What is the treatment for a third-degree burn?

Treatment of Third-Degree Burns

All patients with third-degree (full-thickness) burns should be immediately referred to a specialized burn center for early surgical excision and skin grafting, as this approach significantly reduces morbidity, mortality, and hospital length of stay. 1, 2

Immediate Management at Scene

Stop the Burning Process

• Cool the burn with clean running water (15-25°C) for 5-20 minutes to limit tissue damage and reduce pain 1, 3
• Remove all jewelry from affected areas before swelling occurs to prevent vascular ischemia and compartment syndrome 1, 3
• Monitor for hypothermia during prolonged cooling, especially in children 3
• Never apply ice directly to burns as this causes additional tissue ischemia 3

Assess for Life-Threatening Complications

• Activate EMS immediately if signs of inhalation injury are present (facial burns, singed nasal hairs, soot around nose/mouth, difficulty breathing, stridor) 1, 4
• Evaluate for circumferential burns on limbs or torso that may require emergent escharotomy 1

Escharotomy Indications (Performed Only at Burn Centers)

Circumferential third-degree burns can cause compartment syndrome leading to limb ischemia, thoracic compression, or abdominal compartment syndrome. 1

Timing for Escharotomy

• Immediate escharotomy is indicated only for compromised airway movement or ventilation 1
• Perform within 48 hours for patients with intra-abdominal hypertension or circulatory impairment 1
• Escharotomy should be performed only at a burn center due to risk of hemorrhage, infection, and increased morbidity from poorly performed procedures 1

Definitive Surgical Management

Early surgical excision and skin grafting is the standard of care for third-degree burns and must be performed at a specialized burn center. 1

Why Early Excision Matters

• Prospective randomized trials demonstrate that early surgical excision and skin grafting significantly reduce morbidity, mortality, and hospital length of stay 1
• Direct admission to burn centers reduces time to excision and duration of mechanical ventilation 1
• Delayed transfer increases mortality, particularly in patients with inhalation injuries 1

Surgical Approach

• Primary excision of third-degree burns with wound closure under tension can be performed for smaller burns (up to hand-sized areas) 5
• For massive burns, early excision of all dead tissue within the first 10 days post-burn with immediate autograft and allograft coverage prevents bacterial infection and organ failure 6
• Exposed bones and joints may require decortication with immediate grafting on fresh bone marrow surface 7

Burn Center Referral Criteria

Transfer to a specialized burn center is mandatory for: 1, 3, 2

• All full-thickness (third-degree) burns of any size 3, 2
• Burns involving face, hands, feet, or genitalia 1, 3, 2
• Partial-thickness burns >10% total body surface area in adults (>5% in children) 1, 3
• Any circumferential burns 1, 3
• Signs of inhalation injury 1, 3, 4

Fluid Resuscitation During Transport

For adult patients with ≥20% total body surface area burned (≥10% in children), administer 20 mL/kg of intravenous balanced crystalloid solution. 3

• Use balanced crystalloid solutions (Ringer's lactate) rather than 0.9% NaCl to reduce risk of hyperchloremia, metabolic acidosis, and acute kidney injury 3

Temporary Wound Management Before Transfer

Pain Control

• Administer over-the-counter oral analgesics such as acetaminophen or NSAIDs 1, 3
• Consider multimodal analgesia combining both for significant pain 3

Wound Coverage

• After cooling, loosely cover the burn with a clean, nonadherent dry dressing while awaiting transfer 1, 3
• Do not apply topical agents to third-degree burns in the field, as these will need to be removed for surgical evaluation 3

Critical Pitfalls to Avoid

• Do not delay transfer to a burn center for any third-degree burn - staged transfers through non-specialized facilities increase time to definitive treatment and worsen outcomes 1
• Do not use prophylactic systemic antibiotics - these increase bacterial resistance without proven benefit 2
• Do not perform escharotomy outside a burn center unless specialist consultation confirms it is absolutely necessary and transfer is impossible 1
• Do not apply prolonged cold exposure to large burns as this causes hypothermia and further tissue injury 3