3rd degree skin burn: chemical, thermal.

Such a serious injury as a third-degree burn is characterized by deep damage to the skin layers with the formation of areas of their necrosis. In addition to the skin, muscle tissue and even bone can also be damaged.

In case of a third-degree burn, the victim must be hospitalized, because such an injury is considered very serious and requires qualified medical intervention.

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Epidemiology

According to various sources, third-degree burns may account for approximately 15% of all burn cases.

In addition, there are a number of interesting statistical facts:

• the overall incidence of all burns among other injuries is approximately 6%;
• Half of all diagnosed burns occur as a result of direct contact with flame;
• 20% of all burns occur as a result of exposure to boiling liquids or hot steam;
• 10% of the total number of burns are injuries caused by contact with hot objects;
• more than 70% of all burn injuries are damage to various parts of the hands;
• One in three burn victims is a child.

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Causes third-degree burns

A third degree burn can occur for a number of reasons:

• after exposure to high temperatures;
• after exposure to aggressive irritating chemical liquids;
• under the influence of electric current;
• under the influence of a large dose of radiation.

A thermal burn can result from direct exposure to fire, boiling liquid or steam, or direct contact with hot objects.

The chemical type of burn is always caused by chemical preparations and concentrates containing acids or caustic alkali.

An electrical burn can be caused by exposure to current after short-term contact with conductive elements.

As they say, no one is immune from accidental burns – you can get injured both at home (for example, in the kitchen) and at work.

The most common risk factors that can lead to a 3rd degree burn are:

• failure to comply with safety rules in the kitchen while preparing food;
• failure to comply with the rules for storing chemical solutions, acids and caustic alkalis;
• ignoring safety regulations at work.

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Pathogenesis

The impact of a damaging factor leads to complete or partial destruction of cells and disruption of their functionality. The degree of damage may vary depending on the duration of exposure, the temperature, the density of the skin at the site of damage, and the quality of tissue conductivity.

The wound surface of a third-degree burn usually represents complete destruction of the epidermal layer, dermis, and skin appendages. The affected area is usually dry, compacted, slightly painful, and not prone to self-healing.

A significant role in the pathogenesis of a burn is played by the inflammatory process, which occurs in response to traumatic injury. At the initial stage, vasoconstriction develops, which quickly moves to the dilation stage. In the tissues that have been burned, vascular permeability increases significantly. As a consequence of this process, the wound surface quickly fills with proteins and serum elements, which is visually manifested in the form of increasing edema.

Against the background of increased vascular permeability, neutrophils, platelets and monocytes accumulate in the wound, which cause the development of post-burn hypermetabolism.

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Symptoms third-degree burns

A third-degree burn is divided into two variants of the course, depending on the pathogenetic and clinical features:

• Degree 3a – characterized by damage not only to the epidermal layer, but also to a separate part of the hair follicles, sweat and sebaceous glands. Tissue necrosis occurs against the background of vascular damage and local edema. After a 3a degree burn, a crust of a grayish or brownish hue is formed, with the preliminary appearance of blisters of different sizes with liquid. Without medical assistance, such a wound heals slowly and problematically.
• Degree 3-b – the burn damage extends to all underlying tissues, including the subcutaneous fat layer. Visually, significant blisters containing liquid and blood elements attract attention. Such a burn is not always accompanied by pain, due to damage to pain receptors. It is pointless to count on the spontaneous healing of such a wound.

Types of burn injury	Pathogenetic features	First signs
3rd degree	The entire epidermal layer is subject to injury, even to the point of partial damage to the dermis.	A dry or pliable burn crust of a grayish or brownish hue is formed.
3-b degree	The damage affects the entire epidermal layer, the dermis, and even partial damage to the hypodermis.	The formation of a compacted, dry, brownish scab is observed.

