NUTRITION THERAPY:

BURNS
Adria Bucheli

Etiology
Thermal Burns
May result from any external heat source (flame, hot liquids, hot
solid objects, steam)
Smoke inhalation: toxic products of combustion injure

airway tissues
Hot smoke usually burns only the pharynx because the incoming

gas cools quickly

An exception is steam which carries much more heat energy than
smoke and thus can also burn the lower airways below the glottis
Many toxic chemicals produced in routine house fires injure lower
airways chemically
Hydrogen chloride, phosgene, sulfur dioxide, toxic aldehydes, ammonia
(4)

Etiology cont.
Radiation burns
most commonly result from prolonged exposure to solar ultraviolet
radiation (sunburn) but may result from prolonged or intense
exposure to other sources of ultraviolet radiation (tanning beds) or
from exposure to sources of x-ray or other nonsolar radiation
Chemical burns
may result from strong acids, strong alkalis (lye, cement), phenols,
cresols, mustard gas, phosphorous, and certain petroleum products
(gasoline, paint thinner)
Skin and deeper tissue necrosis caused by these agents may
progress over several hours (4)

Etiology cont.
Electrical burns
result from heat generation and electroporation of cell membranes
associated with massive current of electrons
Electrical burns often cause extensive deep tissue damage to
electrically conductive tissues, such as muscles, nerves, and blood
vessels, despite minimal apparent cutaneous injury (4)

Classification of Burns
First degree burns- affect only the outer layer of the skin

(epidermis), causing pain and redness

Second degree burns- extend to the second layer of the
skin (dermis), causing pain, redness, and blisters that
may ooze
Third degree burns- involve both layers of the skin and
may also damage the underlying bones, muscles, and
tendons. The burn site appears pale, charred, or leathery
Fourth degree burns- extend through the skin and
subcutaneous fat into the underlying muscle and bone (2)

Post-Burn Hypermetabolism
The first phase occurs within the first 48 h of injury and

has classically been called the ebb phase

Decreases in cardiac output, oxygen consumption, and metabolic

rate as well as impaired glucose tolerance associated with its

hyperglycemic state

The metabolic response then gradually increases within

the first 5 days post-injury to a plateau phase and then to

flow phase, characteristically associated with
hyperdynamic circulation and the hypermetabolic state (7)

Complexity of hypermetabolic response

Nutrition Diagnoses
Malnutrition (NI-5.2)

Altered gastrointestinal function (NC-1.4)

Increased nutrient (protein) needs (NI-5.1)

Nutrition Diagnoses
Inadequate oral intake (NI-2.1)

Unintended weight loss (NC-3.2)

Inadequate protein intake (NI-5.7.1)

Common Treatment of Burns

First-degree burns:
Run cool water on burned area for 5-10 minutes or cover the area
with a cool compress
Dont apply oil, butter, or ice to the burn
Take ibuprofen or acetaminophen to relieve pain and swelling
Any burn to the eye requires immediate emergency help
Do not use burn care or other ointments for 24 hours to avoid
sealing in the burn (2)

Treatment of Burns
Second-degree burns:
Do not break blisters
Do not remove clothing that is stuck to the
skin
Run cool water on burned area for 5-10
minutes and cleanse with mild soap
Elevate burned area above the heart
Take ibuprofen or acetaminophen to relieve
pain and swelling
If not near a medical facility apply bacitracin
ointment or honey on broken blisters to
prevent infection
If burn is near the mouth, nose, or eye,
seek emergency medical help immediately
(2)

Treatment of Burns
Third-degree burns:
If the person is on fire, have them
stop, drop, and roll
Call 911
Check airway, breathing, and
circulation
Do not remove clothing that is stuck
to the skin
Run cool water continuously on
burned area
Do not immerse large burn areas in
water
Elevate burned area above the
heart
Cover the burned area with a sterile
bandage or clean sheet
Do not apply any ointments (2)

Rule of Nines
Burn Severity is dictated by:
Percent total body surface area (TBSA) involvement
Burns > 20-25% TBSA require IV fluid resuscitation
Burns >30-40% TBSA may be fatal without treatment
(5)

Rule of Nines

Sample Menu
For the average adult

Breakfast
Breakfast Sandwich

1 bagel
2 tbsp. butter
1 egg
1 slice of cheese

1 cup whole milk

1 cup of fruit

Snack
Milkshake with protein powder
1 package instant breakfast, 1 cup ice cream, 1 cup whole milk, 2 tbsp

chocolate syrup, 1 banana, 2 tbsp. protein powder

Sample Menu cont.

Lunch
2 tbsp peanut butter
2 tbsp jelly
2 slices whole wheat bread
cup broccoli
cup cottage cheese
1 cup whole milk
Snack
1 cup mixed nuts

Sample Menu cont.

Dinner
1 cup tomato soup
4 oz chicken breast
1 cup brown rice
cup mixed vegetables
1 apple
1 cup whole milk
Evening snack
1 cup ice cream

Labs and other parameters

Daily
Electrolytes
Phosphorus and magnesium
Blood urea nitrogen and creatinine
Glucose
Weekly
24-hour urine urea nitrogen (for nitrogen balance)
Protein intake (for nitrogen balance)
Diagnostic tests are affected by hydration, clinical condition,
inflammation, and hypermetabolism (1)

Labs and other parameters cont.

Nitrogen balance measurements are used to evaluate

adequacy of protein intake

Nitrogen losses are obtained from a 12- or 42-hour urine collection

(Graves, 2005).

Nitrogen losses through burned tissue are difficult to

quantify but may be estimated based on the size of the

burn using the following formula (Gottschlich, 1993):
< 10% open wound = .02 g nitrogen/kg/day

11% to 30% open wound = .05 g nitrogen/kg/day

> 31% open wound = .12 nitrogen/kg/day

Nitrogen losses should decrease as wounds heal (1)

Labs and other parameters cont.

