and pain scores between alginate-silver dressing and hydrofiber dressing (Aquacel-A) in 10 patients and 20 donor sites; the results showed that the alginate dressing was associated with shorter time to healing and lower pain scores.The third trial compared Algisite covered by a polyurethane dressing (Opsite) to paraffin gauze dressing; the results showed that the two dressings did not differ in terms of pain scores, time to epithelialization and the assessment of general comfort. Algisite dressings required more dressing changes (34 times) than the paraffin gauze (4 times).
  • Polyurethane dressings – Opsite and Tegaderm films were evaluated in Brolemann’s study, and the results were presented above. Another trial compared the Opsite dressing to a hydrofiber dressing (Aquacel-A); the results showed that Opsite was associated with lower scores of pain.The Biatain-Ibu dressing was compared to Suprathel (polymer dressing) and Mepitel (silicone dressing); the results were presented above with polymer-based dressings. Another study compared Biatain-Ibu to a gauze dressing (Jelonet), and it was reported that Biatain-Ibu was associated with lower pain and itching than Jelonet; however, the study did not report any statistical testing for the differences between interventions.
  • Gauze dressings – Gauze dressings were evaluated in seven trials; the results of four trials were reported earlier in this section,,,,and the remaining three trials were as follows one trial compared Xeroform (gauze dressing) to a multilayer dressing and showed that Xeroform was associated with longer healing time and higher pain scores than Oxyband.The second trial compared paraffin gauze to a hydrofiber dressing (Aquacel) and reported that the paraffin gauze was associated with longer re-epithelialization time and higher pain score during dressing.The last trial compared Jelonet to a multilayer dressing as a dressing over a skin graft (receiver site); the results showed that the two dressings did not affect the time to graft take, number of nursing interventions, or post-operative infections; however, they showed that Jelonet was associated with higher pain score at the time of dressing removal.
  • Hydrocolloid dressings – The efficacy of DuoDerm E was compared to six other dressing materials in Brolmann’s trial; the results of this trial were presented earlier in this section.In another trial, DuoDerm was compared to a silicone-based dressing (AWBAT-D); the trial showed that the two dressings did not differ in terms of pain scores, wound size or time to discharge, but the DuoDerm was associated with shorter time to re-epithelialization.
  • Hydrofiber dressings – The efficacy of Aquacel was studied in six trials; the results of four trials were presented earlier in the section.,,,One of the remaining trials compared Aquacel to carbohydrate wound dressing (Glucan II), and it showed that the two interventions did not differ in terms of time to re-epithelialization, pain scores, or donor site infection.The second trial compared two different protocols of using Aquacel; in the first protocol, Aquacel dressing was covered with gauze, while in the second one, it was covered with polyurethane film (OpSite). The trial reported that the second protocol was associated with a larger number of donor sites healing at day 14 after surgery (88% versus 67%), and it was associated with lower pain during mobility the first day after operation; the two dressings did not differ in pain scores during rest at all time-point evaluations.
  • Silicone dressings – Four trials evaluated the efficacy of silicone-based dressings; the result three of trials were presented earlier in this section.,, The fourth trial compared Mepitel dressing to a nylon dressing (Bridal veil) when used over a skin graft (receiver site). The results of this trial showed that Mepitel dressing was associated with less pain, easier use, and better overall experience for patients.
  • Keratin dressings  – The efficacy of Keranatrix was evaluated in one study the results of which were presented earlier in this section.
  • Self-adhesive fabric dressing (Mefix) with or without fibrin sealant – One trial evaluated the difference between using Mefix alone or with a fibrin sealant; the trial showed that the use of fibrin sealant was associated with lower daily pain and incapacity scores, but it did not affect the time to dressing removal or the time to discharge for the hospital.
  • Multilayer (combination) dressings – The efficacy of Oxyband and Allyven was evaluated in two studies the results of which were presented earlier in this section.,
  • Nylon dressings – The efficacy of Bridal veil was evaluated in one study the results of which were presented earlier in this section.
  • Carbohydrate wound dressings – The efficacy of Glucan dressing was evaluated in one study the results of which were presented earlier in this section.
  • Negative pressure dressings – One trial compared negative pressure dressings with a conventional dressing with gauze; both dressings were used over skin grafts (receiver sites).The trial reported that the negative pressure dressing was associated with a higher percentage of graft take and shorter duration of dressing.

Complication of  Wound Healing

Factors that can slow the wound healing process include

  • Dead skin (necrosis) – dead skin and foreign materials interfere with the healing process.
  • Infection – an open wound may develop a bacterial infection. The body fights the infection rather than healing the wound.
  • Haemorrhage – persistent bleeding will keep the wound margins apart.
  • Mechanical damage – for example, a person who is immobile is at risk of bedsores because of constant pressure and friction.
  • Diet – poor food choices may deprive the body of the nutrients it needs to heal the wound, such as vitamin C, zinc and protein.
  • Medical conditions – such as diabetes, anaemia and some vascular diseases that restrict blood flow to the area, or any disorder that hinders the immune system.
  • Age – wounds tend to take longer to heal in elderly people.
  • Medicines – certain drugs or treatments used in the management of some medical conditions may interfere with the body’s healing process.
  • Smoking – cigarette smoking impairs healing and increases the risk of complications.
  • Varicose veins – restricted blood flow and swelling can lead to skin break down and persistent ulceration.
  • Dryness – wounds (such as leg ulcers) that are exposed to the air are less likely to heal. The various cells involved in healing, such as skin cells and immune cells, need a moist environment.


Avulsions Wound


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What Can Cause Magnesium Deficiency, Treatment

What Can Cause Magnesium Deficiency/Magnesium deficiency or hypomagnesia (not to be confused with hypomagnesemia) refers to inadequate intake of dietary magnesium or impaired absorption of magnesium, which can result in numerous symptoms and diseases. It is generally corrected by an increase of magnesium in diet, oral supplements, and in severe cases, intravenous supplementation.

‘Normal’ serum magnesium levels

0.75–0.95 mmol/L

  • A serum magnesium <0.82 mmol/L (2.0 mg/dL) with a 24-hour urinary magnesium excretion of 40–80 mg/day is highly suggestive of magnesium deficiency.
  • One group of experts has recommended magnesium supplementation in subjects experiencing symptoms that reflect magnesium deficiency if the serum level is below 0.9 mmol/L, with levels less than 0.8 mmol/L necessitating magnesium.
  • Serum magnesium levels above 0.95 mmol/L may indicate hypermagnesaemia.

Magnesium requirements based on older balance studies

Age Requirement
Infants 150–200 mg/day
Children 200–250 mg/day
Adults 250–300 mg/day
Lactating women 400 mg/day

Causes of magnesium deficiency

Magnesium: Deficiency signs and symptoms [].

  • General  – Anxiety, lethargy, weakness, agitation, depression, dysmenorrhea, hyperactivity, headache, irritability, dysacusis, low stress tolerance, loss of appetite, nausea, sleep disorders, impaired athletic performance.
  • Musculature – Muscle spasm, cramps in the soles of the feet, leg cramps, facial muscles, masticatory muscles, and calves, carpopedal spasm, back aches, neck pain, urinary spasms, magnesium deficiency tetany.
  • Nerves/CN – Nervousness, increased sensitivity of NMDA receptors to excitatory neurotransmitters, migraine, depression, nystagmus, paraesthesia, poor memory, seizures, tremor, vertigo.
  • Gastrointestinal tract – Constipation.
  • Cardiovascular syste – Risk of arrhythmias, supraventricular or ventricular arrhythmias, hypertension, coronary spasm, decreased myocardial pump function, digitalis sensitivity, Torsade de pointes, death from heart disease.
  • Electrolytes – Hypokalaemia, hypocalcaemia, retention of sodium.
  • Metabolism – Dyslipoproteinemia (increased blood triglycerides and cholesterol), decreased glucose tolerance, insulin resistance, increased risk of metabolic syndrome, disturbances of bone and vitamin D metabolism, resistance to PTH, low circulating levels of PTH, resistance to vitamin D, low circulating levels of 25(OH)D, recurrence of calcium oxalate calculi.
  • Miscellaneous – Asthma, chronic fatigue syndrome, osteoporosis, hypertension, altered glucose homeostasis.
  • Pregnancy -m Pregnancy complications (e.g., miscarriage, premature labor, eclampsia).

