Download LECTURE ON BURNS BURNS • DEFINITION. Burns may be

LECTURE ON BURNS
BURNS
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DEFINITION. Burns may be defined as thermal injuries resulting in
coagulative necrosis of the tissues.
According to Glaister. A burn may be defined as a lesion which is caused
by application of heat or of chemical substance to the external or internal
surfaces of the body, the effect of which is more or less marked destruction
of the tissues.
CLASSIFICATION OF BURNS
BURNS MAY BE CLASSIFIED UNDER FOLLOWING WAYS.
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ETIOLOGICAL CLASSIFICATION
WILSON’S CLASSIFICATION
DUPUYTREN’S CLASSIFICATION
AMERICAN CLASSIFICATION
THERAPEUTIC CLASSIFICATION
ETIOLOGICAL CLASSIFICATION
DRY HEAT--------------BURNS
MOIST HEAT-----------SCALDS
SUN RAYS--------------ICTINIC BURNS
DUE TO CHEMICALS--CHEMICAL BURNS
ELECTRICITY-----------ELECTRIC BURNS
RADIATION (X RAYS)-RADIATIONAL BURNS
LIGHTENING-----------LIGHTENING BURNS IN RAIN AND THUNDER
STORM.
WILSON’S CLASSIFICATION
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TYPE I – EPIDERMAL BURNS- In this type of burns the lesion is confined to
epidermis and takes the form of erythema with or without superficial
vesications.
TYPE II – DERMO EPIDERMAL BURNS- epidermis as well as dermis are
involved or we can say full thickness of the skin is involved including hair
follicles, sweat and sebaceous glands. They are extremely painful as the
sensory nerve endings are exposed and involved.
TYPE III- DEEP BURNS – Skin is totally destroyed and underlying structures
and bones are exposed and may be destroyed.
DUPUYTREN’S CLASSIFICATION
(Depending upon depth)
FIRST DEGREE BURNS. Consist of an erythema of the skin without
vesication.
SECOND DEGREE BURNS. Result in injury to layers of epidermis with
vesicle formation.
THIRD DEGREE BURNS. There is destruction of full thickness of
epidermis along with epithelial glands and hair follicles.
FOURTH DEGREE BURNS. There is complete destruction of dermis
extending in to sub cutaneous tissues.
FIFTH DEGREE BURNS. Complete destruction of sub cutaneous tissue
with involvement of muscles.
SIXTH DEGREE BURNS. There is complete carbonization of the burnt
parts with charring of bones.
ESTIMATION OF SURFACE AREA OF BURNS
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WALLACE’S RULE OF NINE. This describes the percentage of body surface
burnt represented by various anatomical areas.
RULE OF PALM OF THE HAND. A useful rule of thumb for estimating total
surface area involved by a scattered burn injury is the “PALM OF THE
HAND RULE” that is the surface area of the patient’s palm is roughly 1% of
the total body surface area..
WALLACE’S RULE OF NINE
ESTIMATION OF TIME SINCE BURN (AGE OF BURN)
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REDNESS- Immediate.
VESICATION- With in 2-3 hours.
PUS FORMATION- 36-72 hours.
SEPERATION OF SLOUGH.Deep- About 14 days.
.Superficial- 4-6 days.
SCAR FORMATION- About 3 weeks or more.
CAUSES OF DEATH IN BURNS (IMMEDIATE CAUSES)
SHOCK
SUFFOCATION
TRAUMATIC ASPHYXIA
ACCIDENT/INJURIES
ACUTE TUBULAR NECROSIS
TOXAEMIA
INFLAMMATORY COMPLICATIONS
– Inflammatory Complications of serous membranes and internal organs
such as
1-Meningitis
2-Bronchopneumonia – Is a common cause of death and is very common in
infants.
3-Peleurisy
4-Peritonitis
5-Pericarditis
6-Loss of fluids and electrolytes – may result fatal if replacement is not done.
7-Protein Loss – occurs in the exudates from the burnt areas and further more
excessive catabolism
8-Renal Failure – sometimes acute renal failure may result into death.