Indirect Calorimetry
May be useful in the measurement of actual energy expenditure
Measures energy requirement for metabolic stress
Tests should be preformed late at night or early in the morning
before daily activities to obtain a more accurate assessment of
REE (resting energy expenditure) (1)

Medications
Antimicrobial ointments are used to reduce risk of

infection
Silver sulfadiazine, mafenide, silver nitrate, and povidone-iodine

Antibiotics to treat infection

Oxacillin, mezlocillin, and gentamicin

Prescription pain medications

Acetaminophen with codeine, morphine, or meperidine
Anabolic steroids to help decrease wound healing time
Oxandrolone
(2)

Surgery and other Procedures

Severe burn cases may require:
Debridement: removal of dead tissue
Skin grafting: a piece of skin is surgically sewn over the burn after
dead tissue is removed
(2)

Nutrition and Dietary Supplements

Follow these tips to improve healing and general health
Eat antioxidant foods, including fruits and vegetables
Avoid refined foods such as white breads, pastas, sugar
Eat fewer red meats and more lean meats, cold water fish, tofu, or
beans for protein
Use healthy cooking oils such as olive oil or vegetable oil
Reduce or eliminate trans-fatty acids, found in commercially baked
goods such as cookies, crackers, cakes, French fried, onion rings,
donuts, processed foods, margarine
Avoid caffeine and other stimulants, alcohol, tobacco
Drink 6-8 glasses of filtered water daily
(2)

Nutrition and Dietary Supplements

The following supplements may also help:
A daily multivitamin containing the antioxidant vitamins A, C, E, the
B-complex vitamins and trace minerals such as magnesium,
calcium, zinc, and selenium
Omega 3 fatty acids (fish oil)
Vitamin C (1,000mg 2-6 timers per day)
Vitamin E (400-800 IU a day)
Coenzyme Q10 (100-200mg at bedtime)
L-glutamine (500-1,000mg 3 times daily)
Probiotic supplement (5 -10 billion CFUs a day) (2)

Nutrition Prescription
Recommended nutrient intake for burns that cover more

than 20% of total body surface area (TBSA):

Energy
25 kcal/kg to 30 kcal/kg
Basal energy expenditure x 1.3-1.4
Protein
1.5 g/kg to 2 g/kg
Vitamins and minerals
Daily multiple vitamin
Vitamin C: 500 mg/d
Vitamin A: 10,000 IU/d (1)

Estimating Energy Requirements

Harris-Benedict Equation
Women: 655 + (9.6 x kg) + (1.7 x cm) (4.7 x age)
Men: 66 + (13.7 kg) + (5 x cm) (6.8 x age)
Curreri Formula
(25 kcal x kg of body weight) + (40 kcal x %TBSA)
For burns covering more than 50% TBSA, use a maximum value of
50%

Curreri Formula
Indirect calorimetry measures oxygen consumption and

carbon dioxide production

Detection of overfeeding/underfeeding
Measures energy requirements
Detection of decline in energy expenditure (later in course)

Measure te energy expenditure during sedation and chemical

paralysis

A factor of 20% and 30% may be applied to indirect

calorimetry measurement to account for the following:

Dressing changes
Surgical procedures
Physical/occupational therapy
Nursing care procedures (6)

Estimating Protein Requirements

Protein requirements are increased because of

losses related to burn size, depth, and greater

needs for repair and anabolism
20 to 25% of energy
1.5 g/kg to 2.0 g/kg of body weight
1.2 g/kg of body weight for burns covering less
than 10% of TBSA or for obese patients (1)

Nutrition intervention
Burns covering less than 20% of total body surface
Patients with larger burns, or unable to consume sufficient

energy and protein

meeting less than 75% of goal energy and protein intake for >3

days
Nocturnal tube feedings
Enteral tube feedings (1)

Goals
Provide frequent meals

Prevent weight loss of more than 10% of admission

weight
Never skip meals
Keep snacks readily available
Provide vitamin and mineral supplementation as needed
(1)

References
1. Academy of Nutrition and Dietetics. Nutrition Care Manual Web Site.

Nutritioncaremanual.org. Last updated 2014. Date accessed November 13, 2014.

2 .Steven D. Ehrlich, NMD. University of Maryland Medical Center.

http://umm.edu/health/medical/altmed/condition/burns. Last updated February 14,

2013. Date accessed November 13, 2014.
3. Marc G. Jeschke. Nutrition of the Burned Patient and Treatment of the

Hypermetabolic Response. Toronto, ON, Canada. 2013 Response. Toronto, ON,

Canada. 2013http://ebooks.ohiolink.edu/xtfebc/data/tei/sv2/9783709111338//pdfs/978-3-7091-1133-8_Chapter_7.pdf. Date
accessed November 13, 2014.
4. Steven E Wolf, MD. Merk Manual.

http://www.merckmanuals.com/professional/injuries_poisoning/burns/.html. Last
updated April 2013. Date accessed November 13, 2014.
5. US Department of Health and Human Services (CHEMM)

http://chemm.nlm.nih.gov/burns.htm. Last updated June 25, 2011. Date accessed

November 13, 2014.

References
6. Mayes T, Gottschlich MM. Burns and wound healing. In: Cresci G, ed. Nutrition

Support for the Critically Ill Patient. Boca Raton, FL: CRC Press; 2005:435-456.
7. Marc G. Jeschk, Lars-Peter Kamolz, Shahriar Shahrohki. Burn Care and Treatment:

A Practical Guide. Vienna Springer. March 19, 2013. Date accessed November 13,
2014.