  • Acetaminophen toxicity.
  • Alcoholism.
  • Aluminium (environmental and dietary).
  • Aldosteronism.
  • Alcohol.
  • Ageing  (hypochlorhydria, ie, decreased acid in the stomach).
  • Antacid (including ranitidine and famotidine).
  • Bariatric surgery (small intestinal bypass surgery).
  • Calcium supplements (or a high calcium to magnesium diet).
  • Caffeine.
  • Cancer.
  • Coeliac disease.
  • Colon removal
  • Chronic stress
  • Cisplatin
  • Crohn’s disease.
  • Ciclosporin.
  • Type 1 and type 2 diabetes (uncontrolled glucose levels).
  • Diarrhoea.
  • Diet high in fat or sugar.
  • Digoxin
  • Diuretics non-potassium-sparing diuretics (thiazide and loop diuretics).
  • Excessive ingestion of poorly absorbable magnesium (such as magnesium oxide), leading to diarrhoea and magnesium loss.
  • Emotional and/or psychological stress (overactivation of the sympathetic nervous system).
  • Enzymatic dysfunction (impaired magnesium distribution).
  • Oestrogen therapy (shifts magnesium to soft and hard tissues lowering serum levels).
  • Excessive or prolonged lactation
  • Excessive menstruation.
  • Fasting (or low magnesium intake).
  • Foscarnet
  • Gentamicin and tobramycin.
  • Hyperparathyroidism and hypoparathyroidism.
  • Hyperthyroidism.
  • Kidney diseases (glomerulonephritis, pyelonephritis, hydronephrosis, nephrosclerosis and renal tubular acidosis).
  • Heart failure.
  • Haemodialysis.
  • High phosphorus in the diet (soda, inorganic phosphates contained in many inactive ingredients in processed foods).
  • Hyperinsulinaemia (and insulin therapy).
  • Insulin resistance (intracellular magnesium depletion).
  • Laxatives.
  • Low salt intake.
  • Low selenium intake.
  • Gastrointestinal disorders—malabsorption syndromes (coeliac disease, non-tropical sprue, bowel resection, Crohn’s disease, ulcerative colitis, steatorrhoea), prolonged diarrhoea or vomiting.
  • Liver disease (acute or chronic liver disease, including cirrhosis).
  • Metabolic acidosis (latent or clinical).
  • Pancreatitis(acute and chronic).
  • Parathyroidectomy.
  • Pentamidine.
  • Peritoneal dialysis.
  • Porphyria with inappropriate secretion of antidiuretic hormone.
  • Pregnancy.
  • Proton pump inhibitors.
  • Strenuous exercise.
  • Tacrolimus.
  • Vitamin B6 (pyridoxine) deficiency.
  • Vitamin D excess or deficienc (chronic kidney disease and liver disease can prevent the activation of vitamin D).

Potential clinical signs of magnesium deficiency

Less severe signs

  • Aggression.
  • Anxiety.
  • Ataxia.
  • Chvostek sign (twitching of the facial muscles in response to tapping over the area of the facial nerve).
  • Confusion.
  • Cramps (spontaneous carpopedal spasm or painful cramps of the muscles in your hands and feet).
  • Disorientation.
  • Fasciculations (‘a brief, spontaneous contraction affecting a small number of muscle fibres, often causing a flicker of movement under the skin. It can be a symptom of disease of the motor neurons)’.
  • Hyper-reflexia.
  • Irritability.
  • Muscular weakness.
  • Neuromuscular irritability.
  • Pain or hyperalgesia (decreases the nociceptive threshold).
  • Photosensitivity.
  • Spasticity.
  • Tetany (involuntary muscle spasms).
  • Tinnitus (ringing in the ears).
  • Tremors.
  • Trousseau sign.
  • Vertigo.
  • Vitamin D resistance.

Severe signs

  • Arrhythmias (caused by over-excitation of the heart due to enhanced depolarisation susceptibility, especially torsades de pointes or ventricular tachycardia with a prolonged QT interval).
  • Calcifications (soft tissue).
  • Cataracts.
  • Convulsions.
  • Coronary artery disease.
  • Depressed immune response.
  • Depression.
  • Hearing loss.
  • Heart failure.
  • Hypertension.
  • Migraines/headaches.
  • Mitral valve prolapse.
  • Osteoporosis.
  • Parathyroid hormone resistance and impaired parathyroid hormone release/function.
  • Psychotic behavior.
  • Seizures (overexcitation of the nervous system (nerve cells), which are more likely to fire due to a reduced electric potential difference between the outer and inner surfaces of the membrane).
  • Sudden cardiac death.
  • Tachycardia.

Lab and ECG signs of magnesium deficiency

  • Hypomagnesaemia.
  • Hypocalcemia.
  • Hypokalaemia.
  • Prolonged QTc.
  • ST segment depression (in animals).

Measurements to diagnose magnesium deficiency (best to worst)

Reliable methods

  • Retention of magnesium load (intravenous or oral) after its administration is likely the best indicator of magnesium deficiency. However, the retention test assumes normal kidney function for intravenous magnesium loads and normal gastrointestinal and renal function for oral load tests and is cumbersome and invasive.
  • Mononuclear cell magnesium and muscle magnesium content (muscle biopsy).

Less reliable methods

  • Hair magnesium content (one study concluded: ‘magnesium hair concentration may be an easier, cheaper and less invasive indicator of body magnesium depletion’).
  • Bone magnesium (magnesium depletion in the coccyx may indicate magnesium deficiency).
  • The ratio of ionized magnesium to total magnesium (serum or plasma).
  • Ionized magnesium levels (serum or erythrocytes, ionized magnesium is the physiologically active magnesium not bound to proteins). However, this biomarker is controversial and not always available in clinical labs and hard to measure reliably.
  • Lymphocyte magnesium.
  • Urinary or fecal magnesium excretion (low or high levels may indicate deficiency).
  • Urinary fractional magnesium excretion >4% (some authors have suggested >2% in those with normal kidney function).
  • Total erythrocyte magnesium levels (magnesium deficiency has been suggested when erythrocyte magnesium levels are <1.65 mmol/L).
  • Total serum magnesium levels.
  • It is important to note that choosing only one of the aforementioned methods of measuring magnesium deficiency is not appropriate for diagnosing magnesium deficiency. In general, either symptom of magnesium deficiency must accompany the more reliable methods to diagnose magnesium deficiency (eg, intravenous/oral magnesium load, mononuclear cell or muscle), or two or more of the reliable measurements (eg, intravenous/oral magnesium load, mononuclear cell or muscle) should be used in supporting a diagnosis of magnesium deficiency.

Causes of hypermagnesaemia

  • Oversupplementation (mainly from magnesium-containing antacids).
  • Kidney damage.
  • Inflammation and cellular injury (significant increases in total and ionized magnesium in animals during endotoxin challenge).

Magnesium Deficiency & it Basic Role in Human Body

It is an antidote to stress, the most powerful relaxation mineral available, and it can help improve your sleep.

I find it very funny that more doctors aren’t clued in to the benefits of magnesium, because we use it all the time in conventional medicine. But we never stop to think about why or how important it is to our general health or why it helps our bodies function better.

I remember using magnesium when I worked in the emergency room. It was a critical “medication” on the crash cart. If someone was dying of a life-threatening arrhythmia (or irregular heart beat), we used intravenous magnesium. If someone was constipated or needed to prepare for colonoscopy, we gave them milk of magnesia or a green bottle of liquid magnesium citrate, which emptied their bowels.

Magnesium Deficiency

If pregnant women came in with pre-term labor, or high blood pressure of pregnancy (pre-eclampsia) or seizures, we gave them continuous high doses of intravenous magnesium.

But you don’t have to be in the hospital to benefit from getting more magnesium. You can start taking regular magnesium supplementation today and see results.

The Relaxation Mineral

Think of magnesium as the relaxation mineral. Anything that is tight, irritable, crampy, and stiff — whether it is a body part or an even a mood — is a sign of magnesium deficiency.

This critical mineral is actually responsible for over 300 enzyme reactions and is found in all of your tissues — but mainly in your bones, muscles, and brain. You must have it for your cells to make energy, for many different chemical pumps to work, to stabilize membranes, and to help muscles relax.

When was the last time you had a good dose of seaweed, nuts, greens, and beans? If you are like most Americans, your nut consumption mostly comes from peanut butter.

That is why the list of conditions that are found related to magnesium deficiency is so long. In fact, there are over 3,500 medical references on magnesium deficiency!

Even so, this mineral is mostly ignored because it is not a drug, even though it is MORE powerful than drugs in many cases. That’s why we use it in the hospital for life-threatening and emergency situations like seizures and heart failure.

Magnesium Deficiency Symptoms

Magnesium deficiency has even has been linked to inflammation in the body and higher CRP levels.

