BURNS AND SCALDS

Burns by Dry Heat.

o Thousands of death occur in Pakistan due to
burns caused by fire.
o Burns usually occur as a result of contact with
a naked flame or heated elements or glass.
o Majority of cases occurring in home or due
to smoking, defective electrical wiring,
attempted suicides by self immolation.
o Homicidal burns of young women
by the husband or in – laws.
Wilson’s Classification of Burns

Three Types.

a. Epidermal.
- There is erythema (redness) and blistering without
dermal involvement.
- Capillary dilatation and transudation of fluid into the
tissues resulting in swelling.
- Blister formed contains albuminous fluid covered by
avascular whitened epidermis and surrounded by a
zone of hyperaemia.

Such blisters are painful and heal without scar formation.

b. Dermo – Epidermal

- Involves full thickness of skin, including hair

follicles, sweat and sebaceous glands.
- Are extremely painful as they expose and
affect the sensory nerve endings.
- Healing occurs with scar formation.
. Deep burns

- Deeper tissues, below the skin are destroyed.

- Extent varies from sub – cuteneous tissues to
the muscles and bones.
- Burnt parts may be completely charred.
- Relatively less painful as the nerve endings
are completely destroyed.
Rule of Nine.

Head and Neck 9 % of the whole body surface

Front of Chest 9%
Back of Chest 9%
Front of Abdomen 9%
Back of Abdomen 9%
Right upper Limb. 9%
Left upper Limb. 9%
Front of right lower limb. 9%
Back of right lower limb. 9%
Front of Left Lower Limb. 9%
Back of left lower limb. 9%
Pudendal Area 1%
Total = 100%
Factors Modifying Effect of Burns.

1. Intensity of heat applied.

2. Duration of exposures.
3. Extent of body surface area.
4. Site of the body.
5. Age of the victim.
6. Sex of the victim.
 Causes of Death in Burns

Immediate causes of death.

1. Shock.
a. Primary (neurogenic) shock due to fear,
severe pain, injury to vital organs leading to
immediate death.

b. Secondary (vascular) shock due to loss of

serum from burnt areas leading to hypovolemic
shock resulting in death in 24 to 48 hours.
2. Asphyxia.

Suffocation due to inhalation of smoke and gases of

combustion.

3. Coma.

Congestion of brain and serous effusion into the ventricles.

4. Accidental Injuries.

Injury sustained due to attempt of escape and fall of rubble

of building.
Delayed Causes of Death (after 48 hours).

Victim may die due to following causes.

- Inflammation of Internal Organs.

- Gangrene.
- Exhaustion.
- Toxemia
- Hepatorenal Syndrome.
 Autopsy of Cases of Burn

External Findings.
1. Clothing – Clothes should be removed
carefully and examined for the presence of
petrol, kerosene oil or other inflammable
substance.

2. Belongings – Keys, wrist watch, metallic rings

and ornaments are removed and preserved for
the purpose of identity.
3. Face – Is usually distorted, swollen and tongue
protruded out.

4. Skin – If body is severely burnt and whole skin

is destroyed, it is difficult to differentiate
between antemortem and postmortem burns.

5. If skin is intact vital reaction can be

appreciated i.e. reddened border between
burnt and un-burnt areas. The scalp hair and
other body hair may be singed.
6. Pugilistic attitude – (boxers attitude). It is a condition
wherein the body assumes a rigid position with the limbs
flexed and resembles a boxer in defending position.
- Appearance: All the four limbs are flexed with closed
fist, body is bent forwarded and skin is tense, leathery,
hard and frequently shows splitting.
- Causes: Due to the effect of heat, the muscle proteins
coagulate making them contracted.
Cracks and Fissures resembling incised wound may be seen at
line with blood vessels exposed through them.

Charring of the Body depends on degree of postmortem burns or

burning of the body after death.

Internal Findings.

Skull Bones – may be fractured and burst open due to intense heat
along the skull sutures.
Brain and Meninges.
- Congested

- Heat Hematoma - It resembles extradural

hematoma but is actually an artefect due to
intense heat and is usually opposite to the site of
intense external damage to the skull.
It has chocolate brown colour of blood, the clot is soft,
friable and presents a honey – comb appearance due to
presence of bubbles of steam produced due to boiling of
blood by external heat.

Larynx, Trachea and Bronchial Tubes – Contain carbon

and soot particles and mucosa is congested with frothy
mucous secretions.

