Thermal Injuries

Thermal Injury
Thermal Injuries
It may be defined as the tissue injury resulting
from the application of heat & cold in any form Thermal injuries are those injuries which
to the external & internal surface of the body. result from the effects of systemic/or localized
exposure to excessive heat and cold
Burn
It may be defined as the tissue injury resulting
from the application of flame & heated solid
substance to the body.

Scald
It may be defined as the tissue injury resulting
from application of liquid above 60º C or in its
gaseous form such as steam to the body.

Classification of thermal Burn

Injuries Burn is a dry heat injury caused by
Due to exposure to extreme cold :
application of flame or the heated solid
1. Generalized effect Hypothermia.
substances or chemical substances to the
2. Local effect Frost bite, Trench foot. external or internal surface of the body
which causes tissue destruction.
Due to exposure to extreme heat :
3. Generalized effect Heat stroke, Heat
cramp, Heat syncope
4. Local effect Burns, scalds.
 The minimum temperature and duration
Categories of Burn of time required to cause burn

1. Dry heat
1. If temp is 44* C the application of
2. Moist heat- Scald
time is 5-6 hours.
3. Chemical- Corrosive burn
4. Electric burn
2. If temp is 65* C only 2 sec is
sufficient to cause burn.
5. Radiation burn—X-ray, ultraviolet ray, laser,
microwave oven

Classification of burn( Dupuytren’s Contd

Classification or Old Surgical Classification)
3rd Degree Burn :
1st Degree Burn :
• Whole epidermis and upper dermis.
• Involvement Upper epidermis.
• Singeing of hair.
• Redness of the skin (Hyperaemia), very low grade pain.
• Colour blackish due to deposition of carbonicious
• No scar formation.
particles.
• Blisters may rupture so, chance of infection.
2nd Degree burn :
• Formation of scar very important for
• Involvement Whole epidermis.
identification.
• Hyperaemia of the skin, more painful.
• Blister formation contains liquid substances that
contain protein, Cl- . 4th Degree Burn :
• Involvement Epidermis and whole dermis.
 Contd.
Wilson’s Classification of Burn
5th Degree Burn :
• Involvement Epidermis, dermis and subcutaneous 1st Degree Burn :
tissues
• Involves whole epidermis.
• Charring will be involved, due to sustained burn in full
level
• Hyperaemia of the skin and blister formation.
• There is chance of contracture of the limb involved • Injuries are painful and heals without scar
may cause limitation of the movement of the affected formation.
joint
6th Degree Burn :
• Same as 5th degree burn
• But more severe

1st degree Burn(Wilson’s) 1st degree Burn(Wilson’s)

 Wilson’s Classification of Burn 2nd degree Burn(Wilson’s)
(Cont)
2nd Degree Burn :
• Involves epidermis and whole dermis.
• Blister may rupture, so chance of infection.
• Heals with scar formation.

2nd degree Burn(Wilson’s) Wilson’s Classification of Burn

(Cont)
3rd Degree Burn :
• Involvement Epidermis, dermis and subcutaneous
tissues.
• Heals with scar formation.
• There is chance of contracture formation.
 3rd Degree Burn 3rd Degree Burn

Modern Classification of Burn

Scald
Superficial Burn
• Involves only skin. Scald is a moist heat injury resulting
• Very painful as the nerves are intact. from application of a liquid at or near
• 3rd and 4th degree burn. its boiling point or from steam.
Deep Burn
• Involves skin and structures beyond the skin also.
• No pain as the nerves are destroyed.
• 5th and 6th degree burn
Scald Scald

Scald Scald
point Dry heat Moist heat Chemical
Classification of Burn
Causative agent Flame, heated Steam or any Corrosive acid
solid substance liquid >60 º C and alkalis

Site At & above the At &below the At & below the Wilson’s classification
site of contact site of contact site of contact

If severe Burnt area is Erythema & corroded

destroyed or vesication
• 1st degree (Epidermal) – Reddening &
charred blistering of the skin
Clothing Burnt Usually wet but Characteristics
not burnt stains
• 2nd degree(Dermo-epidermal) –
Charring & destruction of full thickness
Singeing of hair present absent absent
of the skin is lost
Charring present absent Absent

Tickle Marks Absent present present

• 3rd degree(Deep burn) – Destruction

Dupuytren’s Classification Factors upon which the degree of

the injury due
• Temperature--- to burn
Higher depends
the temperature
• 1st degree—Reddening of the skin severe the burn
• 2nd degree—blistering of the skin • Duration of Exposure--- Greater the
• 3rd degree—Skin partially destroyed duration of exposure, more severe the
• 4th degree—Skin completely destroyed burn
• Extent--- The surface area is more
• 5th degree—Subcutaneous tissue are
important than the degree of burn in
burnt
assessing the prog nosis of the case
• 6th degree --- Muscle & bone are
charred.
Contd. Rule of Nine
• Age of the victim--- Children & elder The percentage of the body surface area involved
person are more vulnerable to initial shock in burn is calculated by the Rule of nine. This
& complication rule is important to manage a patient properly
with extensive burn where I/V fluid is a must .
N.B.--44 º C is the lowest temperature
cause burn
– Burns on the head ,neck, trunk& genitals are
more dangerous than on other parts of the
body

