BURNS

Definition :
• Burn is an injury caused by application of heat
or chemical substances to the external or
internal surface of the body, which causes
destruction of the tissues.
• Microscopically , the epithelial cells are
elongated and flattened and stain more deeply
with haemotoxylin.
• The minimum temperature for producing burn
is about 44oC for an exposure of about 5-6
hours.
• At 65oC , two seconds are sufficient to produce
burns and full thickness destruction of skin
occurs within second above 70oC.
 Characteristics/ Types of Burns
• 1 Contact burns : physical contact
between the body and hot object , like
heated solid or molten metal.
When applied momentarily, it produces
a blister with erythema corresponding to
the shape and size of the agent. It will
cause destruction ,or even charring of the
parts, when kept in contact for some time.
• 2. Flame burns : there is actual contact of
the body with the flame . It may produce
vesication , singeing of the hair and
blackening of the skin. Hair singed by
3. Burns caused by kerosene oil, petrol etc.
are usually severe and produce sooty
blackening of the parts and have
characteristic odour .
4. Burns caused by explosions in coal mines
or of gunpowder are usually very extensive
and produce blackening and tattooing due to
driving of the particles of the un exploded
powder into the skin.
5. Burns due to X-ray and Radium vary from
redness of skin to dermatitis with shedding of
hair and epidermis and pigmentation of the
surrounding skin. Severe exposure may
produce burns with erythema, blistering or
6. Burns caused by ultraviolet rays produce
erythema or acute eczematous dermatitis.
7. Radiant heat burns are caused by
heatwave , a type of electromagnetic wave.
8. Microwave burns are well demarcated , full
thickness burns.
9. Chemical burns : Classified into acids ,
alkalis and vesicants ( blister forming ).
Characteristically , there is ulcerated
patches, no blisters, hairs is not singed and
red line of demarcation is absent.
9. Electric and lightening burns.
10. Scalds : they are caused by contact with
hot liquids, most commonly water and
Chemical burns
Sun burn due to ultra violet
rays.
 Classification
• Burns can be classified in many ways but two
classification are given in table
Degree of damage Dupuytren’s Wilson’s
•
Erythema 1 degree Epidermal

Vesication with blister 2 Epidermal

formation
Destruction of superficial 3 Dermo-
skin Epidermal
Destruction of the whole 4 Dermo-
skin including dermis Epidermal