Pleura – Congested and inflamed with serous effusion.

Lungs – Congested and edematous.

Heart – Chamber full of blood, cherry red in colour due to

inhalation of carbon monoxide.
 Forensic Significance

• Identity of deceased
• Whether the burns are post mortem or ante mortem?
• Whether the burning is actual cause of death?
• Accidental, suicidal or homicidal.
• Peri-mortal injuries are those which have occurred a few
minutes before death. They do not show inflammation.
These injuries cannot be assigned as ante-mortem or
post-mortem injuries.
• First degree burns due to hot liquids show no effect on
hair and thus can be differentiated from burns due to dry
heat.
• Internal organs are usually preserved. Thus helping in
identification of a person for sex.

• A person dying of MI and then later on burnt, will have

evidence of MI. Stab wounds may be visible I internal
organs if not through external examination.

• Despite severe burning of the exterior of the body, the

teeth are often well preserved, enabling identification.

• Tongue, trachea and main bronchi show soot, if the

person is breathing whilst caught in fire. Histologically
carbon particles are found in bronchioles.
 Difference between Antemortem and Postmortem Burns
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Characteristics Antemortem Postmortem
-----------------------------------------------------------------------------------------------
Line of redness Present Absent.
Vesicles/Blisters Contain serious fluid Contains air and thin
with albuminous and clear fluid. Base is dry,
chloride contents. Hard and yellowish.
Base is red and Inflamed.
Healing Granulation. Nil
Infection Pus and/or sloughing
(depending upon duration) Nil
Carbon/Soot Present Absent
Particles in
Trachea, bronchus
Carboxyhaemoglobin
In blood Present Absent
Enzymes Peripheral zone of burns
shows increase in enzymes Peripheral zones does not show
reaction increase in enzymes reaction.
Internal organs Congested Not so
3. Whether the burns are the cause of death or not?
- Death is due to burns if presence of carbonaceous or soot
particles in the respiratory tract.

- Cherry red discolourations of blood due to carbon monoxide.

4. Whether the burns are suicidal, accidental or homicidal?

- Suicidal burns are common among the young people.
- Accidental burns are common among children and elderly people,
mostly associated with kerosene stove bursting.
- Homicidal burns e.g. Dowry deaths.

5. Self-inflicted burns for false accusation.

- These burns are usually seen on accessible parts of the body.
SCALDS

Scalds are trauma resulting from the application of moist

heat involving only superficial layers of the skin.

Causes of Scalds.
1. Hot water, oil or any liquid at or near boiling point.
2. Super heated industrial steam.

Autopsy Findings.
Usually the scaled area presents as a swollen, vesicated
and bleached appearance. Since the clothing worn
cools faster, the scalding effect is usually less
prominent in clothed areas.
Scald
However, clinically scalding is classified into three degrees:
(i) erythema, (ii) vesication, and (iii) necrosis of dermis.

Erythema: This is the reddening change of the skin which

appears at once as the moist heat is applied.

Vesication: Also called blister formation is chiefly due to

increased capillary permeability, and this needs a few
minutes to develop. Usually blisters are surrounded by a
bright red zone of inflammation and present as a
swelling. On removing a blister, it leaves open a pink
coloured raw area.
Necrosis of dermis:

This results when deeper layers of skin are

involved.

On healing, scar is much thinner and it produces

less contraction and disfigurement.
 Medicolegal Importance.

- Usually scalds are accidental due to splashing

or pouring of fluid while cooking or bathing, etc.
- The accident is common in children or 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.
- Scalding can be antemortem or postmortem.
 Differences between antemortem and postmortem
scald
Characteristics Antemortem scalds Postmortem
scalds
------------------------------------------------------------------------------
-------------
Line of redness + ve - ve
Vesicle + ve - ve
Content of vesicles Albuminous gas/air
Infection + ve - ve
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At times scalding and dry heat burns may have to be differentiated from each
other. The table gives these differences.

Differences between scalds and burns

-----------------------------------------------------------------------------------------------
Characteristics Scalds Burns
-----------------------------------------------------------------------------------------------
Skin Sodden and bleached Dry and shrivelled
Redness Present Present
Vesicles Seen all over scalled Only seen at the
burnt
area area
Singeing of hair Absent Present
Charring Absent Present
Soot particles in
Upper respiratory
Tract. Absent Present
Scar Thin Thick
Lightning
Thank you