  • In our society, magnesium deficiency is a huge problem. By conservative standards of measurement (blood, or serum, magnesium levels), 65 percent of people admitted to the intensive care unit — and about 15 percent of the general population — have a magnesium deficiency.
  • But this seriously underestimates the problem, because a serum magnesium level is the LEAST sensitive way to detect a drop in your total body magnesium level. So rates of magnesium deficiency could be even higher!
  • The reason we are so deficient is simple: Many of us eat a diet that contains practically no magnesium — a highly-processed, refined diet that is based mostly on white flour, meat, and dairy (all of which have no magnesium).
  • When was the last time you had a good dose of sea vegetables (seaweed), nuts, greens, and beans? If you are like most Americans, your nut consumption mostly comes from peanut butter, and mostly in chocolate peanut butter cups.
  • Much of modern life conspires to help us lose what little magnesium we do get in our diet. Magnesium levels are decreased by excess alcohol, salt, coffee, phosphoric acid in colas, profuse sweating, prolonged or intense stress, chronic diarrhea, excessive menstruation, diuretics (water pills), antibiotics and other drugs, and some intestinal parasites. In fact, in one study in Kosovo, people under chronic war stress lost large amounts of magnesium in their urine.
  • This is all further complicated by the fact that magnesium is often poorly absorbed and easily lost from our bodies. To properly absorb magnesium we need a lot of it in our diet, plus enough vitamin B6, vitamin D, and selenium to get the job done.
  • A recent scientific review of magnesium concluded, “It is highly regrettable that the deficiency of such inexpensive, low-toxicity nutrient results in diseases that cause incalculable suffering and expense throughout the world.” (ii) I couldn’t’ have said it better myself.
  • It is difficult to measure and hard to study, but magnesium deficiency accounts for untold suffering — and is simple to correct. So if you suffer from any of the symptoms I mentioned or have any of the diseases I noted, don’t worry — it is an easy fix!! Here’s how.
  • Magnesium deficiency can be harmful! Low magnesium levels can cause fatigue, seizures, high blood pressure, blood clots, muscle cramps and so on.
  • It’s estimated that 80 percent of Americans have a magnesium deficiency. And this is not a good thing since this mineral affects every organ in the body.
  • According to the Institute of medicine, adult men should consume 400 –
  • 420 mg of magnesium while women should aim for 310 – 360 mg per day. Now, the foods below can help get the recommended amount of magnesium without supplementation.

Magnesium Rich Food to Improve Your Overall Health

Functions of magnesium (selection) [,,,,].

  • Magnesium is involved in more than 300 essential metabolic reactions (e.g., all Adenosine Triphosphate (ATP)-dependent reactions).
Energy production (→ ATP production)
  • Breakdown and energetic utilization of carbohydrates, proteins and fats in intermediate metabolism (e.g., glycolysis, respiratory chain phosphorylation). ATP exists primarily as a complex with magnesium (MgATP).
Enzyme activation (examples)
  • Mitochondrial ATP synthase, Na+/K+-ATPase, Hexokinase, Creatine kinase, Adenylate cyclase, Phosphofructokinase, tyrosine kinase activity of the insulin receptor.
Calcium antagonist/NMDA-receptor antagonist
  • Control of calcium influx at the cell membrane (course of contractions, regulation of vascular muscle tone): muscle contraction/relaxation, neurotransmitter release, action potential conduction in nodal tissue, neuromuscular impulse conduction (inhibition of calcium-dependent acetylcholine release at the motor end plate), maintenance and stabilization of membrane physiology, muscle contraction.
Cardiovascular system
  • Economization of cardiac pump function, regulation of potassium movement in myocardial cells, protection against stress, vasodilation of the coronary and peripheral arteries, reduction of platelet aggregation.
Membrane function
  • Transmembrane electrolyte flux, active transport of potassium and calcium across cell membranes, regulation of cell adhesion and cell migration.
Structural roles
  • Component of mineralized bone (structure, microarchitecture), multiple enzyme complexes, mitochondria, proteins, polyribosomes, and nucleic acids.
Nutrient metabolism
  • Metabolic activation and the utilisation of vitamin D, B-vitamins (e.g., thiamine) and glutathione.

Magnesium Deficiency

  • Okra –  One cup of okra has 70 mg of magnesium – approx. 15 percent of the recommended daily intake. Avoid fried okra, boil or roast it.
  • Dark chocolate – A bar of chocolate has more than half of the daily recommended magnesium.
  • Pumpkin – A cup of chopped pumpkin has 60 mg of magnesium. This food also other numerous benefits so eat it as often as possible.
  • Brown rice – A cup of brown rice supplies about 20 percent of recommended magnesium.
  • Avocado – This alkaline food is a great magnesium source. One medium-size avocado has about 15 percent of the magnesium you need in a day.
  • Almonds – One ounce of this healthy nut has approx. 20 percent of magnesium you need.
  • Beet greens – Beet greens may not be popular, but they have lots of magnesium. One cup has 100 mg of magnesium.
  • Spinach – A cup of spinach has 150 mg of magnesium. This is definitely one of the best sources of this mineral.
  • Squash – This pumpkin-like will give lots of magnesium. One cup has about 40 mg.
  • Broccoli – If you’ve never liked broccoli, its magnesium content might change your mind. A cup has 33 mg.
  • Figs – 4 cups of dried figs can give you all the magnesium you need in a day.
  • Cashew nuts – An ounce of cashew nuts has about 20 percent of the magnesium you need.
  • Bananas – Bananas may be known for being potassium-rich, but they also contain some magnesium.
  • Pumpkin seeds – Pumpkin and squash seeds contain about 19 percent of recommended magnesium per ounce.
  • Lentils – A cup of lentils will give you 18 percent of recommended magnesium.
  • Cucumbers – A cup of cucumbers has about 40 mg of magnesium.
  • Peas – You can get 70 mg of magnesium from a cup of peas.

Magnesium and drug interactions. 

Medications that reduce magnesium levels:
(i) H2 blockers: for example, cimetidine and nizatidine
(ii) Proton pump inhibitors: for example, esomeprazole, omeprazole, and pantoprazole (FDA WARNING: supplementing magnesium will not correct deficiency; you must stop the drug)
(iii) Antacids: aluminum and magnesium hydroxide and sodium bicarbonate
(iv) Antibiotics: for example, amoxicillin, azithromycin, doxycycline, minocycline, levofloxacin, ciprofloxacin, cephalexin,
sulfamethoxazole and trimethoprim, and tetracycline
(v) Antihistamines: for example, astemizole and terfenadine
(vi) Antivirals: for example, delavirdine, lamivudine, and zidovudine
(vii) Antiepileptic medications: phenytoin and phenobarbital
(viii) Blood pressure drugs: hydralazine and combination of ACE inhibitors with HCTZ (enalapril and HCTZ)
(ix) Diuretics: for example, furosemide, ethacrynic acid, chlorothiazide, chlorthalidone, metolazone, and indapamide
(x) Cardiac glycoside: digoxin
(xi) Cardiac drugs: sotalol, amiodarone, bretylium, and quinidine
(xii) CNS stimulants: methylphenidate
(xiii) Cholesterol agents: cholestyramine and colestipol
(xiv) Corticosteroids: betamethasone, dexamethasone, hydrocortisone, prednisone, and triamcinolone
(xv) Inhaled corticosteroids: fluticasone, flunisolide, and triamcinolone
(xvi) Estrogens: DES, estradiol, estring, and estrogen-containing drugs: HRT and BCP
(xvii) Immunosuppressants: cyclosporine and tacrolimus
(xviii) Nonsteroidal aromatase inhibitors for breast cancer: anastrozole
(xix) Osteoporosis: raloxifene
(a) On the other hand, magnesium decreases bisphosphonate absorption
(xx) SERMs (selective estrogen receptor modulators): raloxifene, tamoxifen, and toremifene
(xxi) Sulfonamides: antibiotics and some diabetic medications
(xxii) Nutraceuticals: for example, high-dose calcium, high-dose vitamin D, and caffeine
Medications that may increase serum magnesium:
(i) Lithium carbonate
(ii) Antidepressants: for example, sertraline and amitriptyline
(iii) Potassium sparing diuretics: amiloride and spironolactone reduce magnesium excretion


Magnesium Deficiency


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Treatment of Burns, Complications, Prevention

Treatment of Burns/Burns injury also known as combustion injury is an impairment of the tissue, which is caused by extreme heat, electricity, chemicals, friction or radiation. Concerning children, in Hungary and worldwide the most affected age group is below the age of 5 years. The most common cause of burn injury in children is scald from hot water.

burn is a type of injury to skin, or other tissues, caused by heat, cold, electricity, chemicals, friction, or radiation.[rx] Most burns are due to heat from hot liquids, solids, or fire.[rx] While rates are similar for males and females the underlying causes often differ.[rx] Among women in some areas, risk is related to use of open cooking fires or unsafe cook stoves.[rx] Among men, risk is related to the work environments.[rx] Alcoholism and smoking are other risk factors.[rx]Burns can also occur as a result of self harm or violence between people.[rx]

Treatment of Burns

Types of Burns

Thermal Burns

Thermal burns occur when you come in contact with something hot. Typically, you will suffer a thermal burn when you touch:

  • Flames or fire
  • Hot, molten liquid or steam (referred to as a scald)
  • Hot objects, such as cooking pans, irons, or heated appliances.
  • Put out any fire or flames and stop contact with the hot or heated source.
  • Use cold water to cool the burned area. Do not use ice, as it may further damage the skin.
  • For mild burns, you can find pain relief by applying a cool, wet compress and/or taking acetaminophen or ibuprofen as directed on the bottle. Later, burn creams and ointments can help these burns heal.
  • For more severe burns, loosely apply a sterile bandage or clean cloth to the burned area. Do not remove parts of your skin or pop blisters. Seek medical attention for further treatment.