• Edema in a 3rd degree burn is a natural reaction of the body to a traumatic damaging effect, with a violation of the integrity of tissues and the vascular network. Edema itself is the result of the accumulation of excess fluid in the skin layers - effusion of damaged blood supply vessels. Visually, edema in a 3rd degree burn looks like a small tumor (swelling of the skin) with characteristic redness. Simultaneously with the increase in edema, an inflammatory reaction develops in the tissues, which does not allow the swollen structures to recover.
• Temperature with a 3rd degree burn may indicate the development of toxemia - a pathological condition caused by intoxication of the body with residual products of protein decomposition and toxins entering the bloodstream from damaged tissues. The main sign of this condition is considered to be an increase in temperature - up to 38-39 ° C: the higher the temperature, the less favorable the prognosis should be considered. Toxemia in most cases is detected in victims with 3rd degree burns, which occupy an area of more than 5% of the skin surface.
• A third-degree facial burn always heals very slowly, as the damaged skin undergoes necrosis and is subsequently rejected. Due to the increased blood supply to the facial tissues, there is a high probability of a purulent infection. In most cases, the temperature rises, and epithelialization processes are slow. If the area of the nose or ears is damaged, there is a risk of developing chondritis and necrosis of the facial bones. With third-degree facial burns of any localization, scars are formed and tissues are deformed.
• A third-degree burn of the esophagus is considered very serious and poses a certain danger to the life of the victim. With such a burn, the patient is anxious, he groans, it is difficult for him to swallow not only food, but also his own saliva. The condition is often accompanied by shortness of breath, pale skin, and blue lips. If the burn is chemical (and this happens to the vast majority of patients with esophageal burns), then you can pay attention to damage to the mucous membrane of the oral cavity, tongue, and corners of the mouth.
• A third-degree leg burn is always accompanied by swelling – and this is considered a normal reaction of the body to a burn injury, since in this case not only the skin is damaged, but also the blood vessels and underlying tissues. Symptoms of a third-degree leg burn: watery dense blisters, scab formation, tissue death, and sometimes suppuration of the wound surface. After treatment, scarring usually remains at the burn site.
• A third-degree hand burn most often affects the fingers, less often the wrist area. In the vast majority of cases, due to the small layer of subcutaneous and muscle tissue, the bones and joints of the fingers and hand may be damaged. According to statistics, this type of burn is the most common.

3rd degree burn in children

In children, third-degree burn injuries occur no less frequently than in adults. This is especially true for children under 3 years of age.

However, according to statistics, the severity of such injuries in childhood is always higher. The fact is that the skin of small patients is much more delicate and sensitive than that of any adult, and the blood and lymph circulation system is very developed, and therefore conducts heat faster. Because of this, and also because the compensatory and regulatory reactions in a child are still imperfect, a third-degree burn almost always leads to the appearance of burn disease.

Therefore, any burn injuries in childhood have a more severe course, since children very quickly develop complications such as circulatory failure, electrolyte and protein metabolism disorders, and the function of the main organs - the liver and kidneys - is impaired.

Forms

Burns are divided into different types, depending on the nature of the damaging agent and the depth of the injury.

The damaging agent may be boiling water, fire, hot steam, chemicals, electric current, etc.

Depending on the depth of the burn injury, the following are distinguished:

• superficial burns (1st, 2nd and 3rd degree);
• deep burns (3b and 4 degrees).

A third-degree thermal burn is an injury sustained after contact with any heat carrier – both liquid or solid, and vaporous. The most frequently diagnosed burns are those sustained from contact with open fire sources; less common are burns from boiling water and electric current.

A third-degree boiling water burn is less common than the first two degrees, since in most cases the boiling water has time to cool on the body before the damage reaches the deep tissues. However, cases of combined tissue damage are not uncommon, when the burn is a combination of several degrees. In such a situation, the doctor determines the condition of the victim depending on the area of the wound surface at the deepest affected areas.

A third-degree chemical burn always heals much more slowly than similar burns caused by thermal or electrical exposure. The rejection of dead tissue (scab, crust) begins only by the fourth week, and the wound itself heals extremely slowly, with the formation of dense deforming scars. Sensitivity after a third-degree chemical burn is usually lost.

A third-degree eye burn is not diagnosed very often: such an injury is possible during fires or when a chemical liquid or aerosol with an aggressive filler gets on the face. A burn can lead to a significant decrease in visual acuity (up to its complete loss). Also, cases of corneal leukoma, cicatricial deformation of the eyelids, increased intraocular pressure, and atrophy of the affected visual organ are not uncommon.

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Complications and consequences

Possible complications after a third-degree burn can be divided into several groups:

• The development of burn disease, which consists of several stages, namely:

1. shock period (lasts about 48 hours, sometimes up to 72 hours);
2. period of toxemia (the entry of toxins into the bloodstream as a result of the decomposition of damaged tissues);
3. period of septicotoxemia (development of a purulent process);
4. recovery period (wound healing).

• Development of endogenous intoxication associated with the accumulation of toxic substances as a result of impaired liver and kidney function.
• Development of sepsis and infectious process due to infection from outside and formation of secondary immunodeficiency.

How long does it take for a 3rd degree burn to heal?

