Thermal injuries

Burns & Scalds

 Burns & Scalds
• Burn is an Injury which is caused by
application of heat, chemical substances to
external or internal surfaces of body causing
tissue destruction.

• Scald is Injury from application of hot liquids

or steam.
 Duration of exposure of heat
• 44 deg C is minimum temp required to be
applied for 6h to produce 2nd deg – 3rd degree
burns.
• At 65 deg C only 2sec required to produce
burns.
• > 70 deg C - Instantaneous
• Between 44 to 51 deg C – For each 1 deg C
increase the duration to produce burns will
decrease by half
 Classification
Dupuytren’s Wilson
1st degree Erythema 1st and 2nd of
2nd Blisters. Burn confined to epidermis. Dupuytren’s
degree Complete healing with no scar
3rd degree Upper layers of dermis. (Pap layer). 3rd and 4th of
Pain max. Dupuytren’s
4th degree Whole dermis destroyed. Painless.
Healing with scar formation.
Contraction of scarred area and
disfigurement
5th degree Muscles destroyed 5th and 6th
6th degree Upto bones of
Dupuytren’s
 Causes of death in burns
Early
• Hypovolemic shock
• Accidents during the incident
• CO intoxication
• Edema upper airway
Late
• Biochemical disturb, Secondary shock, Toxemia
• c/c of burns – Gangrene, pyemia, tetanus, Septicemia
• Pulmonary edema, Pulm embolism, ARDS
• ARF, free radicals
 Look out for
• Smell for kerosene, petrol or any other
peculiar smell.
• Clothes, hair preserved sent for examination
• CO/Cyanide levels if incident happened in
closed space
• Crow’s feet
• Pugilistic attitude – Attitude adopted by the
body after severe burns. Coagulation of
proteins, dehydration and contracture.
 AM and PM burns
• Line of redness
• Vital reaction – Marked inflammatory reaction
• COHb
• Soot in airways below
• Blisters – Base red and inflamed. Contain
exudate rich in proteins and chlorides.
Surrounding hyperemia.
• Enzymes – Peripheral zone of burns
 Age of burns
• Immediate – Erythema
• 1 hr – Vesication
• 6 hrs – Epidermis – Coagulated, thinned out. Cells in deeper
layers elongated with the long axes at right angles. Dermis
– Inflammatory reaction starts with PMN
• 12-24h – Exudate drying
• 36 hrs – Pus
• 2-3 d – Dry brown crust
• 4-6 d – Superficial slough falls
• 2 wks – Deep slough falls
• 2-3 wks – Granulation tissue
• Wks to mths - Scar
 Flash burns
• Explosions
• Ignition of highly inflammable liquids or gases
• Sudden ignition of fine particulate matter

• Only on exposed areas of skin

• 1st or 2nd degree burns.
• Uniformity in depth
 Treatment burns
• Wash with running water
• Cold water compresses for analgesic effect
but not ice application
• For chemical and eye burns, copious amount
of water
• Plastic (cling) wrap after cooling
• Pain: Paracetamol 20-30mg/kg; Morphine iv –
0.1 mg/kg in titrated boluses
 Treatment
• Airway assessment
• Immediate intubation/ASAP
– If oropharyngeal burns, singed nasal hairs, stridor,
hoarseness, black sputum, respiratory distress,
significant neck burns, facial swelling
• > 10% BSA – Burns fluid resuscitation
• > 10% Deep partial thickness or full thickness
burns – start feeding within 6-18 hrs.
• > 15% BSA or significant perineal burn – Urinary
catheter
 Treatment
• Fluid resuscitation - Modified Parkland
formula
• 3-4mg/kg/%BSA/24hrs
• ½ in first 8hrs
• ½ in next 16 hrs
 Treatment
• Closed dsgs
• Do not disturb blisters which are small, not
near a joint, not obstructing dsg
 Scalds
• From application of hot liquids (sticky and
nonsticky) and steam
• Can occur through clothing with no damage
to clothes
• Immersion burns
• Splash or spill burns
• Steam burns
 Scalds
• No blackening or charring.
• Evidence of splashing or trickle marks
• No significant scarring or contracture
• Death rare unless extensive scalding
 Scalds classification
• First deg – Reddening
• Second deg – Blister formation
• Third deg – Drying and dessication of deeper
tissues
 Dry heat (Burns) Moist heat (Scalds) (Chemical burns)
Cause Flame or heated solid Liquid > 60C or steam Chemicals like
substance corrosives
Site At or above At orbelow At or below
Edges Sharply defined Sharply defined
Splashing & Absent Present Present
Trickling
Skin Dry, wrinkled, charred Sodden & bleached Destroyed
Vesicles Around the burnt area In the burnt area May be present
Line of redness Present Present Absent
Charring Present May be present
Singeing Present
Ulceration Present
Healing Think and contracted Less scarring Thick &
scar contracted scar
Clothes Not burnt Stains
Scene of crime
 Heat hematoma
• Parieto temporal along sagittal sinus
• Diffuse
• D/t expansion of blood in diploe or rupture of
dural sinuses
• Soft, friable, light chocolate or pink in color.
Honeycomb appearance
• EDH is rubbery, shiny, reddish purple
Heat hematoma
Heat rupture
 Electrocution
• Injury or death by electric current passing
through the body
• 2 types of current
• AC and DC
• AC is more dangerous due to tetanic
stimulation
• AC of about 70 mA can be fatal compared to
DC of 200 to 250mA without much damage.
 Joule burn
• Electric burn at the point of entry
• Resembles size and shape of source causing it
• Generally, round or oval, shallow crater
surrounded by ridge of skin 2-4mm high. Floor
has pale flattened skin with surrounding
hyperemic zone.
 Deaths from electrocution
• VF
• Respiratory failure
• Cerebral anoxia
• Delayed death from complications of burns
• Blunt trauma
Spark burn
Crocodile skin
 Lightning
• Discharge of electricity
• Charge jumps between clouds to earth it is
lightning strike
• 1000MV → 20000A → 20000 deg C
 4 different ways
• Direct strike – Strikes the Victim first.
Flashover effect ; Metallic objects
• Splash – Victim preferred over nearby object.
Strikes victim on its way to the ground
• Ground strike – Lands near the victim and
conducted thro the victim from the ground
• EMP – from close strikes
 External lesions
• Linear burns
• Filigree or Lichtenburg figures (Arborescent
burns)
• Surface burns
Filigree (lichtenburg)