4th Degree Burn


Dermatologists break down the differences between first-degree, second-degree, third-degree, and fourth-degree burns. Read on to find out how to identify the degree of your burn, how to treat your. Fourth-Degree Burns, quest walkthrough and hints. This is a support quest for Judge, Jury, Executioner quest. Burns are classified as first-, second-, third-degree, or fourth-degree depending on how deeply and severely they penetrate the skin's surface. First-degree (superficial) burns. First-degree burns affect only the outer layer of skin, the epidermis.

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  • The deeper the second-degree burn, the slower the healing (fewer adnexa for re-epithelialization) Moist, red, blanching, blisters, extremely painful Superficial burns heal by re-epithelialization and usually do not scar if healed within 2 weeks Deep burns (deep second-degree to fourth-degree burns) Deep second-degree burns (deep partial-thickness).
  • Fourth degree and deeper burns destroy the skin plus fat, muscle and sometimes bone. How is burn size estimated? Total body surface area (or TBSA) burned is the percent (%) of the body that is burned.

General Information

  • After a chemical mass casualty incident, trauma with or without burns is expected to be common.
  • Burn therapy adds significant logistical requirements and complexity to the medical response in a chemical mass casualty incident.
  • Burns complicating physical injury and/or chemical injury decrease the likelihood of survival.
  • Health care providers with burn expertise are needed to optimize burn care.
  • Consultation with American Burn Association Verified Burn Centers is recommended

Diagnosis of Burns

  • Definition: A burn is the partial or complete destruction of skin caused by some form of energy, usually thermal energy.
  • Burn severity is dictated by:
    • Percent total body surface area (TBSA) involvement
      • Burns >20-25% TBSA require IV fluid resuscitation
      • Burns >30-40% TBSA may be fatal without treatment
      • In adults: 'Rule of Nines' is used as a rough indicator of % TBSA
        Rule of Nines for Establishing Extent of Body Surface Burned
        Anatomic Surface% of total body surface
        Head and neck9%
        Anterior trunk18%
        Posterior trunk18%
        Arms, including hands9% each
        Legs, including feet18% each

      • In children, adjust percents because they have proportionally larger heads (up to 20%) and smaller legs (13% in infants) than adults
        • Lund-Browder diagrams improve the accuracy of the % TBSA for children.
      • Palmar hand surface is approximately 1% TBSA
        Estimating Percent Total Body Surface Area in Children Affected by Burns
        (A) Rule of 'nines'
        (B) Lund-Browder diagram for estimating extent of burns
        (Adapted from The Treatment of Burns, edition 2, Artz CP and Moncrief JA, Philadelphia, WB Saunders Company, 1969)
    • Depth of burn injury (deeper burns are more severe)
      • Superficial burns (first-degree and superficial second-degree burns)
        • First-degree burns
          • Damage above basal layer of epidermis
          • Dry, red, painful ('sunburn')
        • Second-degree burns
          • Damage into dermis
          • Skin adnexa (hair follicles, oil glands, etc,) remain
          • Heal by re-epithelialization from skin adnexa
          • The deeper the second-degree burn, the slower the healing (fewer adnexa for re-epithelialization)
          • Moist, red, blanching, blisters, extremely painful
        • Superficial burns heal by re-epithelialization and usually do not scar if healed within 2 weeks
      • Deep burns (deep second-degree to fourth-degree burns)
        • Deep second-degree burns (deep partial-thickness)
          • Damage to deeper dermis
          • Less moist, less blanching, less pain
          • Heal by scar deposition, contraction and limited re-epithelialization
        • Third-degree burns (full-thickness)
          • Entire thickness of skin destroyed (into fat)
          • Any color (white, black, red, brown), dry, less painful (dermal plexus of nerves destroyed)
          • Heal by contraction and scar deposition (no epithelium left in middle of wound)
        • Fourth-degree burns
          • Burn into muscle, tendon, bone
          • Need specialized care (grafts will not work)
        • Deep burns usually need skin grafts to optimize results and lead to hypertrophic (raised) scars if not grafted
    • Age
      • Mortality for any given burn size increases with age
        • Children/young adults can survive massive burns
          • Children require more fluid per TBSA burns
        • Elderly may die from small (<15% TBSA) burns
    • Smoke inhalation injury
      • Smoke inhalation injury doubles the mortality relative to burn size
    • Associated injuries
      • Other trauma increases severity of injury
    • Delay in resuscitation
      • Delay increases fluid requirements
    • Need for escharotomies and fasciotomies
      • Increases fluid requirements
    • Use of alcohol or drugs (especially methamphetamine)
      • Makes resuscitation more difficult