Chemical Burns

You may receive a chemical burn if your skin and/or eyes come in contact with a harsh irritant, such as acid. Substances that cause chemical burns include:

  • Chlorine
  • Ammonia
  • Bleach
  • Battery acid
  • Strong or harsh cleaners

Take these steps if you have been burned by a chemical: Rinse the burned area under running water for at least 10 minutes. If the chemical has entered your eye, rinse your eye for about 20 minutes to remove traces of the chemical. Then, call 911 or go to the hospital if the burn is:

  • Larger than three inches
  • On your face, hands, feet, groin, or buttocks
  • Still very painful after taking over-the-counter pain medication
  • On a major joint, like the knee

Medical treatment for both thermal burns and chemical burns is similar and may include:

  • Wound cleaning and removing dead skin or tissue
  • IV fluids to regulate body temperature and speed healing
  • Antibiotics to prevent or fight infection
  • Skin grafting (covering the wound with healthy skin from another area of the body to close the wound)

Electrical Burns

  • Electrical burns happen when the body comes in contact with an electric current. Our internal systems are not resistant to electricity, so you may be injured if a strong jolt enters your body.
  • The most common cause of electrical burn is coming in contact with an extension cord where the insulation material has worn away. Low-voltage electrical burns can also occur in the mouth, most commonly when young children place noninsulated cords in their mouth.
  • A burn may appear on your skin if an electric current runs through your body. These burns can be treated like a thermal or chemical burn. However, if you come in contact with an electric current, you should seek emergency medical attention immediately. Electricity can affect internal tissues and muscles and have long-term, negative effects on your health.

Friction Burns

  • A friction burn can occur when skin repeatedly rubs against another surface or is scraped against a hard surface. Like other burns, friction burns are categorized into degrees.
  • Many friction burns are first degree and often heal on their own within three to six days. You can use moisturizing cream at home to care for it. For more serious friction burns, you should seek medical care immediately.

Radiation Burns

Cancer patients undergoing radiation therapy may suffer from an injury known as radiation burn. High-energy radiation is used to shrink or kill cancerous cells, and when it passes through the body, skin cells may be damaged. If you’re frequently receiving radiation treatments, your skin cells may not have enough time to regenerate, and sores or ulcers may develop. The term burn is a misnomer for these wounds, because skin has not actually been burned. However, the wounds can look and feel like burns. Skin must regenerate for the wounds to heal, which can take two to four weeks for mild skin reactions or a few months for more serious reactions.

Care for radiation burns includes

  • Cleaning and moisturizing wounds
  • Avoiding sunlight
  • Wearing loose clothing or bandages over the wound

If you have an injury from radiation, you may also have internal complications and should seek medical treatment immediately.

The major factors to consider when evaluating the burned skin are the extent of the burns (usually calculated by the percentage of total body surface area (% TBSA) burned) and the estimated depth of the burns (superficial, partial thickness or full thickness).

Treatment of Burns

Extent of the Burn

Several methods are available to estimate the percentage of total body surface area burned.

  • Rule of Nines – The head represents 9%, each arm is 9%, the anterior chest and abdomen are 18%, the posterior chest and back are 18%, each leg is 18%, and the perineum is 1%. For children, the head is 18%, and the legs are 13.5% each.
  • Lund and Browder Chart – This is a more accurate method, especially in children, where each arm is 10%, anterior trunk and posterior trunk are each 13% and the percentage calculated for the head and legs varies based on the patient’s age.
  • Palmar Surface – For small burns, the patient’s palm surface (excluding the fingers) represents approximately 0.5% of their body surface area, and the hand surface (including the palm and fingers) represents about 1% of their body surface area.

Depth of the Burn

Burn depth is classified into one of three types based on how deeply into the epidermis or dermis the injury might extend.

  • Superficial burns – (First Degree) involve only the epidermis and are warm, painful, red, soft and blanch when touched. Usually, there is no blistering. A typical example is a sunburn.
  • Partial thickness burns – (Second Degree) extend through the epidermis and into the dermis. The depth into the dermis can vary (superficial or deep dermis). These burns are typically very painful, red, blistered, moist, soft and blanch when touched. Examples include burns from hot surfaces, hot liquids or flame.
  • Full-thickness burns – (Third Degree) extend through both the epidermis and dermis and into the subcutaneous fat or deeper. These burns have little or no pain, can be white, brown, or charred and feel firm and leathery to palpation with no blanching. These occur from a flame, hot liquids, or superheated gasses.

When calculating the extent of burn, only partial thickness and full thickness burns are considered, and superficial burns are excluded.

Burns may also produce emotional and psychological distress.

Type[rx] Layers involved Appearance Texture Sensation Healing Time Prognosis Example
Superficial (1st-degree) Epidermis[rx] Red without blisters[rx] Dry Painful[rx] 5–10 days[rx][rx] Heals well.[rx] Repeated sunburns increase the risk of skin cancer later in life.[19] A sunburn is a typical first-degree burn.
Superficial partial thickness (2nd-degree) Extends into superficial (papillary) dermis[rx] Redness with clear blister.[rx]Blanches with pressure.[rx] Moist[rx] Very painful[rx] 2–3 weeks[rx][rx] Local infection (cellulitis) but no scarring typically[rx] Second-degree burn of the thumb
Deep partial thickness (2nd-degree) Extends into deep (reticular) dermis[rx] Yellow or white. Less blanching. May be blistering.[rx] Fairly dry[rx] Pressure and discomfort[rx] 3–8 weeks[xx] Scarring, contractures (may require excision and skin grafting)[rx] Second-degree burn caused by contact with boiling water
Full thickness (3rd-degree) Extends through entire dermis[rx] Stiff and white/brown.[rx] No blanching.[rx] Leathery[rx] Painless[rx] Prolonged (months) and incomplete[rx] Scarring, contractures, amputation (early excision recommended)[rx] Eight day old third-degree burn caused by motorcycle muffler.
4th-degree Extends through entire skin, and into underlying fat, muscle and bone[1] Black; charred with eschar Dry Painless Requires excision[rx] Amputation, significant functional impairment and in some cases, death.[rx] 4th-degree burn

Cause of Burns

Burns may be caused by

  • Abuse
  • Chemicals such as strong acids, lye, paint thinner or gasoline
  • Electric currents
  • Fire
  • Hot liquid
  • Hot metal, glass or other objects
  • Steam
  • Radiation from x-rays
  • Sunlight or ultraviolet light

Symptoms of Burns

  • Blisters
  • Pain  – The degree of pain is not related to the severity of the burn as the most serious burns can be painless
  • Peeling skin
  • Red skin
  • Shock – Symptoms of shock include pale and clammy skin, weakness, bluish lips and fingernails, and a drop in alertness
  • Swelling
  • White or charred skin
  • Heart rhythm disturbances following electrical injury

Diagnosis of Burns

Burn injury patients who should be referred to a burn unit include the following:

  • all burn patients less than 1 year of age

  • all burn patients from 1 to 2 years of age with burns >5% total body surface area (TBSA)

  • patients in any age group with third-degree burns of any size

  • patients older than 2 years with partial-thickness burns greater than 10% TBSA

  • patients with burns of special areas—face, hands, feet, genitalia, perineum or major joints

  • patients with electrical burns, including lightning burns

  • chemical burn patients

  • patients with inhalation injury resulting from fire or scald burns;

  • patients with circumferential burns of the limbs or chest;

  • burn injury patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality;

  • any patient with burns and concomitant trauma;

  • paediatric burn cases where child abuse is suspected;

  • burn patients with treatment requirements exceeding the capabilities of the referring centre;

  • septic burn wound cases.

Treatment of Burns

Basic guidance on first aid for burns is provided below.

What to do

  • Stop the burning process by removing clothing and irrigating the burns.
  • Extinguish flames by allowing the patient to roll on the ground, or by applying a blanket, or by using water or other fire-extinguishing liquids.
  • Use cool running water to reduce the temperature of the burn.
  • In chemical burns, remove or dilute the chemical agent by irrigating with large volumes of water.
  • Wrap the patient in a clean cloth or sheet and transport to the nearest appropriate facility for medical care.

What not to do

  • Do not start first aid before ensuring your own safety (switch off electrical current, wear gloves for chemicals etc.)
  • Do not apply paste, oil, haldi (turmeric) or raw cotton to the burn.
  • Do not apply ice because it deepens the injury.
  • Avoid prolonged cooling with water because it will lead to hypothermia.
  • Do not open blisters until topical antimicrobials can be applied, such as by a health-care provider.
  • Do not apply any material directly to the wound as it might become infected.
  • Avoid application of topical medication until the patient has been placed under appropriate medical care.

