Trace elements, primarily iron, zinc, selenium, and copper, are required for humoral and cellular immunity [83–89]. Iron is also an important cofactor in oxy- gen-carrying proteins [56]. Zinc supplementation aids in wound healing, DNA replication, lymphocyte function, and protein synthesis [83–89]. Selenium replacement improves cell-mediated immunity and activates the transcription factor NFkB, a significant modulator of the inflammatory response [83–89]. Copper is critical for collagen synthesis and wound healing [84]. Deficiencies in copper, in particular, have been linked to fatal arrhythmias and poor outcomes [83–89]. Plasma levels of these trace elements are significantly depressed for prolonged periods after the acute burn injury due to increased urinary excretion and significant cutaneous losses. Replacement of these micronutrients lessens morbidity in severely burned patients [83–89]. Therefore, a complete daily multivitamin/mineral supplementation should be given (Table 7.2).

7.3.1.2 Early Excision

Early excision and closure of the burn wound has been probably the single greatest advancement in treating patients with severe thermal injuries during the last two decades leading to substantially reduced resting energy requirements, subsequent improvement of mortality rates, and substantially lower costs in this particular patient population [1, 90, 91]. It is in our opinion imperative to excise the burn wounds early and cover the excised areas with temporary cover materials or autologous skin. This will decrease the burn-induced inflammatory and stress responses leading to decreased hypermetabolism (Fig. 7.2).

7.3.1.3 Environmental Support

Burn patients can lose as much as 4,000 ml/m2 burned/day of body water through evaporative loss from extensive burn wounds that have not definitive healed [92]. The altered physiologic state resulting from the hypermetabolic response attempts to at least partly generate sufficient energy to offset heat losses associated with this inevitable water loss. The body attempts to raise skin and core temperatures to 2 °C greater than normal. Raising the ambient temperature from 25 to 33 °C can diminish the magnitude of this obligatory response from 2.0 to 1.4 times the resting energy expenditure in patients exceeding 40 % TBSA. This simple environmental modulation, meaning raise in room temperature, is an important primary treatment goal that frequently is not realized [93] (Fig. 7.2).

7.3.1.4 Exercise and Adjunctive Measures

A balanced physical therapy program is a crucial yet easy intervention to restore metabolic variables and prevent burn-wound contracture. Progressive resistance exercises in convalescent burn patients can maintain and improve body mass, augment incorporation of amino acids into muscle proteins, and increase muscle strength and endurance [64, 94]. It has been demonstrated that resistance exercising can be safely accomplished in pediatric burn patients without exercise-related hyperpyrexia as the result of an inability to dissipate the generated heat [64, 94] (Fig. 7.2).