Amity University Haryana

Amity Medical School

Department of Dietetics & Applied Nutrition
ppt on

BURNS
Burn
Burn is a damage to skin and tissues due
to:-
• Dry heat
• Wet heat
• Chemicals
• Radiations
• Electricity
• Lightening
• Sunlight
• cold
 Classification of burns
Burns are classified as first, second, or third degree, depending on how deep and severe they
penetrate the skin's surface.
• First-degree (superficial) burns. First-degree burns affect only the epidermis, or outer layer
of skin. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example.
Long-term tissue damage is rare and usually consists of an increase or decrease in the skin
color.
• Second-degree (partial thickness) burns. Second-degree burns involve the epidermis and
part of the dermis layer of skin. The burn site appears red, blistered, and may be swollen and
painful.
• Third-degree (full thickness) burns. Third-degree burns destroy the epidermis and dermis
and may go into the subcutaneous tissue. The burn site may appear white or charred
• Fourth degree burns. Fourth degree burns also damage the underlying bones, muscles, and
tendons. There is no sensation in the area since the nerve endings are destroyed.
 Classification on the basis of surface area
affected
Burns can also be classified on the basis of body surface area affected.
It also has three categories.
1. minor
• This means less than 15 to 20 % of body surface area is affected by burn. This comes
under first degree of burn.
2. Intermediate
• This means 20 to 40% of body surface area is affected by burn. This comes under the
category of second degree of burn.
3. Severe
• This denotes more than 40 to 50% of body surface area is severely affected by burn.
This comes under the category of 3rd degree of burn.
 Classification on the basis of thickness of
the skin
Just as body surface area affected, burns can also be classified on the basis of thickness of the
skin.
1. Partial thickness
• Partial thickness is the condition in which the epithelial layer of the skin is still present after the
burn, which can be re—epithelialized.
2. Full thickness
• Full thickness is the category in which all epithelial remnants are destroyed. Hence, in the case
it is essential to use skin grafts.
• The damage due to burn can vary from being extremely minor to extremely severe. The degree
of damage depends on the intensity and cause of burn.
• The damage includes scars, swelling, blisters, pain and in severe cases burn can cause shock and
even death. Burns can also lead to some infections, as it damages the skin’s protective barrier.
Treatment of burn depends
ideally upon three factors:-
1. Cause of the burn
2. Depth of skin and tissue
damage
3. Body surface area affected
by burn.
Metabolic changes due to burns
Metabolic changes may include:-
• 1. Increase in the rate of glucose production as well as its utilization.
• 2. Increase in the rate of lipolysis.
• 3. Increase in the rate of protein catabolism and anabolism.
• 4. Increase in the rate at which the energy expenditure takes place in
the body.
The purpose of diet management is-
1. To support proper respiration and blood circulation until the
following objectives are achieved:-
• i) Restored skin cover
• ii) Normal BMR
• iii) Normal fluid and electrolyte balance
• iv) Normal blood volume
• v) Normal nutritional status
2. To prevent infections
 Goals of nutritional
management