The healing period for a 3rd degree burn usually lasts from 6 weeks to 6 months, and for a 3b degree burn – up to 12 months. In most cases, the wound surface does not heal completely, since there are tissues that have undergone necrosis – such areas cannot heal on their own. In order to ensure complete healing, you should contact a surgeon who will perform a skin graft from healthy areas to the burn surface.

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Diagnostics third-degree burns

Diagnosis of a third-degree burn is usually not difficult: the doctor determines the area of damage and the depth (using the pain sensitivity method). As a rule, the deeper the burn, the less pain sensitivity.

Sometimes, to clarify the diagnosis and prescribe the correct treatment, the doctor suggests that the victim take the following tests:

• blood for coagulation degree;
• blood test for anemia;
• blood for the quality of electrolytic metabolism;
• urine for general analysis.

Based on the data obtained as a result of examinations, it is possible to judge the degree of intoxication, blood loss, as well as the functioning of the liver and kidneys.

Instrumental diagnostics are performed only if there are internal injuries. For example, in case of an esophageal burn, endoscopy may be prescribed.

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Differential diagnosis

Differential diagnostics is carried out between burn injuries of degrees 3a and 3b. By the way, such differentiation presents certain difficulties and is finally possible only after the process of rejection of dead tissue.

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Treatment third-degree burns

Treatment for a third-degree burn should consist of a whole range of methods, the main goals of which will be:

• pain relief;
• prevention of anemia;
• prevention of hypoxia;
• normalization of metabolic and equilibrium processes in the body;
• elimination of intoxication;
• prevention of cardiovascular disorders;
• prevention of liver and kidney disorders;
• stabilization of the body's energy potential.

Treatment of third-degree burns in a hospital is mandatory - this can be a burn department or a center. The doctor, using anesthesia, treats the burn and assesses its condition, while deciding how the treatment will be carried out - closed or open.

	Pros	Cons
Closed method of treatment of burn injuries	The risk of infection of the wound surface is minimized. The risk of mechanical damage is minimized.	The dressing process causes additional discomfort to the patient. Increased decomposition of dead tissue leads to additional intoxication.
Open method of treatment of burn injuries	The formation of a dry crust occurs faster. It is much easier to monitor the progress of the healing process.	There is a constant loss of moisture from the affected tissues. The open method has a much higher cost.

Medicines for dressings are, in the vast majority of cases, antiseptic agents:

• Ethacridine lactate is used in the form of 1:2000 solutions, and if skin irritation occurs, a 1:1000 solution can be used. Sometimes, Ethacridine can be used as a powder on a wound.
• Furacilin - used for irrigation and wet dressings, in the form of an aqueous 0.02% solution. In some cases, the drug can cause allergies.
• Silver nitrate 0.5% is used for a short period of time, since the drug can cause a change in skin color (as a result of the accumulation of metallic silver).

In addition, treatment of the wound surface with infrared and UV rays is prescribed - this helps prevent the development of wet necrosis, stop the course of purulent infection and accelerate epithelialization.

Ointments for third-degree burns are used only after the exudation in the wound has ceased. The following external preparations are usually prescribed:

• Synthomycin 10% is applied directly to the wound or under a bandage. Synthomycin should be avoided for infants, as the drug may cause an allergic reaction.
• Furacilin ointment 10% it is applied under a bandage. Rarely this ointment can provoke the development of allergic dermatitis, but most often it is well accepted by the body.
• Gentamicin ointment - it is applied directly to the burnt skin area, 3-4 times a day. Continue treatment with ointment for 1-2 weeks, unless an allergy to the drug occurs.
• Levomekol is used to treat burns in adults and children, starting from 3 years of age. The ointment is not recommended for long-term use. It is advisable to replace this drug with another one after 5-7 days, in order to avoid the development of osmotic shock in healthy tissues.

In addition to ointments, for third-degree burns, use an aerosol with the antibiotic Olazol - a preparation based on sea buckthorn oil, boric acid, benzocaine and chloramphenicol, which promotes wound healing. Olazol is applied daily or once every two days, depending on the degree of tissue damage and the stage of their recovery.

Ointments and other burn treatments should not irritate the wound surface - on the contrary, they should have a softening and analgesic effect. Ointment dressings are replaced daily or every other day.

Systemic antibiotics for third-degree burns are prescribed only individually, and only in cases where the area of damage is more than 10% of the total surface of the skin. Sometimes antibiotics are administered intramuscularly, and only in very severe cases - intravenously. As a rule, medications with a broad spectrum of antibacterial activity are prescribed:

• cephalosporin group drugs;
• penicillin preparations;
• sulbactam with cefoperazone;
• drugs of the fluoroquinolone group.