Destruction of deep fascia, 5 Deep

muscles
• Dupuytren divided burns into six degrees
but they are merged into 3 degrees by
Wilson . The precise depth of a burn can
be measured by high frequency ultrasound
device.
Presently the classification used is :
First Degree ( Superficial )Burns involves
the epidermis only. Red / Pink in color ,
blanches , painful to stimuli such as touch
or pin prick and no blisters . Sunburn is the
most common first degree burn seen in
temperate countries . Healing occurs in 3-
6 days with skin peeling and no residual
First Degree burn
• Second Degree ( Partial or deep partial
) : involves the epidermis and variable
depth of the underlying dermis . Deep red
in color , blanches or slow blanching , very
painful, blister present , moist in
appearance and may heal by scar
formation in 3 weeks .
• Third degree (Full thickness ) burns :
involves structures deeper to dermis .
Waxy white , gray or charred and black in
color , no blanching , painless ( due to
destruction of nerve endings), no blisters ,
dry or leathery appearance. Spontaneous
regeneration of skin will not occur and
such burn require skin grafting.
 Effects of burns
• Effect will depend upon factors like :
1.Degree of Heat Applied : Effects are
severe , if heat applied is great.
2. Duration of Exposure : More
prolonged the exposure , more
severe will be the effect as burning of
human skin temperature and time
dependent .
• 3. Assessing the Size : The total body
surface area (TBSA) involved is usually
worked out by the Wallace Rule of Nine
wherein each upper limb is 9 % of TBSA ,
9% each for front and back of lower limb ,
9 % for front and back of chest , 9% for
front and back of abdomen , the head and
neck 9% and 1% for perineum.
• The patient’s own hand is 1% TBSA and
is useful guide in small burns.
• When burn surface involves 1/3rd of the
body surface area or more ( usually 30-
• In children less than 5 years: head and
neck 15% , each lower limb 15% and for
rest as a adult.
.
4. Site : Burns of the head and neck , trunk
or the anterior abdominal wall are more
dangerous.
5. Age : Children are more susceptible , old
people less.
6. Sex : Women are more susceptible
 Cause of Death
• Immediate cause :
1) Primary or neurogenic Shock : Due to
pain and fright.
2) Asphyxia : Suffocation may result from
inhalation of the CO, CO2, Cyanide (
produced from burning of material
containing nitrogen compound such as
polyurathane in vinyl, wool or nylon ) .
CO poisoning is an important cause in most
of the fire deaths.
Smoke or Heat induced laryngospasm ,
respiratory arrest or vagal reflex caused
cardiac arrest are the other proposed
• Delayed Cause :
1. Hypovolemic , burns or secondary
shock : more than half of the deaths
occur due to secondary shock within 24-
48 hours due to loss of fluid and protein ,
causing decrease in cardiac output and
multi-organ failure.
2. Acute edema of glottis : occurs from
inhalation of irritant smoke or hot gases
with or without pulmonary edema
.Respiratory failure ( inhalation injury,
pneumonia, ARDS) is also a significant
3. Toxemia due to absorption of toxic
products from the burnt surface . Death
occurs in 3-4 days .
4. Sepsis : Most important cause of
death ,ocurring in 4-5 days or longer after
burn . Septicemia can caused by burn
wound infection ( e.g. Pseudomonas
aeruginosa and other Gram-negative
bacteria , Staphylococcus aureus)
pneumonia , UTI following catheterization
, infected IV lines and infection of the skin
donor site .
5. Infective complications : Bronchitis ,
 Remote causes
1. Complications : Anorexia , hematemesis,
indigestion , respiratory complication or
melena.
2. Suppurative Discharges from burn
areas lasting for weeks or months can
result in disease of the internal organs and
death .
3. Gangrene , tetanus ,anemia, edema of
dependant parts and jaundice .
 Post mortem Appearances
• External Findings :
1. Clothing : should be carefully removed
and examined for presence of kerosene,
petrol or may be other inflammable
substance.
2. Site , distribution and extent of burning
are recorded. Distribution is important in
the analysis of whether the burns are
appropriate for the position in which the
body was found.
3 . Face : usually distorted ,swollen. Tip of
the tongue is usually burnt as it protrudes
due to contraction of the tissues of the
neck and face .
There may be absence of burns and / or
soot deposits in the corners of the eyes
and incompletely singed eye-lashes.
In charred bodies the corners acquire a
white translucency and lenses became
opaque.
4. Skin : Owing to the effect of heat on
blood, the veins stands out , giving a
5. Post mortem staining is cherry red in
color from the presence of Carbon mono
oxide , if the individual was alive and
breathing during fire.
6. Kerosene oil burn gives characteristic
odor and sooty blackening of the parts .
7 Blisters , either ruptured / collapsed or
filled with fluid may be seen
8. Degloving may be seen due to cuticular
peeling .
9. Hair may be singed or partially /
completely burnt.
Singed hairs looks curly/ clubbed at its tip
10 . Pugilistic attitude ( boxing,
fencing or defence attitude ) :
It is due to heat stiffening . The legs are