1. To improve and maintain lean body

mass.
2. To promote immune competence
3. to optimise wound healing
4. to reduce subsequent duration of
recovery.
 Researches on burns
• A burn patient needs continuous medical supervision along with adequate diet to recover quickly.
Adequate nutrition is necessary for fast recovery as well as for the replacement of old skin.
• If a person is malnourished before the burn injury then the energy requirements may be 30-300%
more depending on the intensity of burn. New researches are coming up that states ‘no
treatment is successful without proper nutrition’.
• Sandra Brady, a clinical nutritionist at St James's Hospital, Dublin stated that metabolic rate is
highly affected in burn injuries. Hence, not only the affected skin but metabolism also takes a lot
of time for recovery.
• Underfeeding or overfeeding both can affect the health of the patient negatively. Underfeeding
may affect negatively by delaying the wound healing process and overfeeding may cause
hyperglycaemia, hepatic steatosis and elevated production of CO2.
• Enteral feeding method is preferred over parental feeding method, as it has been shown that
enteral mode of feeding decreases mortality rate in burned patients.
 Researches
• If nutritional requirements are not met adequately then the person may not be able to properly
recover even after a long time of injury. Problems such as weight loss, insulin resistance, muscle
wasting, impaired wound healing, reduced resistance to infections may persists for a very longer
time.
• low fat nutrition improves immune response of the body as well as helps in recovery and
shortens the time of stay in hospital.
• According to The Journal of Parenteral and Enteral Nutrition, when a high protein, low fat, linoleic
acid restricted formulation is enriched with omega 3 fatty acids, arginine, cysteine, histidine,
vitamin A, zinc and ascorbic acid diet is provided through modular tube feeding method, then it
shows same positive results on all people of any sex and any age group. This form of diet also
helps to prevent the chances of wound infection and reduces the recovery time as well. It was
also seen to reduce the risk of diarrhoea, improved glucose tolerance, lower levels of serum
triglycerides, reduction in infections and improved muscle mass. It was also stated that almost
70% of burn patients die due to high doses of fat and linoleic acid and hence, modular tube
feeding method is found to improve the body’s response to burn injury.
 Researches
• According to an article on Burns in Science Direct, Sometimes burn injuries and stress causes
insulin resistance. Hence, insulin therapy is given to such patients, which not only maintains
blood glucose levels but also improves muscle protein synthesis, promote muscle anabolism,
maintains skeletal muscle mass and aids in wound healing. But time to time blood sugar levels
should be recorded to prevent hypoglycaemia.
• An article in science direct stated that mental stress also reduces the recovery period and
slows down the metabolism. It explained that burn injuries cause severe fluctuations in
metabolism and if the metabolic rate is not restored to the normal levels in burned patients
then the burn trauma and fluctuations in metabolism may persist for several years even
after recovery. Unstable metabolism not only slows down the speed of recovery but also
reduces immunity and increases the chances of several cardiovascular and hormonal
disorders in the body.
 ROLE OF ENTERAL FEEDING

• According to a Journal by BMC and NCBI in Bio Med Central, It has been found that those
patients who are provided nutrition through enteral feeding as early as 2-12 hrs after
burn show fast recovery and better metabolic response as compared to the patients who
receive nutrition after 24-48 hrs.
• Enteral feeding helps in preventing bacterial translocation by increasing gut blood flow and
decreasing gut mucosal atrophy. Several other advantages of enteral feeding includes:-
1. It reduces weight loss
2. It improves and maintains the metabolic response, which gets elevated due to severe burn injury.
3. It improves nitrogen balance.
4. It reduces recovery period.
5. It decreases mortality rate in patients.
6. It prevents the stress haemorrhage in the upper gastrointestinal tract.
Energy

