What is the initial management of third-degree burns?

Initial Management of Third-Degree Burns

Immediately transfer all patients with third-degree burns to a specialized burn center, as direct admission significantly reduces morbidity and mortality through early surgical excision and specialized care. 1

Immediate On-Scene Actions

Cooling and First Aid

• Cool the burn with clean running water (15-25°C) for 5-20 minutes to limit tissue damage, but only if total body surface area (TBSA) is <20% in adults or <10% in children without shock 2
• Remove all jewelry from affected areas before swelling occurs to prevent vascular ischemia and compartment syndrome 3, 2
• Monitor children closely for hypothermia during cooling and discontinue if hypothermia develops 3, 2
• Never apply ice directly to burns as this causes additional tissue ischemia 2

Pain Management

• Administer over-the-counter oral analgesics (acetaminophen or NSAIDs) for initial pain control 2, 4
• For severe burns requiring hospitalization, use multimodal analgesia with titrated intravenous ketamine combined with other analgesics 1, 2

Critical Assessment for Life-Threatening Complications

Airway Evaluation

• Suspect inhalation injury if the burn occurred in an enclosed space, with facial burns, soot around nose/mouth, singed nasal hairs, carbonaceous sputum, or respiratory distress 3
• Intubate immediately without delay if severe respiratory distress, altered mental status, or severe burns involving the entire face are present 3
• Normal oxygen saturation and chest X-ray do not exclude inhalation injury 3

Circumferential Burn Assessment

• Evaluate for circumferential third-degree burns on limbs, thorax, or abdomen, which can cause compartment syndrome leading to limb ischemia, decreased cardiac output, hypoxia, acute renal failure, and mesenteric ischemia 1
• Escharotomy should only be performed at a burn center due to high risk of complications including hemorrhage and infection when performed by non-specialists 1
• The only urgent indication for immediate escharotomy is compromised airway movement or ventilation; otherwise, perform within 48 hours if intra-abdominal hypertension or circulatory impairment develops 1

Fluid Resuscitation

Initiation Criteria and Protocol

• Begin intravenous fluid resuscitation for adults with ≥20% TBSA burns or children with ≥10% TBSA burns 2
• Administer 20 mL/kg of balanced crystalloid solution (such as Lactated Ringer's) initially 2
• Balanced crystalloid solutions are strongly preferred over 0.9% NaCl to reduce risk of hyperchloremia, metabolic acidosis, and acute kidney injury 2

Wound Management

Initial Wound Care

• After cooling and irrigation, apply a thin layer of petrolatum or petrolatum-based antibiotic ointment (without sulfonamides) 2
• Alternative topical agents include medical-grade honey or aloe vera gel 2
• Cover burns loosely with clean, non-adherent dressings 2

Topical Antimicrobial Therapy

• Silver sulfadiazine cream 1% is FDA-approved as an adjunct for prevention and treatment of wound sepsis in second and third-degree burns 5
• Apply silver sulfadiazine once to twice daily to a thickness of approximately 1/16 inch under sterile conditions after wound cleansing and debridement 5
• Reapply immediately after hydrotherapy and continue until satisfactory healing or the burn site is ready for grafting 5
• Avoid prolonged use of silver sulfadiazine on superficial burns as it may delay healing 4

Mandatory Burn Center Transfer Criteria

The following patients require immediate transfer to a specialized burn center: 3, 2

• Third-degree (full-thickness) burns of any size 2
• Second or third-degree burns involving face, hands, feet, genitals, or major joints 3, 2
• Partial-thickness burns >10% TBSA in adults or >5% TBSA in children 2
• Any circumferential burns requiring potential escharotomy 2
• Any signs of inhalation injury 3, 2
• Burns in children or elderly patients with >10% TBSA 6

Rationale for Burn Center Transfer

Direct admission to a burn center is associated with better survival, decreased morbidity (even long-term), earlier surgical excision, reduced time to definitive treatment, and shorter duration of mechanical ventilation compared to staged transfers 1

Early surgical excision and skin grafting, routinely performed at burn centers, significantly reduce morbidity, mortality, and length of hospital stay for severely burned patients 1

Common Pitfalls to Avoid

• Do not delay transfer waiting for "stabilization" unless the patient has severe hemodynamic or respiratory instability and transport time is long 1
• Do not perform escharotomy outside a burn center unless absolutely unavoidable; obtain specialist advice first if transfer is impossible 1
• Do not use prolonged cold exposure on large burns as this causes hypothermia and further tissue injury 2
• Do not assume absence of inhalation injury based on normal initial oxygen saturation or chest imaging 3