flexed at the hips and knees , the arms are
flexed at the elbows and held out in front
of the body and fingers are hooked like a
claw .
Cause :
Due to coagulation of proteins of muscles
and dehydration which causes contraction
.
Flexor muscles being bulkier than
11. Heat Ruptures :
These are splits occurring in the skin due to
contraction of the heated and coagulated
tissue and the resultant breaches may
simulate incised or lacerated wounds . It is
seen over the area of severe burning , over
flashy area , like calves and thighs and
over extensor surface and joints .
They can be differentiated by :
1) Absence of bleeding in wound and
surrounding tissues , since heat coagulates
the blood in vessels.
2). Intact vessels and nerves are seen in the
floor.
3). Irregular margins
 Internal findings
1. Skull : heat hematoma : is an artifact
and has the appearance of extradural
hematoma
it is large , thick ( about 1.5 cm) and
contains 100-120 ml of blood.
Cause : the blood may come from the
longitudinal venous sinuses or the diploic
veins . The heat may force blood out of
the marrow of the calvarium through
veins and out over the surface of the
dura.
Skull bones may be fractured and burst
2. Brain : Congested and appear swollen
with widening and flattening of the gyri and
obliteration of the sulci due to the
contraction of the coagulating dura against
the surface of the brain. Subdural
hemorrhage may be present.
3 . Neck : Hemorrhage at the root of the
tongue and neck muscle- considered vital
reaction in the burn victims.
4. Larynx trachea and bronchioles :
contains carbon and soot particles and
mucosa is congested with froathy mucous
secretions . This is suggestive of the
6. Lungs : congested and edematous and
may be shrunken.
7. Heart : Chamber full of blood , cherry red
in color due to inhalation of the CO.
8. Stomach and intestine : Stomach may
contain carbon particles impregnated in
the mucous membrane . It may be red in
color . There may be inflammation and
ulceration of Peyer’s solitary glands of
intestines.
Curlings’s ulcers may be seen in severely
burnt patient’s gastric antrum and first part
of duodenum after 72h. It develop due to
mucosal ischemia as a result of stress and
9. Spleen : Enlarged and softened.
10. Liver : Cloudy swelling and fatty liver or
necrosis of the cells , if death is delayed .
Jaundice may occur.
11. Kidney : shows signs of nephritis ,
thrombosis and infarction.
12 . Adrenals : Enlarged and congested.
The prolonged exposure of the body to high
temperature
 Age of burns
Features Age
1. Redness • Immediate
2. Vesication • 1-2 hours
3. Exudate begins to dry • 12-24 hours
4. Dry brown crust formation • 48-72 hours
and pus formation
5. Superficial slough • 4th-6th day
separate • 15th day
6. Deep slough separate • > 15 days
7. Granulation tissue begins • Several days.
to cover
8. Formation of cicatrix and
 Difference between Ante-
mortem burns and Post mortem
Features Ante - burns
mortem Post mortem
1. Line of redness Present Absent
2.Vesicles Contain serous fluid, rich in Contains Air , it
albumin , chloride and some contain little albumin
polymorph. and no chloride
3. Inflammation & repair Present along with pus and Nil
Slough
4. Soot in upper May be present Absent
respiratory tract
5. Base of the vesicles Red and Inflamed Dry, Dull, hard and
yellow
6. Carboxyhemoglobin Present Absent
7. Enzyme Reaction Peripheral zone of burn show No such Increase
increase in enzyme reaction
8. Healing Granulation tissue seen in old Absent
cases
•Whether the burns are
Suicidal
Accidental
Homicidal
Self inflicted ?
 Suicidal burns
• Suicidal burns are common among Indian
women . They pour kerosene on their head and
clothes before setting fire to themselves .
• Classic religious example were seen in certain
Buddhist sects or the rites of ‘Sati’ performed
in some parts of the India ( now prohibited).
 Accidental burns
• Are common in children and elderly
persons .
• Accidental kerosene stove bursting is also
reported.
• Accidents may result from smoking in
bed, especially under the influence of
alcohol or drugs , using usually faulty
equipments and playing with fire.
 Homicidal burns
• They are quite common in India. Custom of
dowry leads to young brides being murdered
by pouring kerosene on them and setting them
on fire by the husband and in laws and later
claimed to be accidental burns.
• Sometime a homicide victim may be burned to
conceal murder by means in an attempt to
cover up or destroy the evidence.
 Self inflicted
• Burns are sometime self inflicted in order to
support a false charge.
 SCALDS
• Definition : A scald is an
injury which results from
application of liquid > 60 o C
or from steam , and involves
only the superficial layers of
skin.
 Types
• It is of three types :
1. Immersion burns : Accidental or deliberate
immersion in hot liquid , usually water.
2. Splash or spill burns : usually accidental.
3. Steam burns : Exposure to superheated steam.
• Hot water account for most of the immersion or
splash burn.
• Scald show sharp demarcation with tickle marks ,
soddening or bleaching , but do not singe the hair or
blacken or char the skin.
 Clinically it is classified into three types :