American Burn Association Burn Unit Referral Criteria *

*Criteria not established for very large mass casualty incidents (MCI)

Summary of Burn Unit Referral Criteria (PDF - 7 KB) (American Burn Association)4th degree burn pain
  1. Second- and third-degree burns greater than 10% TBSA in patients under 10 or over 50 years of age
  2. Second- and third-degree burns greater than 20% TBSA in other age groups
  3. Second- and third-degree burns that involve the face, hands, feet, genitalia, perineum, and major joints
  4. Third-degree burns greater than 5% TBSA in any age group
  5. Electrical burns, including lightning injury
  6. Chemical burns
  7. Inhalation injury
  8. Burn injury in patients with pre-existing medical disorders that could complicate management, prolong recovery, or affect mortality (e.g., significant chemical exposure)
  9. Any patients with burns and concomitant trauma (e.g., fractures, blast injury) where burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient may be treated initially in a trauma center until stable before being transferred to a burn center. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols appropriate for the incident
  10. Hospitals without qualified personnel or equipment for the care of children should transfer children with burns to a Verified Burn Center with these capabilities
  11. Burn injury in children who will require special social/emotional and/or long-term rehabilitative support, including cases involving suspected child abuse or substance abuse


  • General information
    • All burn patients should initially be treated with the principles of Advanced Burn and/or Trauma Life Support
      • The ABC's (airway, breathing, circulation) of trauma take precedent over caring for the burn
      • Search for other signs of trauma
  • Verified Burn Centers provide advanced support for complex cases
    • Certified by the American College of Surgeons (ACS) Committee on Trauma and the American Burn Association (ABA)
    • Resources will give advice or assist with care
  • Burn Unit Referral Criteria (PDF - 7 KB) (American Burn Association)
  • Airway
    • Extensive burns may lead to massive edema
    • Obstruction may result from upper airway swelling
    • Risk of upper airway obstruction increases with
      • Massive burns
        • All patients with deep burns >35-40% TBSA should be endotracheally intubated
      • Burns to the head
      • Burns inside the mouth
    • Intubate early if massive burn or signs of obstruction
      • Intubate if patients require prolonged transport and any concern with potential for obstruction
      • If any concerns about the airway, it is safer to intubate earlier than when the patient is decompensating
    • Signs of airway obstruction
      • Hoarseness or change in voice
      • Use of accessory respiratory muscles
      • High anxiety
    • Tracheostomies not needed during resuscitation period
    • Remember: Intubation can lead to complications, so do not intubate if not needed
  • Breathing
    • Hypoxia
      • Fire consumes oxygen so people may suffer from hypoxia as a result of flame injuries
    • Carbon monoxide (CO)
      • Byproduct of incomplete combustion
      • Binds hemoglobin with 200 times the affinity of oxygen
      • Leads to inadequate oxygenation
      • Diagnosis of CO poisoning
        • Nondiagnostic
          • PaO2 (partial pressure of O2 dissolved in serum)
          • Oximeter (difference in oxy- and deoxyhemoglobin)
          • Patient color ('cherry red' with poisoning)
        • Diagnostic
          • Carboxyhemoglobin levels
            • <10% is normal
            • >40% is severe intoxication
      • Treatment
        • Remove source
        • 100% oxygen until CO levels are <10%
    • Smoke inhalation injury
      • Pathophysiology
        • Smoke particles settle in distal bronchioles
        • Mucosal cells are die
        • Sloughing and distal atelectasis
        • Increase risk for pneumonia
      • Diagnosis
        • History of being in a smoke-filled enclosed space
        • Bronchoscopy
          • Soot beneath the glottis
          • Airway edema, erythema, ulceration
        • Nondiagnostic clinical tests
          • Early chest x-ray
          • Early blood gases
        • Nondiagnostic clinical findings
          • Soot in sputum or saliva
          • Singed facial hair
      • Treatment
        • Supportive pulmonary management
        • Aggressive respiratory therapy
  • Circulation
    • Obtain IV access anywhere possible
      • Unburned areas preferred
      • Burned areas acceptable
      • Central access more reliable if proficient
      • Cut-downs are last resort
    • Resuscitation in burn shock (first 24 hours)
      • Massive capillary leak occurs after major burns
      • Fluids shift from intravascular space to interstitial space
      • Fluid requirements increase with greater severity of burn (larger % TBSA, increase depth, inhalation injury, associate injuries - see above)
      • Fluid requirements decrease with less severe burn (may be less than calculated rate)
      • IV fluid rate dependent on physiologic response
        • Place Foley catheter to monitor urine output
        • Goal for adults: urine output of 0.5 ml/kg/hour
        • Goal for children: urine output of 1 ml/kg/hour
        • If urine output below these levels, increase fluid rate
