THERMAL INJURIES

--> What is Thermal injury/ death?

Injury/ death which results from the effects ( direct or remote) due to
localised or systemic exposure to extremes of temperature- heat or cold.

--> Classification of Thermal injuries:

COLD HEAT

1. Trench foot EXTREMES OF HEAT BURNS

2. Immersion foot
3. Frost bite 1. Heat cramps 1. Highly heated solid body
4. Neonatal cold injury 2. Heat stroke or 2. Flame burns
Heat hyper pyrexia 3. Petroleum products
3. Hear prostration 4. Moist heat ( scalds)
5. Chemical burns
6. Corrosive burns
Electrocution 7. Radiation injury
Lightening stroke 8. Electrical injury
-->INJURIES DUE TO COLD:
1. Hypothermia- Oral or axillary temperature less than 35 degree
Celsius.
2. Immersion foot- moist cold- can be less tolerated than other types
which are “dry cold”.
3. Chief target tissue are : a) Fatty tissue
b) Myelinated nerve fibres
c) Vascular system
4. Temperature regularatory centers may get affected in hypothalamus
gets affected when temperature goes below 30 degrees Celsius.
5.Trench foot % Immersion foot = 5 to 8 degrees temperature+dampness
6. Frost bite= Minus 2-3 degrees temperature.

7. LOCAL EFFECTS:
a)Blanching and paleness of skin( vascular spasm)
b) Erythema(vaso dilatation) & oedema(increased capillary permeability)
c) Blister formation( dehydration )
d) Necrotic changes( ischemia, arterial/capillary occlusion )
8. SYSTEMIC EFFECTS:

a)Stage-1: Patient perceives cold & shivers with fall of body temperature.

b) Stage-2: --> Shivering stops if temperature further falls.

--> Patient becomes depressed, sleepy, lethargic & passes
into stupor & coma.
--> Partial cessation of RS, CVS, enzymatic & metabolic
activities.
c) Stage-3: Coma, collapse & death.
9. PM FINDINGS:

a) External- Pale patches, blisters, gangrene on face and extremities.

b) Internal--> Finding ice crystals in vessels( if examined at same

temperature and not otherwise )
--> bright red colour of blod
--> Fatty necrosis in pancreas( HPE)
--> INJURIES DUE TO HEAT:
1. Heat Cramps-
Due to rapid dehydration in workers engaged at high temperature.
2. Heat Hyper pyrexia-
Rectal temperature more than 41 degrees Celsius.
Pupils CONSTRICTED.
3. Heat prostration-
Collapse without increase in body temperature.

--> BURNS:
1. ANATOMY OF SKIN:
2. DEGREE OF BURNS

DUPUYTREN’S classification WILSON’S classification

1st degree= Only erythema

1st degree= Epidermal
2nd degree= Acute inflammation
& blister

3rd degree= Destruction of epidermis

2nd degree= Dermo epidermal
4th degree= Involvement of dermis

5th degree= Deep fascia & muscles

3rd degree= Deep
6th degree= Bones / internal organs
3. PERCENTAGE OF BURNS RULE OF NINES:
Front Back 11 compartments of 9%= 99
1 compartment of 1%= 01
total = 100
PARKLAND’S FORMULA:
( amount of I/V fluids)
ADULTS:
-- Per 24 hrs: TBSA x wt x 4

--1st half in 8 hrs 2nd half in 16 hrs

CHILD: (24 hrs)
-- 100 ml /kg- for first 10 kg
-- 50 ml / kg – for next 10 kg
-- 20 ml / kg – for each kg> 20
CAUTION:
If urine output is less than 0.5 to
1.0 ml/ kg infusion rate shall be
increased.
Lund & Browder Chart: A= ½ of head, B= ½ of thigh,C= ½ of one leg

Age Area
0 yr A= 9+1/2
B = 2+3/4
C= 2+1/2
1 yr A= 8+1/2
B = 3+1/4
C= 2+1/2
5 yr A= 6 +1/2
B=4
C= 2+3/4
10 yr A= 5+1/2
B = 4+1/4
C= 3
15 yr A= 4+1/2
B = 4+1/2
C= 3+1/4
Adult A= 3+1/2
B = 4+3/4
FRONT BACK
--> TBSA( Total Body Surface area) affected by burn is helpful to:
1. Clinical application to calculate amount of IV fluids required.
2. Determine prognosis-50% or more are usually fatal.
3. Surface covering trunk more fatal .

