Burn Injuries and Its Medicolegal Importance in Indian Scenario

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Burn Injuries and Its Medicolegal Importance in Indian Scenario
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Volume 3, Issue 2, May-August, 2020.
Burn Injuries and Its Medicolegal Importance in Indian Scenario

Swaroop Sonone1, Mayuri Kumari2, Ashwini Kumar3
1M.Sc. Forensic Science, Government Institute of Forensic Science, Aurangabad,
Maharashtra, India
2Dept. of Forensic Science, School of Basic and Applied Science, Greater Noida, U.P,
India
3Department of General Surgery, Nalanda Medical College and Hospital, Patna, Bihar,
India
_________________________________________________________________________________
Abstract
One of the sensitive and sophisticated crime scenes is burning cases, and it is the critical
evidence of injuries in such cases. Burn Injuries are the most violent types of injuries and are
not at all easy to analyse. It constitutes a severe psychological, medical, and public health
problem. It occurs due to mechanical products, electrical and thermal, etc. have a high impact
on skin. Burning accidents amongst Indian Scenarios is very dynamic, as in most Dowry Death
cases, burn injuries are involved. Burn analysis can give answers to ‘Modus Operandi’ of
crime. Burns on the individual, whether living or dead, has a great significance in the criminal
investigation. Commonly cases involving burn injuries sent for Post Mortem examination.
Determination of Antemortem or Post-mortem burns is one of the most crucial tasks in Arson/
Burn Cases. To find out whether a person sustained all burnt injuries or have died due to fatal
conditions is a vital job. The various terms are casting as of Burnt after death, but in reality, it
is not valid. Humans are good at disguising and manipulating evidence, and one must not
easily believe what he sees. These differences in Antemortem & Post-mortem helps in
determining Culprit and his way of action. It may also showcase the intentions behind any case
of burning caused.
Keywords: Burn Injuries, Antemortem & Post-mortem Burns, Arson, Burning Cases, Degree
of Burns.
______________________________________________________________________________
Introduction to the skin or other tissues and these are the

most severe form of trauma that has
The standard definition of burn is a type of afflicted humanity since ancient time and
thermal injury, caused by heat, cold, that over the years the scientific revolution
electricity, chemicals, friction, or radiation has upgraded the results in its treatment.
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Burn injury is caused due to the application 2. Moist heat (scalds): Scalding is a form of a
of heat or chemicals on the skin. It is the thermal burn resulting from heated fluids
fourth common type of trauma in the world, such as boiling water or steam. It can be
following interpersonal violence, falls, seen in the 2nd or 3rd-degree burns. It is
traffic accidents [1, 2]. According to WHO, caused by the application of liquid or near
an estimated 180 000 deaths every year are boiling point or from steam. In these cases,
caused by burns – the vast majority occur only superficial layers of the skin are
in low- and middle-income countries [3]. affected. Vesication (blisters) is an
Non-fatal burn injuries are a leading cause essential feature of this injury. It can be
of morbidity. In developed countries, fatal injury as the tissues and cells of the
accidental burns with residential fires are skin are completely exposed to these
10% of all unintentional death toll, and it is injuries [6,7,8].
the common thing [4]. Burn injuries affect 3. Chemicals: Mostly chemicals are of
not only the physical condition of an corrosive nature, which can cause burn
individual but also shakes the injury to the human skin. The application of
psychological state of mind. Burn injuries chemicals causes these corrosives burns.
are one of the most painful and severe in They produce inflammatory redness of the
treating the patients. Burn injuries are skin, ulcerated patches of skin,
painful to examine as the victim is in discolouration, and staining of skin and
critical condition due to deeper burns. clothing and the presence of the chemical
Sometimes the victim is burnt after death; in the stains. Blackening or tattooing of
to differentiate between antemortem and skin is seen when chemical injuries are
post-mortem wounds, one must need present [6,7,8].
sufficient knowledge of burns [5]. 4. Electrical burns: Human body is a good
conductor of electricity and gives a severe
Reasons for Burn Injuries injury in terms of burning. Electric shock is
1. Dry heat: Dictionary meaning of dry heat responsible for the burning of skin when an
is hot temperatures with little moisture in electrical conductor comes in contact with
the air. It is caused by the application of hot the skin; it carries the charge and helps in
substances, by flames which can cause flowing all over the body. Higher the
simple burns. Generally, whitening of the charge greater will be the damage to the
skin can be observed when contacted with organs. It is caused by electrical contact,
dry heat. On direct contact, such materials electric spark, flashes of lightning. Injury
produce a blister, and if kept in touch for a can be caused when the skin is in
longer time, they provide roasting and connection with the stable electrical source.
charring of the body. An injury produced Lightning can cause severe burns on
by the flame caused roasted patches of skin healthy human skin. An average bolt of
or more in-depth parts of the body, singeing negative lightning carries an electric
of hair or clothes, and deposited of current of 30,000 amperes (30 kA) and
carbonaceous material on the body [6,7,8]. transfers 15 coulombs of electric charge