9-Erosions – Erosions of stomach and duodenum
10-Neurological Disturbances
ANTEMORTEM AND POSTMORTEM BURNS
ANTEMORTEM BURNS
POSTMORTEM BURNS
LINE OF REDNESS AROUND THE INJURED PART i.e. VITAL REACTION
NO LINE OF REDNESS
TRUE VESICATION: VESICLE HAS SEROUS FLUID CONTAINING ALBUMIN
AND CHLORIDE. IT HAS RED INFLAMMED BASE WITH RAISED PAPILLAE
FALSE VESICATION: VESICLES CONTAIN AIR ONLY, IT MAY
SMALL QUANTITY OF ALBUMIN BUT NO CHLORIDES, ITS B
DRY, HORNY AND YELLOW
REPARATIVE PROCESS SUCH AS INFLAMMATION, FORMATION OF
GRANULATION TISSUE, PUS SEEN
NOT SEEN
SOOT PARTICLES IN TRACHEA AND LARYNX SEEN
NO SOOT PARTICLES SEEN
PRESENCE OF CARBON MONO OXIDE IN BLOOD
CARBON MONO OXIDE NOT PRESENT
CURLING’S ULCER IN STOMACH AND DUODENUM SEEN
NOT SEEN
POST MORTEM APPEARENCES
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EXTERNAL:
CLOTHINGS IF PRESENT MAY GIVE SOME IDEA ABOUT THE MANNER OF
BURNING BY SHOWING THE PRESENCE OF STAINS, SMELL OF
COMBUSTIBLE MATERIAL SUCH AS KEROSINE OIL,PETROL,
CORROSIVES.
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PUGILISTIC ATTITUDE; DUE TO HEAT THERE IS COAGULATION OF
ALBUMINOUS MATERIAL OF THE MUSCLES BECAUSE OF WHICH THE
BODY ASSUMES A PECULIAR ATTITUDE IN WHICH THE ARMS AND
KNEES ARE SEMI FLEXED AND THE FISTS ARE CLENCHED, THIS
ATTITUDE OF THE BODY IS ALSO KNOWN AS BOXERS ATTITUDE OR
FENCING ATTITUDE.
DUE TO HEAT STIFFENING THERE IS NO RIGOR MORTIS.
POST MORTEM LIVIDITY IS CHERRY RED IN COLOUR DUE TO FORMATION
OF CARBOXY HAEMOGLOBIN.
REST OF EXTERNAL FINDINGS HAVE ALREADY BEEN DISCUSSED UNDER
BURNS DUE TO DRY HEAT, MOIST HEAT AND CHEMICAL BURNS.
POST MORTEM APPEARENCES
INTERNAL:
ALL THE INTERNAL ORGANS ARE CONGESTED AND BLOOD IS CHERRY
RED IN COLOUR DUE TO INHALATION OF CARBON MONO OXIDE.
BRAIN AND MENINGES ARE CONGESTED,SKULL BONES ARE FOUND
FRACTURED OR BURST OPEN DUE TO INTENSE HEAT, KNOWN AS
BURST FRACTURES. HEAT HAEMATOMAS MAY BE SEEN.
IF DEATH OCCURRED DUE TO SUFFOCATION BY SMOKE, THE
NASOPHARYNX, TRACHEA AND BRONCHIAL TUBE CONTAIN SOOTY
CARBON PARTICLES.
NUMEROUS HAEMORRHAGIC SPOTS ARE SEEN UNDER THE
PERICARDIUM, THE HEART IS DILATED WITH BOTH SIDES FULL OF
BLOOD.
POST MORTEM APPEARENCES
INTERNAL (CONT):
PLEURA ARE CONGESTED AND INFLAMMED AND THERE MAY BE
SEROUS FLUID IN THE CAVITES,
THE MUCOUS MEMBRANE OF THE STOMACH AND DUODENUM IS
REDDENED AND MAY SHOW CURLING’S ULCER. MORE OVER SOOT
PARTICLES MAY BE FOUND IN THE STOMACH.
LIVER SHOWS CONGESTION AND NECROSIS OF THE CELLS.
KIDNEYS ARE CONGESTED AND SHOW SIGNS OF NEPHRITIS.
SPLEEN IS CONGESTED, ENLARGED AND SOFTENED.
COMPLICATIONS
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LOCAL:
INFECTIONS
PORT BURN CONTRACTURES
HYPERTROPHIC SCAR
KELOID FORMATION
IN FACE BURNS, CAVERNOUS SINUS THROMBOSIS.
INJURIES DUE TO HEAT
Disorders due to heat
Three disorders may result form exposure to high temperature:1. Heat cramps.
2. Heat exhaustion (heat prostration, heat collapse, heat syncope).
3. Heat hyper pyrexia, heat stroke, sun stroke or thermic fever.
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Heat cramps (Miner’s cramps)
These are painful spasms of voluntary muscles, following strenuous exercise in a
high environmental temperature. They are caused by rapid dehydration of body
due to loss of water and salts in sweat.
Heat exhaustion
It is a condition of collapse without elevation of the body temperature, seen after
exposure to excessive heat. It is associated with prolonged sweating and chloride
depletion.
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Treat a case of heat exhaustion
It is treated in a cool place by adequate salt and water replacement till
covalescence is complete.
Heat hyper pyexia or sun stroke?
It is endemic in those exposed for considerable periods to unusually high
atmospheric temperature either directly or indirectly on exposure to sun light.