--> EFFECTS OF BURNS:

1. Degree of heat- usually temperature up to 650 degrees is generated.
- 1000 degrees for half to one hour( used for
cremation) reduces whole body into 2-3 kg of ashes.

2. Duration of exposure- more damage with prolonged exposure.

3. Percentage of burns- 50% or more are usually fatal

4. Prognosis- Poor if Head, neck or trunk is involved.

5. Age- Extremes of age groups -more vulnerable

6. Sex- Females more vulnerable

7. State of health- Pre exisiting disease- poor prognosis
--> CAUSES OF DEATH FROM BURNS:
A. Immediate( more common)
1. Primary shock: Neurogenic shock due to pain
2. Secondary shock: Fluid loss--> Dehydration--> Hypovolaemic shock
3. Irrespirable shock: Produced due to combustion- CO, Co2, cyanide
4. Falling of structures in case of fire in building
B. Delayed( Less common)
5. Infection & septicaemia: 36-72 hrs, Gram Negative organisms
( Pseudomonas, Clostridia Welchi etc)
6. Toxemia: Due to absorption of toxic products from burnt tissue- Urea,
Non proteinous Nitrogen ( NPN) substances.
7. Inflammatory changes- Meningitis, Pericarditis,bronchitis, peritonotis
8. Biochemical disturbances: Hypokalaemia, protein loss
9. Acute oedema of glottis
10. Acute renal failure- due to acute tubular necrosis
C. Remote ( Rare)
11. Pyaemia, gangrene, tetanus 12. Pulmonary embolism
13.Jaundice 14. GIT- Hemorrhagic gastritis, Curling’s ulcer
--> POST MORTEM FINDINGS:
[A] EVIDENCE OF BURNS:
1. On clothes: --> Smell of inflammable medium i.e. Kerosene, petrol
--> Blackening due to smoke particle deposition
--> Destruction: partial / complete due to burns
2. External examination of body:
--> Smell of inflammable medium i.e. Kerosene, petrol
--> Blackening due to smoke particle deposition
--> Loosening and pealing of epidermis leading to “partial degloving” of
hands and “partial destocking” of feet.
--> Singeing of hair:
Gross: Fragile, wrinkled, bulbous appearance of tip of hair
Micro: Loss of normal contour with irregular bulbous projections on
surface and irregular vacuoles in the substance( cortex).
3. Internal examination of body:
--> Absence of signs of ante mortem burns &
--> Finding of any other cause of death- injury etc. in case of post
mortem burns.
[B] EVIDENCE / SIGNS OF ANTE MORTEM BURNS:
1. On external examination of body
LINE OF REDNESS BLISTERS VITAL REACTION

Due to hyperaemia due to dehydration due to cellular

exudation

at the junction of Red inflamed base oedema

healthy & burnt contains serous fluid
areas rich in protein and
Chlorides
2. On Internal examination of body
--> Soot ( carbon) particles- Interspersed in midst of frothy mucoid
secretions in nasopharynx, pharynx, larynx, trachea and lower
bronchial tree. ( May be absent ?)
--> Cherry / bright red colour of blood- due to CoHb formation
3. Investigations:
a. Histo pathological examination of skin:
--> Dmaged epidermis or/ and demis( depending on degree of burns)
--> Swollen nuclei with eccentric displacement of chromatin
--> Vesicle( blister)- suprabasilar / intradermal
--> Hyperemia and congestion.
b. CoHb Levels:
--> Blood tobe collected amd sealed with liquid paraffin.
--> Analysis bu Skip’s apparatus id done at FSL.
--> In smokers( other than burns) level up to 10% is found.
--> Level above 35-40% are conclusive for ante mortem burns.
c. Enzyme Histo Chemistry: Positive for enzyme activity.
[C] AGE OF BURNS:
a. Redness-Immediate b. Blisters- 1 to 2hours
c. Inflammation & exudate- 6 to 12 hours
d. Drying of exudate – 12 hours e. Crust formation- 1-3 days
f. Infection and pus formation- 36 to 72 hours
g. Granulation tissue- 5 to 6 days.
[D] EVIDENCE OF PROLONGED EXPOSURE:

1. Heat Contracture Rigor mortis

( Boxing / Pugilistic attitude)
a. Cause - Coagulation of proteins Depletion of ATP
b. Sequence – All at a time In an order
c. Nature - Can be ante mortem Always post mortem
d. Duration- Rigor mortis & other Decomposition
PM changes does not follows
follow/ are delayed.