The aims of first aid should be to stop the burning process, cool the burn, provide pain relief, and cover the burn.burn.[rx]

A superficial scald suitable for management in primary care

  • Stop the burning process—The heat source should be removed. Flames should be doused with water or smothered with a blanket or by rolling the victim on the ground. Rescuers should take care to avoid burn injury to themselves. Clothing can retain heat, even in a scald burn, and should be removed as soon as possible. Adherent material, such as nylon clothing, should be left on. Tar burns should be cooled with water, but the tar itself should not be removed. In the case of electrical burns the victim should be disconnected from the source of electricity before first aid is attempted.
  • Cooling the burn—Active cooling removes heat and prevents progression of the burn. This is effective if performed within 20 minutes of the injury. Immersion or irrigation with running tepid water (15°C) should be continued for up to 20 minutes. This also removes noxious agents and reduces pain, and may reduce oedema by stabilising mast cells and histamine release. Iced water should not be used as intense vasoconstriction can cause burn progression. Cooling large areas of skin can lead to hypothermia, especially in children. Chemical burns should be irrigated with copious amounts of water.water.[rx]
  • Analgesia – Exposed nerve endings will cause pain. Cooling and simply covering the exposed burn will reduce the pain. Opioids may be required initially to control pain, but once first aid measures have been effective non-steroidal anti-inflammatory drugs such as ibuprofen or co-dydramol taken orally will suffice.
  • Covering the burn – Dressings should cover the burn area and keep the patient warm. Polyvinyl chloride film (cling film) is an ideal first aid cover. The commercially available roll is essentially sterile as long as the first few centimetres are discarded. This dressing is pliable, non-adherent, impermeable, acts as a barrier, and is transparent for inspection. It is important to lay this on the wound rather than wrapping the burn. This is especially important on limbs, as later swelling may lead to constriction. A blanket laid over the top will keep the patient warm. If cling film is not available then any clean cotton sheet (preferably sterile) can be used. Hand burns can be covered with a clear plastic bag so as not to restrict mobility. Avoid using wet dressings, as heat loss during transfer to hospital can be considerable.
  • Water-based treatments – Your care team may use techniques such as ultrasound mist therapy to clean and stimulate the wound tissue.
  • Fluids to prevent dehydration – You may need intravenous (IV) fluids to prevent dehydration and organ failure.
  • Pain and anxiety medications – Healing burns can be incredibly painful. You may need morphine and anti-anxiety medications — particularly for dressing changes.
  • Burn creams and ointments – If you are not being transferred to a burn center, your care team may select from a variety of topical products for wound healing, such as bacitracin and silver sulfadiazine (Silvadene). These help prevent infection and prepare the wound to close.
  • Dressings – Your care team may also use various specialty wound dressings to prepare the wound to heal. If you are being transferred to a burn center, your wound will likely be covered in dry gauze only.
  • Drugs that fight infection – If you develop an infection, you may need IV antibiotics.
  • Tetanus shot – Your doctor might recommend a tetanus shot after a burn injury.
  • Cleaning – Mild soap and water or mild antibacterial wash. Debate continues over the best treatment for blisters. However, large blisters are debrided while small blisters and blisters involving the palms or soles are left intact.
  • Covering – Topical antibiotic ointments or cream with absorbent dressing or specialized burn dressing materials are commonly used.
  • Comfort – Over-the-counter pain medications or prescription pain medications when needed. Splints can also provide support and comfort for certain burned areas.

Use of topical creams should be avoided at this stage as these may interfere with subsequent assessment of the burn. Cooling gels such as Burnshield are often used by paramedics. These are useful in cooling the burn and relieving pain in the initial stages.stages.[rx]

The American Burn Association recommends burn center referrals for patients with

  • partial thickness burns greater than 10% total body surface area
  • full thickness burns
  • burns of the face, hands, feet, genitalia, or major joints
  • chemical burns, electrical, or lighting strike injuries
  • significant inhalation injuries
  • burns in patients with multiple medical disorders
  • burns in patients with associated traumatic injuries

Patients being transferred to burn centers do not need extensive debridement or topical antibiotics before transfer.  Whether transferring or referring to a burn center, you should contact them before beginning extensive local burn care treatments.

Remove any Sources of Heat

  • Remove any clothing that may be burned, covered with chemicals, or that is constricting.

  • Cool any burns less than 3 hours old with cold tap water (18 degrees centigrade is adequate) for at least 30 minutes and then dry the patient.

  • Cover the patient with a clean dry sheet or blanket to prevent hypothermia.

  • Use of Burnshield [] is a very effective means of cooling and dressing the injury for the first 24 hours.

  • Rings and constricting garments must be removed.

Assess Airway/Breathing

  • Careful airway assessment must be done where there are flame or scald burns of the face and neck. Intubation is generally only necessary in the case of unconscious patients, hypoxic patients with severe smoke inhalation, or patients with flame or flash burns involving the face and neck. Indications for airway assessment include the presence of pharyngeal burns, air hunger, stridor, carbonaceous sputum, and hoarseness.

  • All patients with major burns must receive high-flow oxygen for 24 hours.

  • Always consider carbon monoxide poisoning in burn patients. They may have the following symptoms: restlessness, headache, nausea, poor co-ordination, memory impairment, disorientation, or coma. Administer 100% oxygen via a non-rebreathing face mask; if possible, measure blood gases including carboxy haemoglobin level.

  • If breathing seems to be compromised because of tight circumferential trunk burns, consult with the burn centre surgeons immediately regarding the need for escharotomy.


  • Stop any external bleeding.

  • Identify potential sources of internal bleeding.

  • Establish large-bore intravenous (IV) lines and provide resuscitation bolus fluid as required in all compromised patients, using standard ATLS protocols []. Perfusion of potentially viable burn wounds is critical.

Estimate the Percentage Total Body Surface Area (%TBSA) Burned

Initially, use the Rule of Nines. In the case of all paediatric patients and for a more accurate assessment, use the Berkow diagram; alternatively, the patient’s unstretched open hand represents 1% of TBSA.

Accurate estimation of burn size is critical to ongoing fluid replacement and management.

Ongoing Losses (Once the Patient Has Been Stabilised)

  • Patients with <10% TBSA burns can be resuscitated orally (unless the patient has an electrical injury or associated trauma). This needs ongoing evaluation and the patient may still require an IV line.

  • In the case of patients with burns 10–40% TBSA, secure a large-bore IV line; add a second line if transportation will take longer than 45 minutes.

  • Burns >40% TBSA require 2 large-bore IV lines.

  • If the transfer will take less than 30 minutes from the time of call, do not delay transfer for an IV line.


IV lines may be placed through the burned area if necessary (suture to secure). Avoid the saphenous vein if at all possible, and avoid cut-downs through unburned skin if possible. An intraosseous line is an excellent alternative in children.

  • Initiate fluids for ongoing resuscitation and fluid losses using the Parkland formula 4mL  crystalloid×(kg of body weight)×(%burn)=mL  in  first  24  hours, with half of this total given in the first 8 hours after injury (note that this is the time from burn, not from presentation to healthcare services). Children must have their daily maintenance fluids added to these replacement fluids (including dextrose).


In the case of a patient weighing 70 kg with a 50% TBSA burn, (4 × 70 × 50) = 14 000 mL needed in the first 24 hours. Half is needed in the first 8 hours after injury.


The fluid requirements of a child weighing 15 kg with a TBSA burn of 40% (4 × 15 × 40) = 2400 mL in the first 24 hours plus maintenance requirements of 1250 mL (1000 mL + 250 mL) = 3650 mL in the first 24 hours. Half is needed in the first 8 hours after injury.


Do not give dextrose solutions (except for maintenance fluids in children)—they may cause an osmotic diuresis and confuse adequacy of resuscitation assessment. Ideally, use Ringer’s lactate or normal saline for replacement fluid and a 5% dextrose-balanced salt solution for the child’s maintenance.

This is only a guide, and ongoing evaluation is essential as patients may need more fluids than calculated. Use the patient’s vital signs and, most importantly, urine output to guide ongoing requirements.

Assess Urine Output (This Is the Best Guide to Resuscitation)

  • Insert a Foley catheter in patients with burns >15% TBSA. Adequate urine output is 0.5 mL/kg/h in adults and 1.5 mL/kg/h in children. Lasix and other diuretics must not be given to improve urine output; increase IV fluid rates to increase urine output. Observe urine for burgundy colour (seen with massive injuries or electrical burns). There is a high incidence of renal failure associated with these injuries, requiring prompt and aggressive intervention.

If the urine is red or brown consult a burn centre.

Insert a Nasogastric Tube

  • Insert a nasogastric tube in any patient with burns >30% TBSA, or any patient who is unresponsive, shocked, or with burns >20% if preparing for air or long-distance transportation.

Decompression Incisions (Escharotomy)

  • Assess for circumferential full-thickness burns of the extremities or trunk. Elevate the burned extremities on pillows above the level of the heart. If transfer will be delayed, discuss indications and methods for decompression incisions (escharotomies) with a burn surgeon.


  • Give tetanus immunisation.

  • After fluid resuscitation has been started, pain medication may be titrated in small intravenous doses (not intramuscular). Blood pressure, pulse, respiratory rate, and state of consciousness should be assessed after each increment of IV morphine.

Wound Care

  • Debridement and application of topical antimicrobials are usually unnecessary. Initial wound care needs to ensure that the burn is kept covered and the patient is kept warm. Plastic food wrap (such as Gladwrap) is ideal.

  • Apply a thin layer of silver sulfadiazine to open areas if transportation will be delayed for more than 12 hours.

  • Use of Burnshield is a very effective means of cooling and dressing the injury in the first 24 hours.

General Items

  • A history, including details of the accident and preexisting diseases/allergies, should be recorded and sent with the patient.