1. Erythema or reddening by vasoparalysis.

2. Vesication or blister formation due to
increased permeability of the capillaries.
3.Necrosis of dermis when deeper layer of
skin is involved.
Differentiation : Dry Heat , moist Heat and Chemical Burns
Feature Dry Heat Moist Heat Chemical Burns

Cause Flame , Heated body Steam or liquid > 60 Corrosive

Site At or above the site of At and below the site At or below the site
contact of contact of contact
Splashing Absent Present Present
Skin Dry, wrinkled and may be Sodden , Bleach Corroded and
charred devitalized.
Vesicles At the circumference of Over burnt area Usually not present
the burnt area
Red Line Present Present Absent

Color Black Bleached Distinctive coloration

Charring & Present Absent Absent

Singeing
Scar Thick and contracted Thin, less contracted Thick and contracted.
 Medico- legal Aspect
• It is usually accidental due to splashing or
pouring of fluid during cooking .
• Accidents are common in children and in the
elderly.
• Boiling water may be thrown intentionally,
usually domestic homicide intent with the
husband being the victim
• Deliberate scalding by hot water is common
form of child abuse, dipping injuries of limbs
appear as well demarcated ‘glove and
stocking’ distribution of scald reflecting the
flow of hot liquid under the influence of
gravity. Areas of scalding round the buttocks
with clear , unaffected areas on the upper
 ELECTRICAL INJURIES (
Electrocution)
• Electricity exert two major effects on
body :
1. Cellular depolarization of nerves
and muscles and
2. Heat production.
 Factors which determine the
consequent pattern of electrical
injury include :
• 1. Kind of current : Alternating current is 4-5
times more dangerous than the direct current
( DC).
At low amperage, AC causes tetany within the
flexor muscle of the hand and forearm and
hence patient is unable to release the device
untill the power is cut-off. It also interfere with
normal cardiac pacing causing cardiac arrest.
In contrast, DC tends to cause a single muscle
contraction, throwing the victim and resulting
in shorter duration of the exposure to
2. Amount of current :
The flow of the current through body is great
, if the voltage is high ( more than 1000
volts) or if resistance is low.
Electrocution is rare at less than 100 volts,
and more deaths occur at more than 200
volts. In India , the voltage of domestic
supply is usually 220 to 240 volts ,
alternating current with 50 cycle per
second .
3. Path of the current :
death is more likely to occur , if the
• Duration of current flow : Severity is
directly proportional to the duration of current
flow . For an electric shock to occur , the
body must be in contact with both the positive
and negative pole or earth .
the earth may be any object not insulated
from ground . When earthing of body is poor
as with dry and rubber shoes , carpets,
wooden floor , fatal electrocution is
uncommon.
The effect of electricity depends on the voltage
and resistance offered by the body . If the
body is well insulated , it does not conduct
the current and no harm result.
 Effects due to passage of
•
electricity
Electrical Injuries are divided into low tension
and high tension injuries :
1. Low tension injuries : Skin burn result
from the heating of the tissues by passage
of electric current . Most common sites of
the low voltage electric contact injury are the
hands ( entry) and that of grounding ( exit) is
the foot or opposite hand .
2. High tension injuries : Burns may be
severe with confluent area of third degree
burns or charring of body. There can be
massive destruction of tissue with loss of
extremities and rupture of organs.
 Characteristics of Injuries :
• Local effects :
1. Burns and blisters : Characteristically ,
there are seen as puckering of the skin
around the edges of the burn .There is no
red line surrounding the burn or
reddening of the base at the point of entry
and exit.
Joule burns , also known as electric
burns /mark is specific and diagnostic of
electric burns and is found at the point of
entry.
 Joule burns
• These marks are round or oval or irregular
, chalky white shallow centrally collapsed
blister , from few millimeters to 1-1.5 cm in