2. Heat rupture Mechanical Injury

a. Site- Extensor surface Any where
b. Bleeding - Absent Present
c. Floor- Intact vessels & nerves cut/ lacerated
d. Vital reaction- Absent Present
3. Heat Fracture Mechanical fracture
a. Cause- Increased ICT due to sharp/ blunt force
steam
b. Site- Sides of skull Underneath external injury
above temples
c. Sutures-May be crossed Not so.

4. Heat hematoma Traumatic ED hematoma

a. Site- Parieto-temporal area Any where
b. Mechanism- Shrinkage of brain Sources of EDH
sinus/ veins
c. Colour- Pink/ chocolate Red
d. Consistency- Soft, friable Firm
e. Appearence- Honey comb Evenly smooth
f. Neighbours- Heat effect present Heat effect absent
g. CoHb- Elevated Normal
5. Cooked appearance of tissues and organs/ charred :
dry, hard, black,fragile.
--> MANNER AND CIRCUMSTANCES:

1. Scene of crime in spot deaths.

2. Dying declaration in hospitalised deaths/ cases.

3.Smell and type of inflammable fluid used.

4. Patten and percentage of burns

5. Association with other cause- poisoning, injury.

TRAIT DRY HEAT MOIST HEAT CHEMICAL BURNS
( SCALDS)
1.Cause Flame/ heated liquid or steam corrosives/ chemicals
solid body above 60 degrees
2. Site At & above At & below At & below
impact area impact area impact area
3. Splashing Absent present present

4. Skin dry, wrinkled & soddened & Brown, hard with

charred bleached destruction
5. Blisters At margins At affected area rare

6. Redline At margins At margins Absent

7. Colour Blackening Bleached Brown/ yellow / of

corrosive
TRAIT DRY HEAT MOIST HEAT CHEMICAL BURNS
( SCALDS)

8. Charring Present Absent Absent

9. Singeing Present Absent Absent

10.Ulceration Absent Absent Present

11. Clothes Burnt& black Wet Brown/ yellow / of

corrosive
12. Soot in Present Absent Absent
trachea & CoHb

13. Examples Flame burns Hot water/ milk Vitriolage

14. Common Suicidal Accidental Vitriolage

manner
 ELECTRICAL INJURIES

1. FACTORS AFFECTING:

A] Type of current- Alternate current (AC) is 4-5 times more dangerous

than Direct current.

B] Amount of current = CV/ R

Where CV= Current in Volts
R= Resistance in body in Ohms.
- Current up to 100 Volts is tolerable.
- More than 200 Volts is usually fatal.
- In India, 220-240 Volts , AC with 50 cycles per second is in use.

C] Path of current – Brain/ Heart in the path of current is more fatal.

D] Duration of flow( exposure)- Severity is directly proportionate to

duration.
2. LOCAL EFFECTS:
Current produces heat
Normal skin
Electrolysis of tissue

Ulcer
Skin explodes and margins
roll back on the surface and lead
to CRATER formation
4.FLASH/ SPARK BURNS
--> No direct contact with the conductor but burns produced due to spark
from the conductor, specifically in high voltage conductors/ HT lines.
--> Crocodile flash burns:A large surface of body is involved showing
multiple burnt and punched out lesions.
5. SPLIT BURNS
--> More extensive in depth.
--> Dry, hard, firm, charred area with ragged edges with aseptic necrosis
of deeper tissues.
6. EXIT MARK
--> larger in size than entry.
--> Split ridges with tissue damage.