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and 1 gigajoule of energy. One can imagine 2. Second Degree: These burns are as in-
the effect of this much current in the human depth as compared to the first degree.
body [6,7,8]. These are caused by the prolonged
5. Radiation burns: Main cause behind application of flames of liquid much above
radiation burns are thermal radiation, the boiling point of water. The skin is
radiofrequency energy, ultraviolet light, blackened, hairs are slightly burnt, painful
and ionizing radiation by X- rays, radium, blisters can be seen, which lasts for a few
laser, microwave oven. X-rays and radium days. No scars are left on healing, but slight
produce redness of the skin. Shedding of staining may see when one carefully
hair & pigmentation is also observed in observes [9].
exposure to X-rays. Severe exposure may 3. Third Degree: It is commonly known as
produce burns with erythema, blistering or full-thickness burns. This burn is
dermatitis, or ulceration. Ultraviolet rays responsible for the destruction of dermis
produced by sun and mercury vapour lamps and epidermis layers. It occurs in blister
cause erythema or acute eczematous formation with a red line. They ulcerate and
dermatitis. Microwave burns are well- may get infected. These are extremely
demarcated, full-thickness burn without painful to suffer. They heal with leaving the
charring. These can be acute as well as fatal formation of a scar [9].
[6,7,8]. 4. Fourth Degree: From this degree, the
6. Non-Accidental burns- Burns like injuries get deeper and deeper. The whole
Cigarette burns, child abuse, self-burning, thickness of the skin is involved. Damages
bride burning, torture, can be categorized may be found in the bones, tissues, and
into non-accidental wounds for the cause of tendons also. These are not much painful
burn injuries. A motor vehicle burns, owing to the destruction of nerve endings.
machine breakage can also be considered in Fourth-degree burns can have serious
this cause [6,7, 8]. consequences. These are usually followed
by sloughing after some days [9].
5. Fifth Degree: Oxygen reacts with the skin
Classification of Burn Injuries resulting in charring of skin. It involves the
According to the depth of tissue, Dupytren penetration of deep fascia and muscles. It
classified burn injuries into six categories: causes permanent damage to the skin. The
results are high scarring and deformity [9].
1. First Degree: These effects on the outer 6. Sixth Degree: Sixth-degree injuries cause
skin, when low degree heat is applied for a most severe burns, irreversible damage. It
short duration, there occurs erythema or involves the charring of the whole limb,
redness over an area of contact, lasts for a including bones, adjacent tissues, and
few hours to several days. Sometimes organs. Usually resulting in death [9].
redness and swelling can also be observed.
It leaves no scar on healing, and the victim According to the clinical classification –
can fully recover [9].