  • Copies of all medical records, including all fluids (calculation of fluids administered) and medications given, urine outputs, and vital signs must accompany the patient. These specific details may be recorded on the back of the burn size assessment sheet.

  • The burn centre will arrange transport if appropriate.

  • In the case of paediatric patients not accompanied by a parent, obtain consent in consultation with your burn centre.

Special Considerations with Chemical Burns (Consult Burn Centre)

Remove all clothing, Brush powdered chemicals off the wound, then flush chemical burns for a minimum of 30 minutes using copious volumes of running water. Be careful to protect yourself.

Never neutralise an acid with a base or vice versa; the heat generated can worsen the burn.

Irrigate burned eyes using a gentle stream of saline. Follow with an ophthalmology consultation if transportation is not imminent. Determine what chemical (and what concentration) caused the injury.

Special Considerations with Electrical Injuries (Consult Burn Centre)

  • Differentiate between low-voltage (<1000 v) and high-voltage (>1000 v) injuries.

  • Attach a cardiac monitor; treat life-threatening dysrhythmias as needed.

  • Assess for associated trauma; assess central and peripheral neurological function.

  • Administer Ringer’s lactate; titrate fluids to maintain adequate urine output or to flush pigments through the urinary tract (see urine output above). Useful laboratory test: arterial blood gas levels with acid/base balance.

  • Using pillows, elevate burned extremities above the level of the heart. Monitor distal pulses.

For burns classified as severe (> 20% TBSA), fluid resuscitation should be initiated to maintain urine output > 0.5 mL/kg/hour.  One commonly used fluid resuscitation formula is the Parkland formula. The total amount of fluid to be given during the initial 24 hours = 4 ml of LR × patient’s weight (kg) × % TBSA.  Half of the calculated amount is administered during the first eight hours beginning when the patient was initially burned. For example, if a 70 kg patient has a 30% TBSA partial thickness burn they will need 8400 mL Lactated Ringer solution in the first 24 hours with 4200 mL of that total in the first 8 hours [(4 mL) × (70 kg) × (30% TBSA) = 8,400 mL LR]. Remember that the fluid resuscitation formula for burns is only an estimate and the patient may need more or less fluid based on vital signs, urine output, other injuries or other medical conditions (see Burns, Resuscitation, and Management for discussion of the management of severely burned patients).

Dressing changes

The practice of subsequent dressing changes is varied. Ideally the dressing should be checked at 24 hours. The burn wound itself should be reassessed at 48 hours and the dressings changed, as they are likely to be soaked through. At this stage the depth of burn should be apparent, and topical agents such as Flamazine can be used.

Depending on how healing is progressing, dressing changes thereafter should be every three to five days. If the Jelonet dressing has become adherent, it should be left in place to avoid damage to delicate healing epithelium. If Flamazine is used it should be changed on alternate days. The dressing should be changed immediately if the wound becomes painful or smelly or the dressing becomes soaked (“strike through”).

Any burn that has not healed within two weeks should be seen by a burn surgeon.

Specialist dressings

Many specialist dressings are available, some developed for specific cases, but most designed for their ease of use. The following are among the more widely used.

Flamazine – is silver sulfadiazine cream and is applied topically on the burn wound. It is effective against gram negative bacteria including Pseudomonas. Infection with the latter will cause the dressing to turn green with a distinctive smell. Apply the cream in a 3-5 mm thick layer and cover with gauze. It should be removed and reapplied every two days. There is a reported 3-5% incidence of reversible leucopenia.

Granulflex  is a hydrocolloid dressing with a thin polyurethane foam sheet bonded onto a semipermeable film. The dressing is adhesive and waterproof and is therefore useful in awkward areas or where normal dressings are not suitable. It should be applied with a 2 cm border. By maintaining a moist atmosphere over the wound, it creates an environment suitable for healing. It usually needs to be changed every three or four days, but it can be left for seven days. A thinner version (Duoderm) is also available.

Mepitel – is a flexible polyamide net coated with soft silicone to give a Jelonet-type of dressing that is non adhesive. It is a useful but expensive alternative to Jelonet when easy removal is desirable, such as with children.

Facial burns

Facial burns should be referred to a specialist unit. However, simple sunburn should be left exposed as dressings can be awkward to retain on the face. The wound should be cleansed twice daily with mild diluted chlorohexidine solution. The burn should be covered with a bland ointment such as liquid paraffin. This should be applied every 1-4 hours as necessary to minimise crust formation. Men should shave daily to reduce risk of infection. All patients should be advised to sleep propped up on two pillows for the first 48 hours to minimise facial oedema.

Follow up

Burns that fail to heal within three weeks should be referred to a plastic surgery unit for review. Healed burns will be sensitive and have dry scaly skin, which may develop pigmental changes. Daily application of moisturiser cream should be encouraged. Healed areas should be protected from the sun with sun block for 6-12 months. Pruritis is a common problem.

Physiotherapy—Patients with minor burns of limbs may need physiotherapy. It is important to identify these patients early and start therapy. Hypertrophic scars may benefit from scar therapy such as pressure garments or silicone. For these reasons, all healed burns should be reviewed at two months for referral to an occupational therapist if necessary.

Support and reassurancePatients with burn injuries often worry about disfigurement and ugliness, at least in the short term, and parents of burnt children often have feelings of guilt. It is important to address these issues with reassurance.[rx]

Surgical and other procedures

You may need one or more of the following procedures:

  • Breathing assistance. If you’ve been burned on the face or neck, your throat may swell shut. If that appears likely, your doctor may insert a tube down your windpipe (trachea) to keep oxygen supplied to your lungs.
  • Feeding tube. People with extensive burns or who are undernourished may need nutritional support. Your doctor may thread a feeding tube through your nose to your stomach.
  • Easing blood flow around the wound. If a burn scab (eschar) goes completely around a limb, it can tighten and cut off the blood circulation. An eschar that goes completely around the chest can make it difficult to breathe. Your doctor may cut the eschar to relieve this pressure.
  • Skin grafts. A skin graft is a surgical procedure in which sections of your own healthy skin are used to replace the scar tissue caused by deep burns. Donor skin from deceased donors or pigs can be used as a temporary solution.
  • Plastic surgery. Plastic surgery (reconstruction) can improve the appearance of burn scars and increase the flexibility of joints affected by scarring.

Complications of Burns

Deep or extensive burns can lead to many complications, including:

  • Breathing problems
  • Bone and joint problems
  • Dangerously low body temperature
  • Infection and sepsis
  • Low blood volume
  • Scarring
  • Tetanus

Infection is the most common complication. In order of frequency, potential complications include: pneumonia, cellulitis, urinary tract infections and respiratory failure. Pneumonia commonly occurs in those with inhalation injuries.

Other complications may include

  • Anemia secondary to full thickness burns of greater than 10% TBSA is common.
  • Electrical burns may result in compartment syndrome or rhabdomyolysis.
  • Blood clotting in the veins of the legs occurs in 6-25% of patients with extensive burns.
  • The hypermetabolic state that may persist for years after a major burn may result in a decreased bone density and muscle mass.
  • Keloids may form subsequent to a burn.
  • Following a burn, psychological trauma and post-traumatic stress disorder my develop.
  • Scarring may aresult in a disturbance in body image.
  • In the developing world, significant burns may result in social isolation, poverty, and child abandonment.

Other Risk Factors

There are a number of other risk factors for burns, including

  • occupations that increase exposure to fire;
  • poverty, overcrowding and lack of proper safety measures;
  • placement of young girls in household roles such as cooking and care of small children;
  • underlying medical conditions, including epilepsy, peripheral neuropathy, and physical and cognitive disabilities;
  • alcohol abuse and smoking;
  • easy access to chemicals used for assault (such as in acid violence attacks);
  • use of kerosene (paraffin) as a fuel source for non-electric domestic appliances;
  • inadequate safety measures for liquefied petroleum gas and electricity.


Burns are preventable. High-income countries have made considerable progress in lowering rates of burn deaths, through a combination of prevention strategies and improvements in the care of people affected by burns. Most of these advances in prevention and care have been incompletely applied in low- and middle-income countries. Increased efforts to do so would likely lead to significant reductions in rates of burn-related death and disability.

Prevention strategies should address the hazards for specific burn injuries, education for vulnerable populations and training of communities in first aid. An effective burn prevention plan should be multisectoral and include broad efforts to

  • improve awareness
  • develop and enforce effective policy
  • describe burden and identify risk factors
  • set research priorities with promotion of promising interventions
  • provide burn prevention programmes
  • strengthen burn care
  • strengthen capacities to carry out all of the above.

The document A WHO plan for burn prevention and care discusses these 7 components in detail.

In addition, there are a number of specific recommendations for individuals, communities and public health officials to reduce burn risk.

