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LECTURE ON BURNS BURNS • • 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. • • • • • 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 • • • 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 • • 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) • • • • • • • • • • • 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 • • 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. • • • • • • • • • • • • • • • 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 • • • • • • 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. • • 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. • • 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 • • • • • 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 • • • • • • • • • • 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. • • • • • 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. thanks THANK YOU