Rule of Nine (Cont) Rule of Nine (Cont)

Burn in body part % of whole body Burn in body part % of whole body area
1. Head & neck 9% 8. Front of the right lower 9%
limb
2. Right upper limb 9%
9. Back of the right lower 9%
3. Left upper limb 9% limb
4. Front of the chest 9% 10. Front of the left lower 9%
limb
5. Back of the chest 9%
11. Back of the left lower 9%
6. Front of the abdomen 9% limb
7. Back of the abdomen 9% 12. Genitalia/perineum 1%
Total 100%
 Rule of Nine
Age of Burn

• Redness occur immediately after a burn

• Vesication with in 2-3 hrs
• Pus formation under the slough with in 36-72
hours
• Superficial slough- 1week
• Deep slough- 2weeks
• After this period granulation tissue begins to
cover the burnt surface & the final result is
formation of scar

Vulnerability in burn cases Fatality in Burn Cases

• Infants and older people are more • 50% burn is fatal(According to
vulnerable textbooks)
• Man can withstand more than woman. • 30% burn is fatal (Practically)
Cause of death in Burn Management of Burn Patient
• Primary neurogenic shock—due to fear & intense
pain General Management
• Hypovolumic shock—due to fluid loss from burn
surface in 48 hours • Removal of the patient from the source of burn
• Asphyxia- Due to inhalation of smoke containing • Removal of clothing
CO, CO2 etc.
• Ensure adequate airway
• Acute renal failure
• Cooling with tap water may help to relieve pain &
• Toxaemia due to absorption of toxic product from decrease damage.
the burnt tissue persist upto 3-4 days.
• Sepsis of the burnt tissue in 4-5 days.

Indication of Fluid

• Incase of children when burn > 10% Symptomatic treatment----

• Incase of adult when burn > 15% • Relief of pain--- analgesic
• Induction of sedation—sedative
Fluid loss is replaced in 1st 24 hrs
• Prevention of infection--- TT, systemic
• Total amount of fluid given---- 3-4ml X body antibiotic
weight X % of burn • High protein diet
• Half of the fluid is given in 1st 8 hrs
• Remaining half is given in next 16 hrs Local treatment
A. Open method—
Monitoring vital signs • superficial burn
• Burn in head & face region
Monitoring urinary output
B. Close method
• In deep burn
• Infected superficial burn Burn Contracture
C. Skin grafting---
• In full thickness burn
D. Prevention of contracture
• Keeping the affected part in functioning
position
• Avoidance of pillow under head to prevent
neck contracture

Burn Contracture Burn Contracture

 P.M appearance in burn

Burn Contracture External

• Face is swollen, distorted

• Burn area may be red, blistered, charred.
• Examination of clothing for evidence of kerosene.
• The appearances of the skin----
• Blackening of the skin & singeing of the hair—burn
by flame
• Blackening & tattooing – due to coal mine
explosions& gun powders
• Roasting—due to prolong application of hot objects
• Black spot—due to kerosene burn

• Pugilistic attitude: It is due to heat

stiffening. The legs are flexed at the hips & Boxer
knees, the arms are flexed at the elbows &
the fingers are hooked like claws. This
condition is due to the coagulation of muscle
protein & dehydration which causes
contraction. It is permanent does not pass
off.

• Heat rupture– Heated skin contracts

markedly & splits producing heat rupture.
 Pugilistic Attitude Pugilistic Attitude

Internal Contd.
• Heat Heamatoma--- When severe
heat applied to the head, blood • Presence of Carbon particles in the upper
escape from the venous sinus or respiratory tract
diploic spaces into the extradural • Stomach & duodenum—show general
spaces. This is soft ,friable clot of inflammatory reaction. Ulcer may be found in
duodenum
light chocolate color & resembles
honey comb appearance. • Petechial haemorrhage in pleura, pericardium,
endocardium
• Heat fracture--- occurs when the
head exposed to intense heat & the
skull bone are charred
• Difference between Antemortem &
Burn Index (By Brook Army Medical Centre
postmortem Burn burn unit USA Army) for patient prognosis
Point Antemortem Burn Postmorte Burn and effectiveness of treatment.

Line of redness Present Absent

• Half mark for each % area of second degree
Vesicle Contain Contain Air burn.
Albuminous fluid
& chloride • 1 for each % of third degree burn.
• If, in the patient it is 45, mortality rate is
Infection Pus & sloughing Nil 50 %.
Carbon particle in Present Absent
URT
Carboxyhaemoglobin Present Absent
Enzyme Increase Not such increase

Medico legal Importance of Burn

• Accidental ---- usually accidental
• Suicidal ---- self immolation
• Homicidal ---- Rear, Dowry death
• Self Infected ---- False Charge
• PM-Burn ---- To Conceal cause of death by
other means.