• The average healthy adult needs about

1800 to 2000 calories per day.
• But after burn, the person may need upto
2500-3000 calories to meet the calorie
needs of the body as BMR increases.
 Carbohydrates
• Carbohydrate is the most important
source of energy for burn patients.
• It has been seen those patients who
receive high carbohydrate diets show less
muscle protein degradation as compared
to those who receive high fat diets.
• 7g/kg/day is the maximum rate at which
the glucose can be oxidised by cells to
provide energy to the body.
 Fats
• Fat is required in very limited amounts by the burn
patient.
• After burn, the rate at which the lipids are utilised to
form energy is highly decreased.
• Only 30% fats are metabolised and rest gets stored in
the liver.
• Thus, fat intake should not exceed 30 percent of
calories.
• Studies have also shown that increased fat intake also
slows down the immune response of the body and leads
to the formation of ketone bodies.
• Omega 6 fatty acids are highly preferred in fats group.
 Proteins
• An increase in proteins is essential in burn patients as they are very
important for wound healing, forming new tissues, replacement of
the loss and improving metabolism.
• Proteins are highly increased in burn cases. Proteins are even used
as a source of energy when energy by carbohydrates is limited.
• 1.5-2g/kg/day for adults and 2.5-4g/kg/day is the estimated protein
requirements.
• Proteins are very important as they fasten the wound healing
process and prevents muscle loss.
• All amino acids in combinations are necessary to support quick
recovery.
• Glutamine amino acid has to be increased because it readily provides
fuel for lymphocytes and enterocytes and strengthens immune
function. 2.5g/kg/day glutamine would reduce mortality but also
improves recovery.
• Arginine amino acid is also very important as it stimulates t-
lymphocytes and improves body’s resistance to infections.
• Post burns body breaks down muscles to obtain energy for healing
process. Protein is also lost through the burn wounds. The
breakdown of proteins can exceed 150 g per day. Hence, 1.5 – 2 g
proteins per day are necessary to prevent muscle loss and enhance
healing.
 Micronutrients
• Micronutrient loss takes place very quickly from the body.
• Loss of elements from the urine also increases in burn
patients. Hence, supplementation are essential in such cases.
• Vitamins and minerals play an important role in replacing
losses and healing of the injury.
• Vitamin C is very necessary for the synthesis of collagen and
also boosts immunity.
• Vitamin A is necessary for quick epithelialisation and for the
maintenance of immune system response to infections.
• As energy requirement is increased in burn patients to meet
up body requirements for recovery, the demand of vitamin B
also increases simultaneously.
• Low levels of vitamins and minerals have been linked to
decrease wound healing and suppression of the immune
system.
Role of various vitamins and minerals
Vitamins and minerals also play an important role in the wound healing. Role of
various vitamins and minerals are as follows:-
1. Vitamin A improves wound healing action.
2. Vitamin C helps in forming new issues.
3. Vitamin D helps in improving bone density.
4. Zinc is important for wound healing, functioning of lymphocytes and protein
synthesis.
5. Iron is important, as it is a cofactor for oxygen carrying proteins.
6. Selenium improves immunity.
7. Copper is essential for healing and synthesis of collagen.
According to a health article by the
University of Utah, Dietary suggestions
for burn patients are:-
• 6-11 servings of bread, grains, cereals
• 3-5 servings of vegetables
• 2-4 servings of fruit
• 3-4 servings of meat, poultry, beans,
nuts, fish
• 3-4 servings of milk, yogurt, cheese.
Foods to eat
• Beef, spinach and nuts provide zinc, iron and selenium.
• Sweet potatoes, spinach, red pumpkin and carrots are high in vitamin A.
• Vitamin D needs can be met through swordfish, salmon and fortified food products.
• Citrus fruits like lemon, oranges, sweet lime, berries, amla provide good amount of
vitamin C.
• Food from all food groups should be incorporated in the diet.
• Smoothies, custard, soups, milkshakes, cereals, whole grains, whole pulses, high
biological value proteins, low fat foods, eggs, beans, milk, tofu, peanut butter should
also be consumed.
• Cook food with spices and herbs, such as rosemary, mint, garlic, cayenne pepper, and
basil.
• Drink water during the day to stay hydrated and avoid unnecessary calories.
 Foods to avoid

• Deep fried foods

• Mechanically, thermally, chemically
irritating foods.
• Pickles, spicy foods
• Avoid foods with little nutritional
value, such as sugary beverages,
desserts, candy, fatty meats, whole-
fat dairy, and white breads or
crackers.
 ENERGY ESTIMATION FORMULAS FOR BURN PATIENTS

In an IOSR Journal of Dental and Medical sciences, Dr. Mariappan Natarajan and
Dr. D.R. Sekhar explained several energy estimation formulas that are as follows:-
2. Modified Schofield Equation
1. Modified Harris Benedict Equation • W = Weight in Kg
• Energy expenditure (EE) in males • Energy = BMR x IF x AF
• 278 + (57.5 x kg body weight) + 20.9
x (Height in Cm) – 28.3 – age
• Energy expenditure (EE) in females
• 2741 + (40 x Body Weight in Kg) +
7.7 x Height in Cm – (19.6 x age)
• Energy required = EE x injury factor