If a fungal infection occurs, levorin or diflucan is prescribed, and if an anaerobic infection occurs, metronidazole is prescribed.

First aid for 3rd degree burns

The rules of first aid for a possible third-degree burn are the following recommendations:

• The first step is to eliminate the source that caused the burn: put out the fire, pour water on the affected area of the body, remove burning clothing, etc.
• Clothes that have become “stuck” to the body cannot be removed by force!
• If the victim is unconscious, witnesses should be asked about how exactly the injury occurred, and an ambulance should be called as soon as possible.
• It is recommended to place the affected limb under running cold water for 15 minutes.
• The burn surface should be covered with gauze or bandage to avoid infection.
• Severely affected limbs are immobilized with splints.
• If the burn area is large, the victim should be given as much water (tea, juice, etc.) as possible.
• If there is severe pain, you can give the person an analgesic (baralgin, ibuprofen, etc.).
• If the victim is unconscious, the need for artificial respiration and chest compressions should be assessed.

Vitamins

• Tocopherol is taken to prevent the formation of rough scars on the skin. Children are prescribed from 100 to 300 IU, and adult patients - from 200 to 800 IU. The drug is taken throughout the entire period of burn treatment.
• Retinol is taken to facilitate the absorption of tocopherol, 25 thousand IU daily.
• Ascorbic acid will help prevent excessive nervousness and anxiety, increase immune defense and stimulate the healing process. The dose of ascorbic acid for a 3rd degree burn is 500-1000 mg daily.

Additionally, doctors recommend taking multivitamin preparations with a high content of B vitamins (for example, Undevit). Regular consumption of brewer's yeast has a good stimulating and strengthening effect.

Physiotherapy treatment

Physiotherapy procedures for third-degree burns help relieve pain and stop the development of the inflammatory process, and also accelerate skin recovery.

• After the acute period is over – approximately on the 3rd-4th day – to relieve pain, you can use the Lenar, Transair, El Esculap Medteko devices, which operate using the transcranial electrical stimulation method.
• During the period of scab formation, the wound surface is treated with the Geska device - 2 sessions per day, 25 minutes each, for 14-20 days in a row.
• During the period of active recovery and formation of granulations, the following are used:

1. electrical stimulation (14-15 sessions);
2. franklinization (daily for a month);
3. ultraviolet therapy using suberythemal doses (10-12 sessions, every other day);
4. low-frequency magnetic therapy (35 minutes daily for 15 days);
5. permanent magnetic therapy using elastomagnetic sheets (15 five-hour procedures);
6. laser therapy (helium-neon, 20 daily sessions of 20 minutes).

• At the stage of formation of cicatricial changes the following is prescribed:

1. electrophoresis with lidase;
2. paraffin applications (temperature 50°C);
3. hydrocortisone by means of ultrasound phonophoresis (12 sessions).

Treatment of 3rd degree burns at home

A third-degree burn is a fairly serious injury that cannot be treated effectively at home. Folk remedies can only be useful as an additional method, along with traditional medical care.

In case of a burn, especially of the 3rd degree, special attention should be paid to the presence of vitamins E and C in the diet - they help stop the inflammatory reaction and restore injured tissue structures. In addition, ascorbic acid takes an active part in the formation of collagen fibers, which are the main components of scar tissue. The necessary vitamins are found in fresh vegetables, berries, fruits and unrefined vegetable oils.

At the stage of wound healing, aloe juice can help - it usually accelerates regeneration processes and maintains primary tissue tension. The simplest recipe for using aloe: drop a few drops from the thick part of the leaf onto the affected area of skin.

Some time after receiving a burn, when the acute period of injury is behind you, you can apply compresses of freshly grated potatoes - for about 1-1.5 hours daily.

Green tea poultices speed up healing – and it is known to be an excellent antioxidant. The poultices are soaked in strong tea and applied to the wound.

At the healing stage, you can use a calendula-based ointment. To prepare it, mix the pharmacy calendula tincture and Vaseline in a 1 to 2 ratio.

Herbal treatments can only be used if approved by the attending physician. For example, patients often use the following popular recipes:

• Black elderberry leaves are doused with boiling water and, after cooling, applied to the affected area.
• 100 g of St. John's wort is boiled in 0.5 l of vegetable oil (for half an hour), then filtered and cooled. It is used for application to burn wounds.
• A decoction is prepared from the rhizome of the galangal (for 1 tbsp of root - 250 ml of water). It is used for lotions on the wound.
• Plantain leaves are doused with boiling water, cooled and applied to the site of the burn injury.