      • Preferred fluid: Lactated Ringer's Solution
        • Isotonic
        • Cheap
        • Easily stored
      • Resuscitation formulas are just a guide for initiating resuscitation
      • Resuscitation formulas:
        • Parkland formula most commonly used
          • IV fluid - Lactated Ringer's Solution
          • Fluid calculation
            • 4 x weight in kg x %TBSA burn
              • Give 1/2 of that volume in the first 8 hours
              • Give other 1/2 in next 16 hours
              • Warning: Despite the formula suggesting cutting the fluid rate in half at 8 hours, the fluid rate should be gradually reduced throughout the resuscitation to maintain the targeted urine output, i.e., do not follow the second part of the formula that says to reduce the rate at 8 hours, adjust the rate based on the urine output.
          • Example of fluid calculation
            • 100-kg man with 80% TBSA burn
            • Parkland formula:
              • 4 x 100 x 80 = 32,000 ml
              • Give 1/2 in first 8 hours = 16,000 ml in first 8 hours
              • Starting rate = 2,000 ml/hour
            • Adjust fluid rate to maintain urine output of 50 ml/hr
            • Albumin may be added toward end of 24 hours if not adequate response
      • Resuscitation endpoint: maintenance rate
        • When maintenance rate is reached (approximately 24 hours), change fluids to D50.5NS with 20 mEq KCl at maintenance level
      • Maintenance fluid rate = basal requirements + evaporative losses
        • Basal fluid rate
          • Adult basal fluid rate = 1500 x body surface area (BSA) (for 24 hrs)
          • Pediatric basal fluid rate (<20kg) = 2000 x BSA (for 24 hrs)
            • May use
              • 100 ml/kg for 1st 10 kg
              • 0 ml/kg for 2nd 10 kg
              • 20 ml/kg for remaining kg for 24 hrs
        • Evaporative fluid loss
          • Adult: (25 + % TBSA burn) x (BSA) = ml/hr
          • Pediatric (<20kg): (35 + % TBSA burn) x (BSA) = ml/hr
    • Complications of over-resuscitation
      • Compartment syndromes
        • Best dealt with at Verified Burn Centers
        • If unable to obtain assistance, compartment syndromes may require management
        • Limb compartments
          • Symptoms of severe pain (worse with movement), numbness, cool extremity, tight feeling compartments
          • Distal pulses may remain palpable despite ongoing compartment syndrome (pulse is lost when pressure > systolic pressure)
          • Compartment pressure >30 mmHg may compromise muscle/nerves
          • Measure compartment pressures with arterial line monitor (place needle into compartment)
          • Escharotomies may save limbs
            • Performed laterally and medially throughout entire limb
            • Performed with arms supinated
            • Hemostasis is required
          • Fasciotomies may be needed if pressure does not drop to <30 mmHg
            • Requires surgical expertise
            • Hemostasis is required
        • Chest Compartment Syndrome
          • Increased peak inspiratory pressure (PIP) due to circumferential trunk burns
          • Escharotomies through mid-axillary line, horizontally across chest/abdominal junction
        • Abdominal Compartment Syndrome
          • Pressure in peritoneal cavity > 30 mmHg
            • Measure through Foley catheter
          • Signs: increased PIP, decreased urine output despite massive fluids, hemodynamic instability, tight abdomen
          • Treatment
            • Abdominal escharotomy
            • NG tube
            • Possible placement of peritoneal catheter to drain fluid
            • Laparotomy as last resort
        • Acute Respiratory Distress Syndrome (ARDS)
          • Increased risk and severity if over-resuscitation
          • Treatment supportive
  • Wound Care
    • During initial or emergent care, wound care is of secondary importance
    • Advanced Burn Life Support recommendations
      • Cover wound with clean, dry sheet or dressing. NO WET DRESSINGS.
        • Simple dressing if being transported to burn center (they will need to see the wound)
        • Sterile dressings are preferred but not necessary
        • Covering wounds improves pain
        • Elevate burned extremities
      • Maintain patient's temperature (keep patient warm)
        • While cooling may make a small wound more comfortable, cooling any wound >5% TBSA will cool the patient
    • If providing prolonged care
      • Wash wounds with soap and water (sterility is not necessary)
      • Maintain temperature
      • Topical antimicrobials help prevent infection but do not eliminate bacteria
        • Silver sulfadiazine for deep burns
        • Bacitracin and nonsticky dressings for more superficial burns
    • Skin grafting
      • Deep burns require skin grafting
      • Grafting may not be necessary for days
      • Preferable to refer patients with need for grafting to Verified Burn Centers or, if not available, others trained in surgical techniques
        • Grafting of extensive areas may require significant amounts of blood
        • Patient's temperature must be watched
        • Anesthesia requires extra attention
  • Medications
    • All pain meds should be given IV
    • Tetanus prophylaxis should be given as appropriate
    • Prophylactic antibiotics are contraindicated
      • Systemic antibiotics are only given to treat infections