7. POST MORTEM APPEARENCE:

--> Entry and exit marks( absent if path is interrupted with bed conductor.
--> No evidence if the contact surface/ s is/ are wet.
--> Internal findings:
a) Of asphyxia

b) Current pearls- small balls of molten metal driven deep in to tissue

near entry wound.

c) Bone pearls or Wax droppings- Calcium phosphate( in bone) get

melted due to heat transmitted to bones leading to round denesity foci
demonstrable radiologically.

8. HISTO LOGICAL APPEARENCE:

--> Micro vesicles in the epidermis.
--> “Nuclear streaming”- pyknotic epidermal nuclei with elongation and
arranged in parallel or palisading alignments.
--> Separation of lower dermis.
--> Trans- cutaneous coagulation extending in to dermis.
9.CAUSES OF DEATH IN ELECTROCUTION:

A) Limb to head --> brain stem & upper

cervical cord--> Paralysis of medulary
centres of respiration.

B) Arm to Arm --> Upper cervical cord

--> Paralysis of medulary centres of
respiration

C) Left arm to any limb--> Heart

-->Ventricular fibrillation
10. MEDICO LEGAL ASPECTS:
a) Improper handling of electrical gazettes.

b) Faulty insulation in wiring.

c) Farmers pass electrical current ( illegal) in the fence to prevent

entry of animals, thieves etc. The subject unknown to fact may
become victim.

d) Act of urination in water having electric current( also a method of

torture)
:LIGHTENING STROKE:
1. INTRODUCTION:
--> Electrical discharge from a cloud to earth worth 1000 million Volts
or more.
--> Higher points are attracted.
--> Electrical gazettes in “live” state also can attract.
2. TYPE OF BURNS

a)Linear: more common in moist

creases.

b)ARBORESCENT or FILIGREE
BURNS:
Found at the path of current on
superficial parts of body due to
Staining of tissue by lysed red cells
– fern like pattern of erythema
DOES NOT CORRESPOND TO
PATTREN OF VASCULAR
CHANNELS.

c) Surface burns / true burns

3. CAUSE OF DEATH: same as electrocution but more severe.
4. MEDICO LEGAL ASPECTS: Thunder storm in monsoon.

:RADIATION INJURY:

1. INTRODUCTION- Decomposition of certain atoms( Thorium, Uranium,

Cadmium) liberate radiant energy i.e. Alpha, beta, gamma rays etc.
which converts infra red frequencies into thermal heat which causes
damage to tissues.
2. MODE OF EXPOSURE-
a. Industrial Infra red sterilisation, nuclear energy reactors, Radio
diagnosis, Radio therapy.
b. Radio Immuno Assay (RIA)
c. Iodine in thyroid, phosphorous in bones- cause localised irradiation.
3. ACTION : Production of ions--> alter chemical structure of enzymes,
cells undergoing mitosis are most sensitive ones-->leads to
chromosomal damage--> abnormality of growth including neoplasms.
4. FACTORS:
a. Age & sex- foetus, child, female.

b. DOSE--> 50 rads – Hematological changes possible.

--> 50-100 rads - Hematological changes likely
--> 100-200 rads - Mild manifestations
--> 200-250 rads – Manifestations with likely mortality
--> 250-500 rads – Rising mortality
--> 500 rads and above – 100% mortality

c. Type of radiation: X-radiation( internal), infra red

d. Rate: Shorter duration

e. Surface area exposed: Proportionate damage

f. Half life of RA material: More risk with long half life

g. Type of tissue: Bone marrow, epithelial tissue

5. RADIATION SYNDROME:
--> Dose less than 500 rads.
--> Due to damage to nervous system
--> Features: of dehydartion
--> Erythema and cutaneous burns

6. DELAYED EFFECTS: Hematological, reproduction, neoplasm.

7. RADIATION AND MEDICAL MEN:

A] Radiology department- Design of unit, TLD( Thermo Labile Density)
tags for staff, amount of exposure in a given duration is reflected on
analysis of such tags.
B] Autopsy & Disposal- Dead bodies with radio activity above
5 milli-curies need special precautions as:
--> Heavy rubber gloves, shoe cover, spectacle, apron- all plastic.
--> Instruments with long handles.
--> Avoid spillage of fluids. --> Deep burial in isolated space.