  • Enclose fires and limit the height of open flames in domestic environments.
  • Promote safer cookstoves and less hazardous fuels, and educate regarding loose clothing.
  • Apply safety regulations to housing designs and materials, and encourage home inspections.
  • Improve the design of cookstoves, particularly with regard to stability and prevention of access by children.
  • Lower the temperature in hot water taps.
  • Promote fire safety education and the use of smoke detectors, fire sprinklers, and fire-escape systems in homes.
  • Promote the introduction of and compliance with industrial safety regulations, and the use of fire-retardant fabrics for children’s sleepwear.
  • Avoid smoking in bed and encourage the use of child-resistant lighters.
  • Promote legislation mandating the production of fire-safe cigarettes.
  • Improve treatment of epilepsy, particularly in developing countries.
  • Encourage further development of burn-care systems, including the training of health-care providers in the appropriate triage and management of people with burns.
  • Support the development and distribution of fire-retardant aprons to be used while cooking around an open flame or kerosene stove.

To reduce the risk of common household burns

  • Never leave items cooking on the stove unattended.
  • Turn pot handles toward the rear of the stove.
  • Don’t carry or hold a child while cooking at the stove.
  • Keep hot liquids out of the reach of children and pets.
  • Keep electrical appliances away from water.
  • Check the temperature of food before serving it to a child. Don’t heat a baby’s bottle in the microwave.
  • Never cook while wearing loose fitting clothes that could catch fire over the stove.
  • If a small child is present, block his or her access to heat sources such as stoves, outdoor grills, fireplaces and space heaters.
  • Before placing a child in a car seat, check for hot straps or buckles.
  • Unplug irons and similar devices when not in use. Store them out of reach of small children.
  • Cover unused electrical outlets with safety caps. Keep electrical cords and wires out of the way so that children can’t chew on them.
  • If you smoke, never smoke in bed.
  • Be sure you have working smoke detectors on each floor of your home. Check them and change their batteries at least once a year.
  • Keep a fire extinguisher on every floor of your house.
  • When using chemicals, always wear protective eyewear and clothing.
  • Keep chemicals, lighters and matches out of the reach of children. Use safety latches. And don’t use lighters that look like toys.
  • Set your water heater’s thermostat to below 120 F (48.9 C) to prevent scalding. Test bath water before placing a child in it.


Treatment of Burns


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Acute Motor Sensory Axonal Neuropathy, Treatment

Acute Motor Sensory Axonal Neuropathy/Guillain–Barré syndrome (GBS) is a rapid-onset disorder in which the body’s immune system attacks part of the peripheral nervous system & muscle weakness caused by the immune system damaging the peripheral nervous system. The initial symptoms are typically changes in sensation or pain along with muscle weakness, beginning in the feet and hands. This often spreads to the arms and upper body, with both sides being involved. The symptoms develop over hours to a few weeks. During the acute phase, the disorder can be life-threatening, with about 15% developing weakness of the breathing muscles requiring mechanical ventilation. Some are affected by changes in the function of the autonomic nervous system, which can lead to dangerous abnormalities in heart rate and blood pressure. Guillain-Barre syndrome is also known as polyneuropathy, which is a disease that involves several nerves.

Another name of Guillain–Barré syndrome

  • acute inflammatory demyelinating polyradiculoneuropathy
  • acute motor axonal neuropathy
  • acute motor neuropathy with conduction block
  • acute motor-sensory axonal neuropathy

Guillain-Barré Syndrome or Acute Polyneuropathy is a disorder which affects the peripheral nervous system.

Types of Guillain–Barré syndrome

Once thought to be a single disorder, Guillain-Barre syndrome is now known to occur in several forms. The main types are:

  • Acute inflammatory demyelinating polyradiculoneuropathy (AIDP), the most common form in the U.S. The most common sign of AIDP is muscle weakness that starts in the lower part of your body and spreads upward.
  • Miller Fisher syndrome (MFS), in which paralysis starts in the eyes. MFS is also associated with unsteady gait. MFS occurs in about 5 percent of people with Guillain-Barre syndrome in the U.S. but is more common in Asia.
  • Acute motor axonal neuropathy (AMAN) and acute motor-sensory axonal neuropathy (AMSAN) are less common in the U.S. But AMAN and AMSAN are more frequent in China, Japan and Mexico.
  • Acute Motor Sensory Axonal Neuropathy: This is similar to motor axonal neuropathy but in this form also affected are the sensory nerves.
  • Acute Panautonomic Neuropathy: This is rarest form of GBS. It sometimes occurs with associated encephalopathy. Since there is cardiovascular involvement with this form of GBS, it has a high mortality rate. Some symptoms of this form of GBS are dysphagia, constipation alternating with diarrhea, dry itchy skin, etc.
  • Bickerstaff’s Brainstem Encephalitis: In this form of GBS, symptoms involve acute onset of ophthalmoplegia, ataxia, altered consciousness, and increased reflexes. It can also be relapsing-remitting.

Clinical subtypes of Guillain–Barré syndrome

A number of subtypes of Guillain–Barré syndrome are recognized.Despite this, many people have overlapping symptoms that can make the classification difficult in individual cases.All types have partial forms. For instance, some people experience only isolated eye-movement or coordination problems; these are thought to be a subtype of Miller Fisher syndrome and have similar antiganglioside antibody patterns.

Type Symptoms Population affected Nerve conduction studies Antiganglioside antibodies
Acute inflammatory demyelinating polyneuropathy (AIDP) Sensory symptoms and muscle weakness, often with cranial nerve weakness and autonomic involvement Most common in Europe and North America Demyelinating polyneuropathy No clear association
Acute motor axonal neuropathy (AMAN) Isolated muscle weakness without sensory symptoms in less than 10%; cranial nerve involvement uncommon Rare in Europe and North America, substantial proportion (30-65%) in Asia and Central and South America; sometimes called “Chinese paralytic syndrome” Axonal polyneuropathy, normal sensory action potential GM1a/b, GD1a & GalNac-GD1a
Acute motor and sensory axonal neuropathy (AMSAN) Severe muscle weakness similar to AMAN but with sensory loss Axonal polyneuropathy, reduced or absent sensory action potential GM1, GD1a
Pharyngeal-cervical-brachial variant Weakness particularly of the throat muscles, and face, neck, and shoulder muscles Generally normal, sometimes axonal neuropathy in arms Mostly GT1a, occasionally GQ1b, rarely GD1a
Miller Fisher syndrome Ataxia, eye muscle weakness, areflexia but usually no limb weakness This variant occurs more commonly in men than in women (2:1 ratio). Cases typically occur in the spring and the average age of occurrence is 43 years old. Generally normal, sometimes discrete changes in sensory conduction or H-reflex detected GQ1b, GT1a

Causes of Guillain–Barré syndrome

Acute Motor Sensory Axonal Neuropathy

  • A viral infection, such as herpes, cytomegalovirus, or Epstein-Barr virus is the cause of over two-thirds of the new cases each year.
  • It’s uncommon – Guillain-Barre Syndrome is pretty rare, affecting only 1 or 2 people per 100,000.
  • It’s a serious autoimmune disorder. According to the National Library of Medicine, Guillain-Barre Syndrome is a serious disorder that occurs when the body’s immune system mistakenly attacks part of the nervous system.
  • It results in muscle weakness – The disorder causes inflammation in the body that creates weakness and sometimes even paralysis.
  • Much is unknown – The causes of Guillain-Barre Syndrome are widely unknown. Many times Guillain-Barre Syndrome symptoms will follow a minor infection, such as a lung or gastrointestinal infection.
  • There is no cure – So far, scientists have not found a cure for Guillain-Barre Syndrome, although many treatment options are available to handle complications and speed up recovery.
  • The cause of the disease is unknown – Many speculate that this is an immune-system disorder. Symptoms often begin 5 days to 3 weeks after a viral infection, immunization, or surgery. The disease affects peripheral nerves, nerve roots, and cranial nerves. Evaluation of the peripheral nerves reveals sections of the nerve with demyelination. Under microscopic exam, the nerve tissue is infiltrated with certain types of white blood cells.
  • Fluoroquinolones -The Fluoroquinolones have been responsible for triggering many different disease states, including Neuropathies from other causes, and be sure to read our page on how Fluoroquinolones Contribute to Autoimmune Disease to see how other diseases are often triggered by these antibiotics. These dangerous drugs accomplish their damage through multiple methods of action, including causing Mitochondrial Damage, DNA Damage to cells, the binding of and excretion of certain nutrients,
  • GBS, unlike multiple sclerosis or amyotrophic lateral sclerosis, is a peripheral nerve ailment and does not cause injury to the brain or the spinal cord.
  • This syndrome causes the destruction, removal, or loss of the myelin sheath of a nerve. Myelin is the substance of the cell membrane that coils to form the myelin sheath. The myelin sheath serves as an electrical insulator to nerve fibers
  • In 1977, there were over 500 cases of Guillain-Barre syndrome associated with a United States flu vaccination program. The cause of this outbreak was never discovered.
  • 5-10% of new cases will occur up to 4 weeks after surgery.

Symptoms of Guillain–Barré syndrome

Symptoms of GBS, including weakness, instability, and pain, typically start in the lower body and move upwards.