Special Burns

  • General information
    • Often require specialized care
    • Calling a Verified Burn Center is advised
  • Electrical injuries
    • Extent of injury may not be apparent
      • Damage occurs deep within tissues
      • Damage frequently progresses
      • Electricity contracts muscles, so watch for associated injuries
    • Cardiac arrhythmias may occur
      • If arrhythmia present, patient needs monitoring
      • CPR may be lifesaving
    • Myoglobinuria may be present
      • Color best indicator of severity
      • If urine is dark (black, red), myoglobinuria needs to be treated
        • Increase fluids to induce urine output of 75-100 ml/hr in adults
        • In children, target urine output of 2 ml/kg/hour
        • Alkalinize urine (give NaHCOi3)
        • Check for compartment syndromes
        • Mannitol as last resort
    • Compartment syndromes are common
    • Long-term neuro-psychiatric problems may result
  • Chemical Burns
    • Brush off powder
    • Prolonged irrigation required
    • Do not seek antidote
      • Delays treatment
      • May result in heat production
    • Special chemical burns require contacting a Verified Burn Center, for example:
      • Hydrofluoric acid burn

American Burn Association Information

  • The American Burn Association (ABA) is an organization of burn caregivers who have set up a network to assist with management of burn disasters.
  • The ABA has set up a system to verify burn centers (similar to Verified Trauma Centers) as meeting standards for managing patients with burns of all types of severity.
  • Verified Burn Centers participate in disaster planning and have set up a network for transporting burn patients throughout the country.
  • Verified Burn Centers are always available for advice and assistance in managing burn patients.
  • To find the nearest Verified Burn Center near you,
    • contact the ABA Web site: www.ameriburn.org or
    • e-mail: [email protected] or
    • call: 312-642-9260
  • The ABA offers ABA Advanced Burn Life Support (ABLS), a Self-directed, Web-based Learning Program.

