TOPIC: Non-fatal and Fatal Burn Injuries
Subtopics
Fatal Burn Injuries
· Effects of Burns
· Classification of burn
· Cause of death in burns
· Medicolegal importance of burns
Non-fatal burn injuries-scalds
Notes for the topic: Burns can be classified as either superficial, partial thickness or full thickness. To estimate degree of burn there is a rule called rule of nines, which helps in estimating fluid loss, shock, etc. Under this, the body is divided into different areas, each representing 9 per cent. When surface area involved is more than 20 per cent the fluid loss is marked, resulting in shock and usually, involvement of 30 to 50 per cent is fatal. Causes of death in burns in 1st few hours are hypovolemic shock ,coma ,aphysxia .Causes of death in burns occuring within few days include inflammation of internal organs leading to meningitis, peritonitis, pneumonia, bronchitis, pleurisy, enteritis, Curling’s ulcer in the duodenum, gangrene, exhaustion due to severe pain and dehydration from loss of fluid, sepsis (pseudomonas is most common organism responsible for infection), toxaemia, hepato-renal syndrome (in every case of burns of any severity, absorption of altered protein occurs and this in turn leads to cellular damage to liver and kidneys (acute tubular necrosis). Heart may also undergo similar damage. Scalds are trauma resulting from the application of moist heat commonly involving only superficial layers of the skin.
Fatal Burn Injuries
Deaths due to fire or burns usually result from the application of dry heat to the body.
Incidence of Burns : Incidence of burns could be due to building catching fire, clothes worn catching fire, inflammable liquid fire explosions, industrial furnace burns, etc.
There are different types of classification : Dupuytren’s classification • Heba’s classification • Modern classification.
Effects of Burns : Scarring is usually more with burns due to dry heat. It would be present in cases involving dermis. Burns involving only epidermis will heal without scar formation. Keloid formation is more common with corrosive burns. Curling’s ulcer is a rare sequel of severe burns, seen in the duodenum. It is due to tissue hypoxia and capillary endothelial damage.
Classification of Burns
Superficial Burns : These burns are usually red, moist and very painful. The outermost layer of the skin is involved (the epidermis) and there may be blisters present. Healing generally occurs within 7-10 days with minimal or no scarring.
Partial Thickness Burns • Mid-dermal: The outermost layer of skin is lost, as well as parts of the dermis (the next layer of skin). The burn is pink in colour, with small white patches. The skin still blanches on pressure and is painful. Healing occurs in 7-14 days depending on the degree of skin destruction. Some mild pigmentation or scarring may result.
Deep-dermal burns: Here there is deeper dermal destruction. The burn appears white and does not blanched on pressure. The skin is less sensitive and takes a longer period of time of heal, with scarring.
Full Thickness Burns: Full thickness burns extend deep down into the dermis. The burn is leathery, ranges in colour from white/grey/black and is non-painful. There is loss of sensation and it does not blanch on pressure. Healing occurs from around the edges of the surrounding skin but the process is slow, with scarring and contracture.
To estimate degree of burn there is a rule called rule of nines, which helps in estimating fluid loss, shock, etc. Under this, the body is divided into different areas, each representing 9 per cent. When surface area involved is more than 20 per cent the fluid loss is marked, resulting in shock and usually, involvement of 30 to 50 per cent is fatal. Table below present the idea of estimating the percentage of body surface area involved in burns. Lund and Browder chart for children is useful to calculate body surface area in which age of victim is an additional factor incorporated. ‘Rule of nines’ is used to calculate the body surface area burnt in an adult. This does not apply to infants whose body proportions are different from adults. Recently, computer-based software have been introduced with colour coded calculation and instant resuscitation guide.
Anatomic areas Percentage of body surface
|
Head and neck |
9 |
|
Right upper limb (Arm) |
9 |
|
Left upper limb (Arm) |
9 |
|
Right lower limb (leg) (Front and back) |
18 |
|
Left lower limb (leg) (Front and back) |
18 |
|
Anterior trunk (Thorax and abdomen) |
18 |
|
Posterior trunk (Thorax and abdomen) |
18 |
|
External genitalia/perineum |
1 |
Causes of Death in Burns: ( 1st few hours)
Shock
• Primary (neurogenic) due to—fear, severe pain, injury to vital organs leading to death within 24 to 48 hours
• Secondary (vascular) due to loss of serum from burnt area— developing depletion of blood volume and hypovolaemic shock, leading to death within 24 to 48 hours.
Coma: Coma due to congestion of brain and serious effusion into ventricles. Asphyxia: Suffocation due to the inhalation of smoke or gasps of combustion.
Asphyxia may also be caused by pressure on the chest due to falling roof, beams, walls, etc. when a house is on fire.
Causes of Death in Burns: ( within few days)
Inflammation of Internal Organs :These are inflammation leading to meningitis, peritonitis, pneumonia, bronchitis, pleurisy, enteritis, and Curling’s ulcer in the duodenum.
Gangrene: Complications connected with the ulcers produced by burn such as gangrene, erysipelas, tetanus, profuse haemorrhage on separation of slough, etc.
Exhaustion: Exhaustion due to severe pain and dehydration from loss of fluid.
Sepsis : Septic absorption occurs from excessive suppuration. Suppurative case death may occur by 5 to 6 weeks or even after a longer time. Pseudomonas is most common organism responsible for infection and sepsis in turn.
Toxaemia: Toxaemia occurs due to absorption of histamine formed as a result of combustion of tissue.
Hepato-renal Syndrome: In every case of burns of any severity, absorption of altered protein occurs and this in turn leads to cellular damage to liver and kidneys (acute tubular necrosis). Heart may also undergo similar damage.
Non- fatal burn injuries
Scalds are trauma resulting from the application of moist heat commonly involving only superficial layers of the skin. Moist heat is generated in the following forms: a) Hot water or oil or any liquid at or near boiling point b)Superheated industrial steam.
Clinical Features: Usually the scalded area presents a swollen, vesicated and bleached appearance. Since the clothing worn cools faster, the scalding effect is usually less prominent in clothed areas. Likewise, the temperature of the moist heat cools gradually as it disperses all around from the point of contact producing maximum damage at point of commencement. However, clinically scalding is classified into three degrees: i. Erythema, ii. Vesication, and iii. Necrosis of dermis
Medicolegal Importance • Usually scalds are accidental due to splashing or pouring of fluids while cooking or bathing, etc. The accident is common in children or in elderly. Boiling water may be thrown with malicious intent. Deliberate scalding by hot water is common in child abuse. However, suicide and homicide by scalding is extremely rare.
Medicolegal importance of burns
1. Identification of the deceased—Though identification of the deceased is difficult when the body is completely burnt, following may be helpful:
• Metallic objects on the body like rings, bangles, keys, etc.
• Sex of the deceased: Prostate and nulli-parous uterus will not get burnt even at very high temperature and could help in sex identity.
• Age of the deceased: Usually established by the teeth and ossification of the bones.
2. Whether the burns are antemortem or postmortem can be differentiated.
3. Whether the burns are the cause of death or not can be determined . Following two factors confirm burns as cause of death:
• Presence of carbonaceous or soot particles in the respiratory tract mixed with mucoid secretions.
• Cherry red discolouration of blood due to carboxyhaemoglobin.
4. Whether the burns are suicidal, accidental or homicidal can be judged.
7. Dead body of victim may be burnt after death to conceal homicide.
5. Self-inflicted burns for false accusation—these burns are usually seen on accessible parts of the body.
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