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1. Superficial burns- If intact skin is degree burns are involved in these burns.
damaged, then this is known as superficial These injuries are not much more profound
burns. 1st-degree burns to 4th-degree burns than the next categories. Skin is damaged,
come under superficial burns. The affected and redness followed with swelling can be
region is of upper skin. They are not as observed [9].
painful as other injuries [8]. 2. Dermo – Epidermal burns - These burns
2. Deep burns– Muscles are involved in these are more profound than epidermal and
burns. Specifically, the injuries are deeper cause injuries to the greater depths. These
in depth. Commonly 5th and 6th-degree burns are painful and can cause blisters
burns are considered in this category. They with whitening of skin after some days [9].
are more prominent and painful than 3. Deep burns- These burns are deeper as
superficial burns [8]. compared to the above two; more
According to Hebra’s Classification - significant destruction is caused to tissue,
muscle, and bones. These burns can be fatal
1. Epidermal burns- As the name suggests,
and may consist of blackening or tattooing
these burns are epidermal. 1st & 2nd-
of skin [9].
Table showing Classification of Burn Depth [6]

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Effect of Burns body, then it can be fatal or dangerous.
Similarly, 6th-degree burn to the head or
Burns can have a severe effect on physiology chest region can prove fatal to the victim
as well as the psychology of human beings. [10].
Burns can cause deteriorate skin cells,
tissues, and organs too. Damage to the skin is Time of exposure – Lower duration of
more significant than any other part. Extreme exposure results in lesser burns. Greater
burning of skin can affect blood arteries and exposure to heat indirectly can also result in
veins. 1st to 4th-degree loss can be reversible fatality [10].
but are different in after effect as some may Surface Area – The surface area is a
leave scars that are present for quite some significant and essential factor in
days. Whereas 5th and 6th-degree burns can determining burn and its treatment. More the
damage bones and muscles, which are surface greater will be the injury in case of
irreversible, and the individual may burning. Body surface affected is measured
encounter serious health problems [10]. by various rules/techniques, some of which
Degree of heat – Greater the degree of heat, are Rule of Nine given by Wallace, Rule of
higher will be the damage. If an individual palms, Lund & Browder for assessing burns
encounters 1st degree burns to the whole in children [10].
Table Depicting the percentage given to the burn area of the body [10]
Total Body Surface Area, i.e., TBSA, is commonly measured by Wallace’s Rule of Nine [10].

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Figure Depicting “Rule of Nine” [11]
Figure Depicting Lund & Browder Chart [12]

