NUTRITION FOR INTUBATED CASUALTIES

Casualties who are intubated and/or sedated and held at the Role 1 for up to 48-72 hours should receive a feeding tube (nasogastric or orogastric) to initiate enteral nutrition. If there is concern for facial fractures/skull base fracture, place orogastric tube and avoid nasogastric tube placements. Although a controversial topic, feeding at the Role 1 – is possible, as demonstrated by Frizzi, et al.16 Evidence shows that delaying nutrition in large burn patients (≥20% TBSA) increases odds of mortality by 2% for each hour delayed in enteral feeding initiation.17 This translates to an increased mortality risk of 96% in 48 hours, emphasizing the importance of early enteral feeds when possible. Before tube feeds are initiated, it is imperative to ensure proper tube position, with x-ray confirmation being the gold standard. If x-ray is not available and tube feeds are deemed necessary, the following methods should be used to clinically confirm proper position: 1) quickly push air through the tube while auscultating the left upper quadrant (over the stomach) to confirm a “whoosh” AND 2) return of gastric or bile aspirate.

- Better: If casualty is hemodynamically stable, consider placement of a feeding tube and provide trophic feeds using a standard formula (10-20 ml/hr). If enteral formula is not available, an improvised tube feeding can be made by mixing ultra-high temperature milk alone or mixed with the protein drink powder found in Meals-Ready-to-Eat. To maintain tube patency, ensure 30 ml free water flush completed every 4 hours.
- Best: If able and comfortable consider increasing tube feed rate by 10 ml/hr Q4hr until optimal rate of 60 ml/hr is achieved. Provide a polymeric, high-protein enteral nutrition formula, if able; otherwise provide improvised tube feeding.

For enteral nutrition contraindications, please refer to the JTS CPG for Nutritional Support Using Enteral and Parenteral Methods.

***Placement of a feeding tube, particularly in a patient with altered mental status without appropriate confirmation of proper positioning may lead to significant morbidity or mortality from aspiration risk.