Homeopathy

Usually, when receiving lighter burns - for example, 2nd degree, but with the formation of blisters with liquid - it is recommended to use the drugs Arnica 30, Aconite 30 and Cantharis 30, with an individually selected dosage.

For third degree burns, with severe tissue necrosis, stronger homeopathic remedies may be required:

If the victim is in a state of shock and does not complain of pain, then the drug Opium 1m should be used;

For chemical burns caused by concentrated acids or alkalis, Sulfuricum acidum 30 is recommended.

Unless a homeopathic physician prescribes a different dosage, take 2 tablets of the listed preparations every half hour, but no more than three times. The patient's condition should improve within 2 hours. If the preparations are diluted more than 30 (for example, 6 or 12), they are given every 15 minutes.

Surgical treatment

The most common operation after a third-degree burn is skin grafting, which consists of three consecutive procedures:

• removal of the transplant material (usually skin from healthy areas of the patient will do);
• preparation of the wound surface (cleaning, rinsing with isotonic solution, drying);
• direct transplantation of material onto the wound.

The transplant operation is performed under general anesthesia. Skin grafts are fixed with a bandage or sutures, pre-perforated to improve survival. The average period of time for the transplanted skin to take hold is one week.

In addition to skin transplantation, surgical interventions are sometimes used after third-degree burns to eliminate scars and skin deformations. Scars after third-degree burns are excised, and skin deformations are replaced with healthy material - a transplant.

Rehabilitation after 3rd degree burns

Rehabilitation measures after a third-degree burn injury are carried out after the relief of acute symptoms and the prevention of possible complications. The rehabilitation period involves the use of procedures and methods that promote the final healing of the wound and the restoration of the victim's ability to fully move and lead a normal life (or, at least, to independently serve their needs).

However, this period is still accompanied by:

• metabolic disorders (for example, anemia and dysproteinemia);
• disorders of the heart and blood vessels (for example, low blood pressure);
• disorders of the respiratory system (difficulty breathing, shortness of breath);
• digestive system disorders (loss of appetite, constipation);
• impaired renal function.

In addition to measures to prevent possible adverse effects and to accelerate the body's recovery, procedures are carried out to prevent cicatricial changes in the skin.

Nutrition for 3rd degree burns

Immediately after receiving a third-degree burn, the patient is recommended to follow a gentle diet, with predominant consumption of dairy products, broths, freshly squeezed juices, vegetable oil. After a few days, gradually increase the caloric content by regularly consuming carbohydrate foods - cereals, fruit purees, berry jellies. In case of water-electrolyte imbalance, as well as to accelerate the removal of toxic substances from the body, it is recommended to drink a sufficient amount of liquid - mineral water, compotes, herbal teas, jelly, fruit drinks.

The diet should be enriched with foods containing sufficient amounts of B vitamins, ascorbic acid, vitamins D and A.

In cases of burns that are extensive in area and depth, as well as in cases of dysphagia, probing is used.

Prevention

In order to prevent third-degree burns, doctors advise paying attention to the following tips:

• You should be careful in the kitchen when preparing food, especially if there are children in the family;
• It is better to place pots with boiling liquids on the burners farthest from the edge of the stove;
• It is unacceptable to keep matches and other ignition sources in places accessible to children;
• if there are small children in the family, it is essential to insulate open sockets, extension cords and places with a concentration of electrical wires;
• It is unacceptable to have exposed wires and unsecured switches or sockets in the house;
• chemical solutions must be kept in special containers, which must have a label describing the contents;
• Storage areas for chemicals and liquids must be kept out of reach of children;
• Do not smoke: this will reduce the risk of fires and burns by almost half;
• A fire extinguisher must be present in the house: it must be placed in a place where small children cannot get to, but where an adult can easily use the device in any situation.

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Forecast

With timely medical care, the prognosis for third-degree burns can be relatively favorable, but this depends on how deep and extensive the tissue damage was. A third-degree burn can be accompanied by a positive prognosis if the following measures were taken in relation to the victim:

• quality first aid;
• surgical treatment;
• physiotherapy procedures;
• rehabilitation methods and recommendations for further care of the damaged area.

If the third degree burn was relatively small in size and shallow, then the prognosis for its complete recovery can be considered favorable.