Symptoms and other complications include

Diagnosis of Guillain–Barré syndrome

After a physical exam, a physician may recommend the following tests:

  • Blood tests and urine tests These are done to check for infections and other problems.
  • Nerve conduction exam – Electrodes are taped to the skin, and the speed of nerve signal conduction is tested by passing small shocks along the nerves through the skin. In GBS, the signals travel more slowly along the nerves.
  • Electromyography (EMG) Thin, needle-like electrodes are used to test the nerve function within muscle fibers.
  • Spinal tap, also known as a lumbar puncture A sample of cerebrospinal fluid (CSF) is removed from the spinal canal and tested in a laboratory for specific signs of the disease. More protein is present in the CSF of people with GBS. Your cerebrospinal fluid is then tested to detect protein levels. People with Guillain-Barré typically have higher-than-normal levels of protein in their cerebrospinal fluid. This test is also referred to as a lumbar puncture.
  • Electromyogram (EMG) This test measures the electrical activity of a muscle or a group of muscles. An EMG can find abnormal electrical muscle activity caused by diseases and conditions that affect the nerves and muscles.
  • Pulmonary function testThis is a breathing test done by a respiratory therapist. It shows your child’s lung capacity and how strong his or her respiratory muscles are. This test is often used to decide if a child needs breathing support with a ventilator.
  • Electrolyte levels
  • Liver function tests (LFTs)
  • Creatine phosphokinase (CPK) level
  • Erythrocyte sedimentation rate (ESR)

Biochemical screening can also be conducted and would include the following studies:

Needle EMG and nerve conduction studies

  • Nerve conduction slowing
  • Prolongation of the distal latencies
  • Prolongation of the F-waves
  • Conduction block or dispersion of responses – Evidence frequently demonstrated at sites of natural nerve compressionWeak muscles showing reduced recruitment: Demonstrated with needle examination.

Associate disease tests

Treatment of Guillain–Barré syndrome

  • Plasma exchange (plasmapheresis). The liquid portion of part of your blood (plasma) is removed and separated from your blood cells. The blood cells are then put back into your body, which manufactures more plasma to make up for what was removed. Plasmapheresis may work by ridding plasma of certain antibodies that contribute to the immune system’s attack on the peripheral nerves.
  • Immunoglobulin therapy. Immunoglobulin containing healthy antibodies from blood donors is given through a vein (intravenously). High doses of immunoglobulin can block the damaging antibodies that may contribute to Guillain-Barre syndrome.
  • Intensive care unit – Admission to the intensive care unit (ICU) should be considered for all patients with labile dysautonomia, a forced vital capacity of less than 20 mL/kg, or severe bulbar palsy.Any patients exhibiting clinical signs of respiratory compromise to any degree also should be admitted to an ICU. 

Competent intensive care includes the following features

  • Respiratory therapy
  • Cardiac monitoring
  • Safe nutritional supplementation
  • Monitoring for infectious complications (eg, pneumonia, urinary tract infections, septicemia)Subcutaneous unfractionated or low ̶ molecular-weight heparin (LMWH) and thromboguards are often used in the treatment of immobile patients to prevent lower-extremity deep venous thrombosis (DVT) and consequent pulmonary embolism (PE).
  • Immunomodulation – Immunomodulatory treatment in GBS has been used to hasten recovery. Intravenous immunoglobulin (IVIG) and plasma exchange have proved equally effective.

Physical, occupational & speech therapy of Guillain–Barré syndrome

In I.V.I.G, immunoglobulins are given intravenously which shows a positive impact on the speed of recovery. But it has been shown to be less effective than plasmapheresis.

Further medical management can be done according to the symptoms and the complications :
a. Supportive Care

  • ICU monitoring
  • Basic medical management often determines mortality and morbidity.

b. Ventilatory Support

  • Atelectasis leads to hypoxia.
  • Hyper-carbia later finding; arterial blood cases may be misleading.
  • Vidal capacity, tidal volume and negative inspiratory force are best indicators of diaphragmatic function.
  • Progressive decline of these functionsindicatese an impending need or ventilatory assistance.
  • Mechanical ventilation usually required if VC drops below about 14 ml/kg; ultimate risk depending on age, presence of accompanying lung disease, aspiration risk, and assessment of respiratory muscle fatigue
  • Atelectasis treated initially by incentive spirometry, frequent suctioning, and chest physiotherapy to mobilize secretions.
  • Intubation may be necessary in patients with substantial oro-pharyngeal dysfunction to prevent aspiration.
  • Tracheostomy may be needed in patients intubated for 2 weeks who do not show improvement.

c. Autonomic dysfunction

d. Nosocomial infections usually involve pulmonary and urinary tracts.

  • Occasionally central venous catheters become infected.
  • Antibiotic therapy should be reserved for those patients showing clinical infection rather than colonization of fluid or sputum specimens.

e. Venous thrombosis due to immobilization poses great risk of thromboembolism.

Physiotherapy of Guillain–Barré syndrome

Aims of the treatment are to

  • Respiratory therapy
  • Maintain clear airways
  • Prevent lung infection
  • Maintain anatomical joint range
  • Support joint in functional position to minimize damage or deformit
  • Prevention of pressure sores
  • Maintain peripheral circulatio
  • Provide psychological support for the patient and relatives. 1. Maintenance of clear airway & prevention of lung infection
  1.  Respiratory therapy
  • Respiratory therapy
  • The patients breathing will be assisted by intermittent positive pressure ventilation (IPPV) via a cuffed tracheostomy tube.
  • Posturally drain areas of lung tissues, 2-hourly turning into supine or side lying positions.
  • A suction catheter is used to remove secretions from respective passage until the cough reflex re-appears.
  • Manual techniques like vibration with/ without over pressure.
  • 2-4 litre anesthetic bag can be used to enhance chest expansion. Therefore , 2 people are necessary for this technique, one to squeeze the bag and another to apply chest manipulation.
  • Rib springing to stimulate cough.
  • After the removal of ventilator and adequate expansion, effective coughing must be taught to the patient
  • As neurons recover, active assisted or active breathing exercises may commence with good amount of relaxing time.
2. To maintain normal joint movement 

Gentle passive movements through full ROM at least three times a day especially at hip , shoulder, wrist, ankle, feet.

3.Support joints

Use of light splints(eg. using PLASTAZOTE) may be required for the following purpose listed below
  • Support the peripheral joints in comfortable and functional position during flaccid paralysis.
  • To prevent abnormal movements.
  • To stabilize patients using sandbags, pillows. 4. Prevention of pressure sores :
2- hourly change in patients position from supine to side lying. If the sores have developed then UVR or ice cube massage to enhance healing. 5. Maintenance of circulation
  • Passive movements
  • Effleurage massage to lower limbs.

Relief of pain

  • Transcutaneous electrical nerve stimulation
  • Massage with passive ROM
  • Patient can demonstrate increased sensitivity to light touch, a cradle can be used to keep the bed sheet away from the skin.
  • Low pressure wrapping or snug fitting garments can provide a way to avoid light touch.
  • Reassurance and explanation of what to expect can help in alleviation of anxiety that could compound the pain.
Exercises to be prescribed to the patient should be started with low repetitions and short, frequent bouts of exercises matched to the patients muscular strength. According to Bensman (1970), the following four guidelines are to be followed for prescription of exercises
  • Use short periods of non-fatiguing exercises matched to the patients strength.
  • Progression of the exercise should be done only if the patient improves or if there is no deterioration in status after a week.
  • Return the patient to bed rest if a decrease in muscle strength or function occurs
  • The objective should be directed towards not only at improving function but also in improving strength.

Complications of Guillain–Barré syndrome

Guillain-Barre syndrome affects your nerves. Because nerves control your movements and body functions, people with Guillain-Barre may experience

  • Breathing difficulties The weakness or paralysis can spread to the muscles that control your breathing, a potentially fatal complication. Up to 30 percent of people with Guillain-Barre syndrome need temporary help from a machine to breathe when they’re hospitalized for treatment.
  • Residual numbness or other sensations Most people with Guillain-Barre syndrome recover completely or have only minor, residual weakness, numbness or tingling.
  • Heart and blood pressure problems Blood pressure fluctuations and irregular heart rhythms (cardiac arrhythmias) are common side effects of Guillain-Barre syndrome.
  • Pain – Up to half of people with Guillain-Barre syndrome experience severe nerve pain, which may be eased with medication.
  • Blood clots – People who are immobile due to Guillain-Barre syndrome are at risk of developing blood clots. Until you’re able to walk independently, taking blood thinners and wearing support stockings may be recommended.
  • Residual numbness or other sensations – Most people recover completely or have only minor, residual weakness, numbness or tingling.
  • Heart and blood pressure problems Blood pressure fluctuations and irregular heart rhythms (cardiac arrhythmias) are common side effects of Guillain-Barre syndrome.
  • Bowel and bladder function problems Sluggish bowel function and urine retention may result from Guillain-Barre syndrome.
  • Blood clotsn –  People who are immobile due to this illness are at risk of developing blood clots. Wear support stockings and take blood thinners.
  • Pressure sores Being immobile also puts you at risk of developing bedsores (pressure sores). Frequent repositioning may help avoid this problem.
  • Relapse – Around 3 percent of people with Guillain-Barre syndrome experience a relapse.


Acute Motor Sensory Axonal Neuropathy



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