diameter and have raised border of about
1-2 mm around , part or the whole
circumference .
• THE Crater floor is lined by pale flattened
skin .there may be mild hyperemia of the
adjacent intact skin , due to rapid dilatation
of pre- capillary vessels.
• The blister is created by the steam
produced in the heating of the tissues by
electric current, the so called endogenous
burns . When the current ceases, the
blister cools and collapse to leave a crater
with raised rim
• When contact is more prolonged , skin
mark become brown and further contact –
 Exit marks
• Variable in appearance , but some
features are those of the entry mark .
Often seen as split in the skin at points
where the skin has been raised by
passage of the current
• In high voltage current , the exit often
appears as a ‘blow out’ type wound.
 Flash or Spark burn
• Where the contact is less firm , so that an
air gap exist between skin and conductor ,
the current jumps the gap as a spark and
causes the outer skin keratin to melt over
small area . On cooling the keratin fuses
into a hard brownish nodule , usually
raised above the surrounding surface so
called Flash /spark burn.
• In high voltage burns, such as those
sustained from high tension grid
transmission cable , sparkling may occur
over many centimeters . It causes
numerous individual and confluent areas
• Flash burns are also called exogenous
burns as the flame is produced outside the
body. The flash can ignite the patient’s
clothes causing flame burns along with
singeing of the hair .
• Wounds :
-There will be lacerated or punctured with
contusion of the margins.
-The heat generated at the site of entry may
cause atomization of metallic wire which may
give a metallic lustre.
-Small balls of molten metal derived from the
metal of contacting electrode, so called
current pearls, may be carried deep into
tissues, which can be identified by Scanning
electron microscopy.
-Heat generated by current may melt the
calcium phosphate which is seen in X ray of
limb as typical round dense foci known as
 Systemic effects
1. Immediate death from shock .
2. CNS : Hemiplegia or paraplegia ,aphasia,
headache, vertigo and convulsions.
3. Eye : Cataract, optic atrophy and coroido-
retinitis may occur . In case of close range
of electric flash , singeing of eyelashes
along with first degree burn of the skin of
face may occur
4. Pulseless , hypotensive , loss of response
to external stimuli , cold and cyanotic and
without respiration – suspended animation
 Cause of death
Ventricular fibrillation ( low voltage current)- most
common cause.
• Less commonly paralysis of respiratory muscles
(asphyxia) and rarely direct effect on the brain
stem as a result of current passing through the
head and neck.
• Inhibition of respiratory centre , electro-thermal
injury or ventricular asystole.
• Secondary cause : complications like, infection or
septicemia or from mechanical injuries, like fall
from height.
 Post mortem findings
• Before autopsy , it is important to examine the scene
and the tools, appliances or machinery involved in the
incident .
• Examination of entire body, particularly the hands and
especially for fingers and shoes of electrical burns is of
utmost importance.
• External :
1. Face is pale , eyes are congested and pupils are dilated .
Patechiae are seen eyelids and conjuctiva.
2. Rigor mortis appear early and dark blue red post
mortem staining is well developed.
3. Joule burn at the site of entry.
 Internal
1. Lungs : congested and edematous .
2. Heart : Focal necrosis with variable hemorrhage
and acute contraction bands in myocardium and
conduction system may be seen .
3. Brain, meninges and parenchymatous organs are
congested.
4. Patechial hemorrhage may be found along the
line of passage of current , under the
endocardium, pericardium , pleura brain and
spinal cord.
 Medico legal importance
• Deaths are usually accidental. Suicides are rare
and homicides are even rarer.
• Iatrogenic accidents may lead to charge of
negligence.
• Traumatic injury may be sustained from
electric shock itself electro convulsive therapy
in treatment of mental disorder.
• It is not possible to differentiate between ante-
mortem and post mortem electric burns.