4th Degree Burn Hand

Acknowledgement: This CHEMM Web page was adapted from REMM and prepared in consultation with Dr. David Greenhalgh, President of the American Burn Association, August 2006

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  2. Orgill DP. Excision and skin grafting of thermal burns. N Engl J Med. 2009 Feb 26;360(9):893-901. [PubMed Citation]
  3. Holmes JH 4th. Critical issues in burn care. J Burn Care Res. 2008 Nov-Dec;29(6 Suppl 2):S180-7. [PubMed Citation]
  4. Singer AJ, Dagum AB. Current management of acute cutaneous wounds. N Engl J Med. 2008 Sep 4;359(10):1037-46. [PubMed Citation]
  5. White CE, Renz EM. Advances in surgical care: management of severe burn injury. Crit Care Med. 2008 Jul;36(7 Suppl):S318-24. [PubMed Citation]
  6. Yurt RW, Lazar EJ, Leahy NE, Cagliuso NV Sr, Rabbitts AC, Akkapeddi V, Cooper A, Dajer A, Delaney J, Mineo FP, Silber SH, Soloff L, Magbitang K, Mozingo DW. Burn disaster response planning: an urban region's approach. J Burn Care Res. 2008 Jan-Feb;29(1):158-65. [PubMed Citation]
  7. Barillo DJ, Wolf S. Planning for burn disasters: lessons learned from one hundred years of history. J Burn Care Res. 2006 Sep-Oct;27(5):622-34. [PubMed Citation]
  8. Saffle JR, Gibran N, Jordan M. Defining the ratio of outcomes to resources for triage of burn patients in mass casualties. J Burn Care Rehabil, 2005 Nov-Dec;26(6):478-82 [PubMed Citation]
  9. Allison K, Porter K. Consensus on the pre-hospital approach to burns patient management. Injury. 2004 Aug;35(8):734-8. [PubMed Citation]
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Burns are a type of painful wound caused by thermal, electrical, chemical, or electromagnetic energy. Smoking and open flame are the leading causes of burn injury for older adults. Scalding is the leading cause of burn injury for children. Both infants and the older adults are at the greatest risk for burn injury.

What are the different types of burns?

There are many types of burns caused by thermal, radiation, chemical, or electrical contact.

  • Thermal burns. These burns are due to heat sources which raise the temperature of the skin and tissues and cause tissue cell death or charring. Hot metals, scalding liquids, steam, and flames, when coming into contact with the skin, can cause thermal burns.

  • Radiation burns. These burns are due to prolonged exposure to ultraviolet rays of the sun, or to other sources of radiation such as X-ray.

  • Chemical burns. These burns are due to strong acids, alkalies, detergents, or solvents coming into contact with the skin or eyes.

  • Electrical burns. These burns are from electrical current, either alternating current (AC) or direct current (DC).

The skin and its functions

The skin is the largest organ of the body and has many important functions. It is made up of several layers, with each layer having a specific functions:




The epidermis is the thin, outer layer of the skin with many layers including:

  • Stratum corneum (horny layer)
    This layer is made up of cells containing the protein keratin. it keeps body fluid in while keeping external substances out. As the outermost layer, it continuously flakes off.

  • Keratinocytes (squamous cells)
    This layer is made up of living cells that are maturing and moving toward the surface to become the stratum corneum.

  • Basal layer
    This layer is where new skin cells divide to replace the old cells that are shed at the surface.

The epidermis also contains melanocytes, which are cells that produce melanin (skin pigment).


The dermis is the middle layer of the skin. The dermis contains the following:

  • Blood vessels

  • Lymph vessels

  • Hair follicles

  • Sweat glands

  • Collagen bundles

  • Fibroblasts

  • Nerves

The dermis is held together by a protein called collagen, made by fibroblasts. This layer also contains nerve endings that conduct pain and touch signals.


The subcutis is the deepest layer of skin. The subcutis, consisting of a network of collagen and fat cells, helps conserve the body's heat and protects the body from injury by acting as a 'shock absorber.'

In addition to serving as a protective shield against heat, light, injury, and infection, the skin also:

  • Regulates body temperature

  • Stores water and fat

  • Is a sensory organ

  • Prevents water loss

  • Prevents entry of bacteria

What are the classifications of burns?

Burns are classified as first-, second-, or third-degree, depending on how deep and severely they penetrate the skin's surface.

