In the United States, more than 450,000 people require medical treatment for burn injuries annually. In our last article, we discussed the diagnosis, treatment, and prevention of first- and second-degree burns, especially as they pertain to off-grid settings. Now, for a far more difficult issue: third-degree burns.

A third-degree burn is also known as a “full thickness” burn. This type of burn destroys the outer layer of skin (epidermis) and the entire layer beneath (the dermis). Third-degree burns penetrate through both and can damage deep structures.

Although many sources use the term “third-degree” to describe any severe burn, some others differentiate further into fourth-, fifth-, and sixth-degree. A fourth-degree burn extends into fat, while a fifth-degree involves muscle below the fat. A sixth-degree burn goes all the way down to bone. All of these are serious, often life-threatening injuries.

LIKELY CAUSES OF THIRD-DEGREE BURNS

Unlike first- and second-degree burns (“partial-thickness burns”), which can occur through sun exposure, third-degree burns usually require more intense heat to destroy both epidermis, dermis, and deeper structures. Events like those below are often to blame:

FLAMES FROM FIRES OR FLASH FROM EXPLOSIONS. Along with scalds, these are known as “thermal burns” and represent 80% of U.S. burn victims. Tissues are physically damaged with varying thicknesses due to the intensity of the exposure.

SCALDS. Scalds are thermal burns caused by hot liquids such as boiling water or steam. Burns can be very painful and cause swelling, redness, peeling skin, blisters, and white or charred discoloration.

CHEMICAL SPILLS. Although most associate burn from chemical spills with acids (pH < 7), bases (alkali) can be worse. Acid burns form a scab and don’t tend to penetrate as deeply as alkali burns.

ELECTRICAL SHOCKS. Burns from electricity can travel through the body and damage internal organs even if external skin damage is minimal. Damaged organs which lead to serious injury and fatalities include the heart, kidneys, bones, muscles, and nervous system.

Of course, any hot object applied to skin for extended periods of time can also cause severe burns.

SYMPTOMS OF THIRD-DEGREE BURNS

Depending on the depth of penetration and the origin of the heat source, third-degree burns can vary in appearance. They may appear:

• Black
• Brown
• White
• Yellow
• Gray

Damaged tissue will look dry, waxy, or leathery. If significant tissue is lost, the burn area may appear indented. Swelling is common, but pain may be minimal due to damage to sensory nerves. Discomfort may be most noted in the less-burnt outside borders of the injury.

TREATING THIRD DEGREE BURNS

Any third degree burn or worse, even if very small, should merit the full attention of the medic. Actions should include:

1)            Removing the heat source immediately.

2)            Running cool water over the burn for at least 15-20 minutes as soon as possible. Don’t use ice, which can traumatize the wound.

3)            Removing rings and jewelry before swelling develops.

4)            Removing loose debris like smoldering clothing. If clothing sticks to skin, cut around it.

5)            Elevating the burned extremity.

6)            Cover the wound loosely and not entirely around an arm or leg. Keep the dressing at least three inches over the wound borders.

Third-degree burns or worse will rapidly cause dehydration, as the protective layer (the skin) that holds fluids in is lost. Broken capillaries will leak fluid into the wound around the clock. Replacing liquids with oral rehydration solution is essential to keep the patient stable (as long as the patient tolerates it).

In normal times, all third-degree burn victims are treated with intravenous fluids. Indeed, in some cases, the loss of fluids may be so rapid as to only be replaceable with intravenous hydration, a major challenge for the survival medic due to lack of access to these products. If available, Lactated Ringers solution, the common IV fluid closest in electrolyte content to natural plasma, is preferred. Rectal rehydration, discussed in other articles on this website, is a possible option.

DEBRIDEMENT OF DEAD TISSUE

Removal of dead tissue (also called “debridement”) from burns is necessary to allow healing. The process of sharp debridement is as follows:

1)            Wash the wound with soap and water.

2)            Use a sterile scalpel or knife to cut away non-viable tissue. As the tissue is dead, it shouldn’t hurt or bleed. Some small amount of bleeding may be noted at the border with live tissue.

3)            Once all dead tissue is removed, cover the wound with a wet-to-dry dressing. Keeping the area moist is important. This may be accomplished by dripping half-strength sterile normal saline onto the dressing at regular intervals.

4)            If the injury is on an extremity, elevate it to decrease swelling.

5)            Change dressings at least daily.

6)            Debride additional non-viable tissue as needed.

You probably know that skin serves as protection against infection. As the skin no longer exists in these burns, infection is very likely after 48 hours or so, especially if the wound isn’t covered. Spenco Second Skin or even raw unprocessed honey are options as burn wound covers. Celox hemostatic gauze may also serve as a burn dressing. When moistened, the gauze forms a gel-like dressing that may provide a helpful barrier.

A more detailed discussion on debridement and dressings can be found elsewhere on this site. Note that dressings should cover the entire burn area.

ANTIBIOTICS IN THIRD DEGREE BURNS

Antibiotics given preventively are discouraged in first- and second-degree burns, but third-degree burns are more problematic. Mupirocin (Bactroban) cream is a topical option, but avoid the use of mostly oil-containing material; heat might be trapped in the wound.

Oral antibiotics like cephalexin, clindamycin, or sulfamethoxazole/trimethoprim may be given in survival scenarios if infection is suspected. This is a complicated issue, as healing wound edges in burns may mimic signs of a wound infection. In normal times, intravenous antibiotics are used for severe burns. Off the grid, topical application of raw unprocessed honey may be an option.

Any third-degree burns larger than an inch in diameter usually requires a skin graft to heal completely. Scarring is common and may limit the range of motion of a limb. Keep the injured area splinted in a natural position and perform range of motion exercises daily. These burn care procedures will help decrease limited mobility due to scarring effects.

A person with third-degree burns over more than ten percent of the body surface is in a life-threatening situation and will likely go into shock. Without advanced care, expect a poor outcome. Even for survivors, healing in the area may lead to loss of mobility from thick scars known as “contractures.” Skin grafts are needed but unavailable in survival settings.

Even the most skilled medic in survival scenarios will encounter cases where the patient is injured to the point that survival is unlikely. Still, they must do what they can, with what they have, where they are.

Joe Alton MD

Find out more about burns and 200 other medical issues in survival settings with a copy of the Book Excellence Award-winning “Survival Medicine Handbook: The Essential Guide for when Help is NOT on the Way.” Plus, check out our entire line of quality medical kits and individual supplies at store.doomandbloom.net. You’ll be glad you did.