Third degree burns involve the epidermis (outermost layer of skin) and extend down through the entire dermis. The burned area will appear leathery and feel dry, and may appear white or brownish in color. These burns are not painful due to destruction of nerve endings. Severe scarring, infection, contractures and amputation are possible complications of third degree burns.Cooling the Burn
Regardless of the degree of burn, all burns require initial cooling to prevent extension of the burn down into deeper layers and underlying structures. Cooling may be accomplished with the use of cold running water (at home) or cold compresses (towels or cloths can be used at home). If burns are extensive, the burn victim must be monitored for hypothermia (abnormally low body temperature).Once the burn has been cooled sufficiently, it should be covered with a clean, dry dressing or sheet. All third degree burns should be assessed in hospital.
Initial care at the hospital involves assessment of airway, breathing and circulation.
• provision of supplementary oxygen if oxygen levels are low (victims of smoke inhalation may require assistance or mechanical ventilation to breathe)
• assessment of airway (mouth, throat, trachea, lungs) if the victim was burned in a fire
• intravenous therapy (provides a route for fluid resuscitation, pain medications and other medication)
• vital signs, including temperature, pulse, blood pressure, respiratory rate and oxygen saturation
Fluid resuscitation is needed for burns in children that are greater than 10% of the total body surface area (greater than 15% in adults). The amount of fluid given is calculated according to the patient’s weight and the total body surface area of the third degree burn. The Parkland formula is frequently used to determine the amount of fluid to be provided when a patient has suffered a third degree burn and is adjusted according to vital signs, urine output and other factors. Burn Treatment
Once the burn has been cooled, any dead skin present will be removed (debrided) and a dressing will be applied to the burn. If it is likely that a third degree burn is going to require surgery, no topical medications or creams are applied.
• Pain medication- can be given intravenously once an IV has been started (Morphine or Fentanyl are often used)
• Catheter- a catheter may be inserted into the bladder measure urine output, which helps determine if fluid resuscitation is adequate
• Tetanus prophylaxis- a tetanus shot may be given as burn wounds are prone to tetanus
• Antibiotics- some physicians will begin antibiotics as prophylaxis against infection in third degree burns (although this practice is somewhat controversial)
Early surgical closure of burn wounds may be necessary. In addition, burns that are circumferential (involving the entire circumference of a limb, for example) may require escharotomy (surgical incising of scar tissue) to prevent impairment of circulation below the burn wound, which could cause tissue death necessitating amputation. Preparing the patient for surgery may begin in the emergency room and surgery may take place once the patient with third degree burns has been stabilized.