When the area of burns is greater than 35%, reduce 1.0% to the head until adult values
then usually it is considered fatal. The use are reached. Rule of palm consists of using
of Wallace’s rule of nine is not done when the victim's palm, which is considered as
children's burns are involved. For the 1% of total body surface area (TBSA), and
accuracy of child burns, the Lund & is used for assessing the burns [12].
Browder method is used. According to the
Age – Infants and elders above 65+ age is
Lund & Browder method in children < 1
more prone to burning cases than
year, the head is 18% of TBSA, and each
remaining individuals [13].
leg is 14% of TBSA. For each year above
one-year-old, add 0.5% to each leg and
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Location of Burns – Location of burns is 1. Pulmonary Edema – Swelling in body parts
also vital as severe burning of hand or palm caused due to burns is responsible for the
cannot result in a fatality, but severe burns death of the victim in 3-4 days.
to the head or chest region can. Face, Head, 2. Chemical Imbalance – Chemical balance in
Chest, and Abdominal regions are the body is disturbed, causing the death of
susceptible to burn injuries [13]. an individual. Electrochemical
disproportion is one of the reasons for it.
Cause of Death 3. Toxaemia - Absorption of toxins in blood
The cause of death is dependent on the can prove fatal. Proper care is needed for a
factors mentioned above. Sometimes burn victim.
instant death can occur due to shock or 4. Kidney Failure – Necrosis can lead to renal
haemorrhage. While in some cases, the failure causing the death of an individual.
victim is treated for longer durations but 5. Ulcerations – Ulcers can form in the
cannot adapt to the situations and results in gastrointestinal tract, stomach, and
death [14]. intestine also, when neglected or left
untreated, can cause death [14].
Immediate Deaths – Death can occur
Ante-mortem & Post-mortem
within a day or two.
Burns:
Reasons are –
If a person may be murdered and heat
1. Primary shock or impact on the brain, heart, applied to the dead body to conceal the
or lungs can cause death. crime. It is crucial to know the
2. Secondary – due to loss of blood, arteries, differentiating features of antemortem from
and veins abrupt openings, or damage to post-mortem burns. The differentiation
liquid connective tissue. Both primary & depends on the presence of a vital reaction,
secondary causes can result in death in 24 as seen by the naked eye or by histological
to 48 hours. examination.
3. Coma – serious injury to the brain causes
coma; this can be a possible reason behind Ante-mortem Burns appearance-
death. ● In antemortem burns, redness (hyperaemia)
4. Asphyxia – the inability to inhale oxygen of the parts is shown, which is the sign of
causes asphyxia. Black smoke, soot vital reactions.
particles, and unavailability of oxygen may ● If Vesication is present, blisters are
cause death [14]. surrounded by a thin bright red line of
inflammation.
Delayed Deaths - these deaths are caused ● They contain highly albuminous fluid,
after a long time of incidence; death occurs chlorides, and blood corpuscles, and when
while treatment is going on. Deaths after 2 ruptured, the base is found to be injected.
to 3 weeks are considered as delayed death. ● When a vesicle contains pus, it means that
Reasons can be – the person has lived for at least 36 hours
after injury.
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Post mortem burns appearance: muscle proteins coagulate, causing them to
become contracted.
There are two types of post mortem burns h) The cracks and fissures resembling incised
appearance: wounds may be seen in line with blood
1. External Appearance– vessels exposed through them.
a) The cloth should be removed carefully i) The charring of the body depends on the
from the body and examined for the degree of post-mortem burns after death.
presence of kerosene, petrol, and other j) Post-mortem staining is cherry red due to
hazardous and combustible substances. the presence of carbon monoxide (CO) if
b) If any other articles such as ornaments, the individual was alive and breathing
metallic rings, etc., worn on the body during a fire.
should be carefully removed and preserved, k) Due to the contraction of the heated and
it may be useful in establishing identity. coagulated tissue skin split, which is known
c) Usually, the face is distorted, swollen with as heat ruptures [15].
tongue protruded out. It may be an absence 2. Internal Appearances-
of burns or soot deposits in the corners of a) In the skull, heat hematoma is caused due
the eyes, which is known as crow’s feet. to rupture of vessels caused by heat with
