From the Guidelines
Fourth-degree burns require immediate emergency medical attention and treatment in a specialized burn center to minimize morbidity, mortality, and improve quality of life. These burns are the most severe type of burn injury, extending through all layers of skin and into underlying tissues including muscle, tendons, and bone, as noted in the management of severe thermal burns in adults and children 1. The characteristics of fourth-degree burns include a charred black or white appearance, a dry and leathery feel, and a lack of sensation in the affected area due to destruction of nerve endings.
Treatment Approach
The treatment approach for fourth-degree burns involves:
- Hospitalization in a specialized burn center
- Aggressive fluid resuscitation to prevent shock and organ failure
- Surgical debridement of dead tissue to prevent infection and promote healing
- Often, amputation of the affected limb or area to prevent further complications
- Infection prevention using topical antimicrobials and systemic antibiotics
- Recovery typically requires multiple surgeries, skin grafting, and extensive rehabilitation
Pain Management
Pain management is crucial in the treatment of fourth-degree burns, and multimodal analgesia can be used to control pain, with all analgesic medications titrated on the basis of validated comfort and analgesia assessment scales 1. This may include the use of titrated intravenous ketamine combined with other analgesics to treat severe burn-induced pain. Non-pharmacological techniques can also be combined with analgesic drugs for dressings, where appropriate.
Outcome
The severity of fourth-degree burns stems from the complete destruction of the skin's protective barrier, massive fluid loss, high risk of infection, and potential for systemic complications including shock, organ failure, and death. Due to their depth and extent of tissue damage, fourth-degree burns have the poorest prognosis among all burn classifications, and treatment should prioritize minimizing morbidity, mortality, and improving quality of life 1.
From the Research
Characteristics of Fourth-Degree Burns
- Fourth-degree burns are characterized by exposure of viable tissue such as tendon or bone 2, 3
- These injuries are often associated with challenging wound closure and require multistage reconstructive procedures 3
- Fourth-degree burns can lead to significant functional impairment and may require amputation in some cases 3
Treatment of Fourth-Degree Burns
- Negative pressure wound therapy can be a reliable alternative method in the treatment of fourth-degree burns 2
- Reconstruction goals include providing adequate soft tissue coverage and restoration of function 2
- Treatment modalities may include split-thickness skin grafts, bipedicled local flaps, and free-tissue transfers 2, 3
- Early operative intervention and wound closure are important for improving outcomes 4
- Local wound care, excision, and grafting are crucial for managing the functional, cosmetic, and physiologic derangements caused by burn injuries 5
Additional Considerations
- Fourth-degree burns require a team approach to patient care, with a focus on resuscitation, monitoring, and prevention of complications such as hypothermia and compartment syndromes 4
- Judicious fluid resuscitation is essential for large burns 5
- Electrical, chemical, and inhalational injuries require additional care and are often associated with increased morbidity 5