POST MORTEM APPEARANCE
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EXTERNAL
Rigor mortis is well marked, it comes early and passes off rapidly. Putrefaction
follows immediately. Petechial and livid patches on skin may be present.
The brain and meninges are congested and may be haemorrhages in the brain.
The ventricles may contain serum.
LUNGS ARE :
Congested and oedematous. Hear-right side full of dark fluid blood. Left side empty
and contracted. Abdominal organs are congested.
MEDICO LEGAL IMPORTANCE
All cases are accidental, bodies are found lying dead on roadside or in railway trains.
ELECTROCUTION
ELECTROCUTION CAN BE DIVIDED IN TO THREE GROUPS
DOMESTIC: THE VOLTAGE OF DOMESTIC CURRENT VARIES
FROM COUNTRY TO COUNTRY.STANDARD DOMESTIC
IN PAKISTAN IS 220-240 VOLTS. IN UNITED STATES IT IS 110
VOLTS.
INDUSTRIAL: VERY HIGH VOLTAGES UP TO 400,000 VOLTS
IN ELECTRIC GRID STATIONS FOR BULK TRANSFER OF
POWER.
LIGHTENING: LIGHTENING FLASHES ARE ELECTRIC
CURRENT OF ABOUT 100,000 VOLTS.
TYPES OF CURRENT
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AC (ALTERNATING CURRENT). It reverses its direction at regular intervals (25-60
cycles per second).
DC (DIRECT CURRENT). Is one in which current flows in the same direction.
Alternating current is more dangerous as it causes violent muscular contractions
which is responsible for HOLD ON phenomenon.
PASSAGE OF CURRENT THROUGH THE BODY
THE PASSAGE OF CURRENT THROUGH THE REGION OF HEART IS MOST
DANGEROUS,THUS FLOW OF CURRENT FROM LEFT HAND TO RIGHT LEG
AND FROM HAND TO HAND IS MOST DANGEROUS AS HEART IS INVOLVED.
WHEN HEAD COMES DIRECTLY IN CONTACT ELECTRICITY BRAIN STEM
MAY BE DIRECTLY INVOLVED LEADING TO PARALYSIS OF CARDIAC AND
RESPIRATORY CENTRE.
DURATION OF CONTACT
LONGER THE CONTACT GREATER WILL BE THE DAMAGE.
CAUSES OF DEATH
VENTRICULAR FIBRILLATION
SPASM OF RESPIRATORY MUSCLES (TETANIC ASPHYXIA)
PARALYSIS OF RESPIRATORY CENTRE
SECONDARY CAUSES, SUCH AS FALL FROM HEIGHT, HEAD INJURIES,
SEVERE BURNS.
ENTRY AND EXIT POINTS
THE POINT WHERE THE ELECTRICITY ENTERS THE BODY IS KNOWN AS
ELECTRIC MARK OR JOULE BURN.
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A contact burn is due to close contact with an electrically live object with domestic
voltage. The damage varies from a small superficial burn to charring depending
upon the time the contact is maintained. A characteristic injury is usually present at
the point of entry and exit. It may however be absent. The commonest lesion at the
point of entry is a raised blister containing either gas or a little fluid. The lesion is
often seen at the pads of the fingers and thumb. At the point of exit the tissue
usually split in the form of punctured or lacerated wound.
SPARK BURNS
A spark burn is due to poor or intermittent contact with the electrical equipment
and the resistance of the dry skin. The damaged area shows a dry pitted lesion
(often very tiny) due to arching of the current from the conductor to the skin. A
yellowish parchment like scab may form with a pale halo around it due to capillary
contraction. These lesions may be multiple but still may be hard to find on
calloused hands of a workman and microscopic examination may be necessary to
establish their nature. Similar lesions may be found on the soles of the feet where
the metal studs on the shoes have arced to the skin.
FLASH BURNS
Flash burns are due to contact with very high voltages. They are seen on the line
men working on the grid system and sometimes in thieves stealing copper wires
from high voltage overhead lines. With very high voltage such as 40,000 there may
be an actual arcing of the current to an approaching person without actual contact
occurring. The man may be hurled from the vicinity by the force of the discharge.
All types of burns may occur. Actual charring of the tissue with carbonization is
common but depending on the degree there may be (1) brownish discoloration of
large areas of skin apart from actual burning (2) arborescent pattern of lightning
burns or (3) crocodile skin effect consisting of confluent multiple spark burns over
large areas of skin.
POST MORTEM FINDINGS
External – There will be local lesions at entrance and exit of current and all
appearances of shock e.g. pale face, congested eyes, dilated pupils, dry cuticle,
insignificant wheal, little burning, local capillary contraction causing dead white
pallor.
Internal – are not characteristic – organs are congested, lungs edematous, minute
hemorrhages in meninges, Tordieus spots in pleura etc.
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