d) When highly heated solid objects are subsequent escape and coagulation of
applied momentarily, it causes blisters and blood and has specific characteristics. It is
reddening on the skin corresponding to the a soft, crumbly clot, of light chocolate
shape and size of the material used. colour and may pink if the blood contains
e) When heated objects are applied for monoxide. The lump is not uniformly solid,
prolonged, then it causes charring and but spongy and not closely related to the
roasting of skin. For example- explosions site of heat fractures.
in coal mines or by gun powder cause b) The brain is congested and appears swollen
blackening and tattooing of the parts. The with widening and flattening with widening
characteristics of kerosene oils burn are and flattening of the gyri and obliteration of
sooty blackening of the skin and odour. the sulci due to contraction of the
f) The singeing of hair is a peculiar effect of coagulating dura against the surface.
heat, and if singed hair looks curly, then it Subdural haemorrhage may be present.
is highly fragile. c) The haemorrhage in the root of the tongue
g) Pugilistic attitude or Boxer’s attitude or and neck muscles is considered a vital
Fencing attitude is a condition wherein the reaction in burn victims.
body assumes a rigid position with the d) In the larynx, trachea and bronchioles
limbs flexed and resembles a boxer in contain carbon and its soot particles, and
defending the position. All the four limbs the mucosa is congested with frothy mucus
are flexed with a closed fist, the body is secretions due to inhalation of gases.
bent forward, and the skin is tense, However, soot usually disappears by the
leathery, hard, and frequently shows 2nd day of hospitalization. The detachment
splitting. It is caused due to heat, the of the mucosa of the trachea bronchial tree,
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pharynx, epiglottis or oesophagus, and ● When metallic objects on the body like
epiglottic swelling, and it is indicators of rings, bangles keys, etc.
vitality. ● When the prostate and nulliparous uterus
e) The congested and inflamed with severe do not burn even at very high temperatures,
effusion in the pleura. it could help in sexual identity.
f) The congested and edematous may be ● The age of the deceased is usually
shrunken in the lungs. established by the teeth and ossification of
g) The heart chamber fills with blood, and the the bones [18,19].
colour is cherry red due to the inhalation of 2. The two factors confirm death due to burn
CO. are:
h) The stomach may contain carbon particles ● The presence of soot particles or
impregnated in the mucous membrane. It carbonaceous in the respiratory tract which
may be red. There is inflammation and mixed with mucoid secretions.
ulceration of Peyer’s solitary glands of ● The color of blood becomes cherry red due
intestines. Curling’s ulcers may be seen in to carboxyhemoglobin[18,19].
severely burnt patient’s gastric antrum and 3. Whether the burns are suicidal, accidental,
the first part of duodenum after 72 hr. It or homicidal?
develops due to mucosal ischemia as a ● Suicidal burns: These burns are common
result of stress and shock and related to among Indian women. They poured
acidity. kerosene oil and set fire to themselves and
i) The spleen becomes enlarged and softened. women stuffed clothes inside by others.
j) Cloudy swelling and fatty liver or necrosis ● Accidental burns: this burn is common
of the cells, if death is delayed. Jaundice among children and older people.
may occur. Accidental kerosene stove bursting is also
k) Show signs of nephritis, thrombosis, and reported often.
infarction in kidneys. ● Homicidal burns: These burns are quite
l) Adrenals may be enlarged and congested. common in India. The pernicious customs
The prolonged exposure of the body to high of dowry among certain Hindu castes,
temperatures resulted in vaporization of sometimes leads to young maidens, being
body fluids along with the direct effect of murdered by pouring kerosene and set on
the heat cause shrivelling of the internal fire by husband or in-laws later claimed to
organs which became firm, hardened, and be an accidental burns death. It has lead to
cooked by heat or so-called ‘puppet the concept of dowry deaths or bride
organs’[16,17]. burning which has imposed a rule by the
Medicolegal Importance Home Ministry Of India to involve a panel
of two doctors in conducting the
1. When the body is wholly burnt, then the postmortem examination of married
identification of the deceased is difficult. It women dying of burns or any other reasons
may be helpful in the following situations: within seven years of marriage or if her age
is less than 30 years at the time of death in