  • First-degree (superficial) burns
    First-degree burns affect only the epidermis, or outer layer of skin. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example. Long-term tissue damage is rare and usually involves an increase or decrease in the skin color.

  • Second-degree (partial thickness) burns
    Second-degree burns involve the epidermis and part of the dermis layer of skin. The burn site appears red, blistered, and may be swollen and painful.

  • Third-degree (full thickness) burns
    Third-degree burns destroy the epidermis and dermis. Third-degree burns may also damage the underlying bones, muscles, and tendons. When bones, muscles, or tendons are also burned, this may be referred to as a fourth-degree burn. The burn site appears white or charred. There is no feeling in the area since the nerve endings are destroyed.

Burns that are more severe and extensive need specialized treatment. Because the age of a burn victim and the percentage of the body's surface area that has been burned are the most important factors affecting the outlook of a burn injury, the American Burn Association recommends that burn patients who meet the following criteria should be treated at a specialized burn center:

  • Individuals with partial-thickness burns over 10% or more of the total body surface area (TBSA)

  • Any age with full-thickness burns

  • Burns of the face, hands, feet, or groin, or genital area, or burns that extend all the way around a portion of the body

  • Burns accompanied by an inhalation injury affecting the airway or the lungs

  • Burn patients with existing chronic conditions such as diabetes, high blood pressure, heart disease, kidney disease, or multiple sclerosis

  • Suspected child or elder abuse

  • Chemical burn

  • Electrical injury

The effects of burns

A severe burn can be a seriously devastating injury -- not only physically but emotionally. It can affect not only the burn victim, but the entire family. Persons with severe burns may be left with a loss of certain physical abilities, including loss of limb(s), disfigurement, loss of mobility, scarring, and recurrent infections because the burned skin has decreased ability to fight infection. In addition, severe burns can penetrate deep skin layers, causing muscle or tissue damage that may affect every system of the body.

Burns can also cause emotional problems such as depression, nightmares, or flashbacks from the traumatizing event. The loss of a friend or family member and possessions in the fire may add grief to the emotional impact of a burn.

The burn rehabilitation team

4th Degree Burn

6th Degree Burn

Because so many functions and systems of the body can be affected by severe burns, the need for rehabilitation becomes even more crucial.

Many hospitals have a specialized burn unit or center and some facilities are designated solely for the rehabilitation of burn patients. Burn patients need the highly specialized services of medical professionals who work together on a multidisciplinary team, including the following:

  • Physiatrists

  • Plastic surgeons

  • Internists

  • Orthopedic surgeons

  • Infectious disease specialists

  • Rehabilitation nurses who specialize in burn care

  • Psychologists/psychiatrists

  • Physical therapists

  • Occupational therapists

  • Respiratory therapists

  • Dietitians

  • Social workers

  • Case managers

  • Recreation therapists

  • Vocational counselors

The burn rehabilitation program

Burn rehabilitation starts during the acute treatment phase and may last days to months to years, depending on the extent of the burn. Rehabilitation is designed to meet each patient's specific needs; therefore, each program is different. The goals of a burn rehabilitation program include helping the patient return to the highest level of function and independence possible, while improving the overall quality of life -- physically, emotionally, and socially.

To help reach these goals, burn rehabilitation programs may include the following:

  • Complex wound care

  • Pain management

  • Physical therapy for positioning, splinting, and exercise

  • Occupational therapy for assistance with activities of daily living (ADLs)

  • Cosmetic reconstruction

  • Skin grafting

  • Counseling to deal with common emotional responses during convalescence, such as depression, grieving, anxiety, guilt, and insomnia

  • Patient and family education and counseling

  • Nutritional counseling

3rd and 4th degree burn

Advances in the understanding and treatment of burns, state-of-the-art burn units and facilities, comprehensive burn rehabilitation services, and integrated medical care have all contributed to the increase in the survival rate and recovery of burn patients.


Laser Treatments for Burn Scars: Startish’s Story

When Startish Rivers was burned by an assailant, laser scar revision treatment at Johns Hopkins Bayview helped lessen the visual reminders of the attack, and helped her heal.