% BURN < 10 11-20% 21-30% 31-50% > 50%

INJURY 1.2 1.3 1.5 1.8 2.0
FACTOR
3. Ireton Jones Equation

(i) For spontaneous breathing (ii) For ventilator dependent patients

patients • 1784 – 11 (A) +5 (W) +244 (G) + 239 (T) +804 (B)
• A – Age
• Energy = 629 – 11(A) + 25 (W) -609
(O) • W – Weight
• G – Gender
• A = Age in years • Male - 1
• W = Weight in Kg • Female – 0
• O = Obesity • T – Trauma
• Absent – 0
• If the weight is > 30% above Ideal • Present – 1
Body Weight • B – Burn
• Yes – 1 No – 0 • Absent – 0
• Present – 1

4. The Curreri Formula

• 25 Kcal/ Kg Body Weight + 40 Kcal / % total body surface area
burn
 References

• Audra Clark, Jonathan Imran, 17 April 2017, Nutrition and Metabolism in burn patients, Burns and Trauma, BMC, NCBI,
ISSN- 2321-3876.
• B Srilakshmi, 2014, Dietetics, nutrition support in burn patients, page 213, ISBN: 978-81-224-3500-9.
• David N. Herndon, 7 June 2004, support of the metabolic response to burn patient, The Lancet- Science Direct, volume
363, issue 9424, pages 1895-1902, https://doi.org/10.1016/S0140-6736(04)16360-5.
• Donna J. Rodriguez, 1 January 1996, nutrition in patients with severe burns: state of the art, the journal of burn care and
rehabilitation, volume 17, issue 1, pages 62-70, https://doi.org/10.1097/00004630-199601000-00013
• Dr. Craig Porter, Ronald G Tompins, 7 October 2016, the metabolic stress response to burn trauma, Science Direct, The
Lancet, volume 388, issue 10052, pages 1417-1426, https://doi.org/10.1016/S0140-6736(16)31469-6.
• Dr. Mariappan Natrajan, Dr. D. R. Sekhar, march 2017, Nutrition in burn patient, IOSR, Journal of Dental and Medical
Sciences, e-ISSN: 2279-0853, p-ISSN:2279-0861, volume 14, issue 3, pages 38-54, www.iosrjournals.org.
• Healthy eating for burn patients, University of Utah, Health.
• Michele M Gottschlich, Glenn D. Warden, 1 may 1990, Differential effects of three enteral dietary regimens on selected
outcome variables in burn patients, Journal of parenteral and enteral nutrition, volume 14, issue 3, pages 225 – 236.
• Nazem Naman, Michel M. Pugeat, 1 November 1995, improved clinical status and length of care with low fat nutrition
support in burn patients, Journal of parenteral and enteral nutrition, volume 19, issue 6, pages 482-491.
• Noe A. Rodriguez, Marc G. Jeschke, 1 November 2011, Nutrition in burns, Journal Of Parenteral and Enteral Nutrition,
volume 35, issue 6, pages 704-714, https://doi.org/10.1177/0148607111417446.
• Robert Gibson, Dana K. Andersen, august 2010, glucose metabolism in burn patients: the role of insulin and other
endocrine hormones, Burns, Science Direct, Elsevier, volume 36, issue 5, pages 599-605.
• Robert R. wolfe, Farook Jhoor, 13 August 1987, effect of severe burn injury on substrate cycling by glucose and fatty acids,
the new England journal of medicine, 317: 403-408.
• Sandra Brady, Nutrition- Post burn nutrition support, INMO.
• Shubhangini A Joshi, nutrition and dietetics, 2015, burns, pages 423-425, ISBN: 978-93-392-2015-0.
Thank you