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suspicious circumstances (IPC, Section About 45% of the burns patients are dying
304B)[18,19]. due to septicemia. Examination of victims
4. Self-inflicted burns are usually for false who have died from smoke inhalation
accusations which are seen on accessible usually reveals soot in the nostrils and
parts of the body[18,19]. mouth as well as burns, and coating of the
5. Spontaneous combustion and larynx, trachea, and bronchi. Further, the
preternatural- Occasionally, cases are extent of the injury will be determined by
reported of burns occurring due to natural the classic ‘‘rule of nine’’. Most victims of
gases evolved in the intestine (flammable house fires die from exposure to carbon
gases such as hydrogen sulfide, methane, monoxide gas or at least are affected by it.
etc.). When these gases are passed out per In enclosed areas, in addition to carbon
anal, come across a flame that may lead to monoxide, hydrogen cyanide is responsible
burns[18,19]. for death from smoke inhalation. The
6. The dead body of a victim may be burnt various reasons behind this may be
after death to conceal homicide. Head personal, domestic, occupational, social
injury and fatal neck compression are tragedy, and particularly dowry. Homicidal
commonly reported methods of homicide by the burning of women who are married
[18,19]. is a significant concern in India for the
7. Identify the age of burn: medical and legal authorities associated
● Redness appears immediately after-burn. with disputes of dowry all over the country.
● Vesication or blisters are appearing within Injuries due to burn cause intriguing
one hour. problems to the forensic experts. The main
● Epidermis, dermis shows inflammatory difficulty is to determine whether the cause
exudate after 6-8 hours. of the burn was an accident or a deliberate
● After 72 hours exudate forms a dry brown attempt to cause injury to the victim.
crust
Another problem that is faced commonly is
● After 12-24 hours, the exudate begins to
to establish the immediate cause of death in
dry.
burn injury which is either “hypovolemic
● After 2 to 3 days, pus may form due to
shock” due to severe loss of body fluids or
infiltration of WBCs
infection of burn wounds later on leading to
● After 4-6 days, superficial slough
“sepsis” and septic shock. Forensic experts
separates.
should have adequate technical knowledge
● After 1-2 weeks, deeper sloughs separate
of postmortem artefacts of burn injury and
[20, 21].
how they are different from antemortem
Conclusion injuries and changes. Electric burns should
In developing countries, the problem of be recognized even in the absence of a
burn injuries is more severe due to the history of electrocution. The parts and the
reason that the care of burn patients body surface involved in the burn is of
requires specialized units that are prime significance in reporting the case.
expensive and not always readily available. Hence a thorough knowledge of injuries
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caused due to burning and the changes after 16. Nagesh Kumar G Rao, Textbook of Forensic
that are necessary for the forensic experts. Medicine and Toxicology, Jaypee Brothers Medical
Publishers, Second Edition, 2010; 316.
References 17. Review Of Forensic Medicine And Toxicology,
Gautam Biswas, The Health Science Published,
Third Edition 2015; 271,272.
1. Pekka S, Knight B. The pathology of burns. In:
Pekka S, Knight B, editors. Bernard Knight’s 18. K. S. Narayan Reddy, The essentials of forensic
medicine and toxicology, Published by K. Suguna
Forensic Pathology. 3rd ed. New York: Oxford
Devi, Hyderabad; 31st edition, 2012; 301-303.
University Press Inc, 2004; 322.
2. Cooper, P. N. (2006). Burn injury. In Essentials of 19. Nagesh Kumar G Rao, Textbook of Forensic
Medicine and Toxicology, Jaypee Brothers Medical
Autopsy Practice (pp. 215-232). Springer, London.
3. Organization WH. Burns: Fact sheet. Geneva:
World Health Organization, 2016. Available 20. Textbook of Forensic Medicine, Ajay Kumar,
Avichal Publishing Company Second Edition,
from:http://www.who.int/mediacentre/factsheets/fs
2016; 192.
365/en/ [Last accessed on 2017 Aug 10]
4. Van Rijn OJ, Bouter LM, Meertens RM. The
21. Bittner EA, Shank E, Woodson L, Martyn JA. Acute
and perioperative care of the burn-injured patient.
aetiology of burns in developed countries: Review
Anesthesiology. 2015 Feb;122(2):448-464.
of the literature. Burns, 1989; 15: 217‑21.
5. Ghaffar UB, Husain M, Rizvi SJ. Thermal burn: an
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Forensic Med, 2009; 30: 10-4.
6. Jeschke, M.G., van Baar, M.E., Choudhry, M.A. et
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http://notesmedicalstudent.blogspot.com/2017/07/r
ule-of-9-burn.html Accessed Date [72/8/2020]
12. Broadis, E., Chokotho, T., & Borgstein, E. (2017).
Paediatric burn and scald management in a low
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Swaroop S Sonone Mayuri Kumari

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Burn Injuries and Its Medicolegal Importance in Indian Scenario

Introduction to the skin or other tissues and these are the

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INTERNATIONAL MEDICO-LEGAL REPORTER JOURNAL, VOL, 3, ISSUE-2,

Table showing Classification of Burn Depth [6]

INTERNATIONAL MEDICO-LEGAL REPORTER JOURNAL, VOL, 3, ISSUE-2,

Figure Depicting Lund & Browder Chart [12]

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