Burn injuries are the cause of considerable morbidity and mortality worldwide. This following pages provide an overview of the epidemiology of burn injuries, the clinical assessment of the wounds associated with burns and scalds, and the medico-legal assessment of those injuries.
In the UK it has been estimated that approximately 175,000 people presenting to accident and emergency departments have burn injuries, of which 13,000 require hospital admission (Lawrence and Lilly 1999 p.92, Greaves et al 2001 p.205).
The number of people dying from burn wounds has been decreasing over the last 50 years, but there are still some 700 to 800 burn and scald deaths each year (Cooper 2003 p.186, Lawrence and Lilly 1999 pp.91-92).
Deaths as a % of all burn/scald deaths
Fires in buildings
Other water spilt
Causes of burns and scalds in UK (1981-1990) (Adapted from Lawrence and Lilly 1999)
Burns and scalds affect those in the extremes of age disproportionately, and scalds are the most common thermal injury affecting children (particularly those under 4 years).
Indeed, scalds in children have consistently risen over the last 50 years. 50% of contact burns in children under 4 years have been said to be inflicted during non-accidental injury. (Cooper 2003 p.183, Lawrence and Lilly 1999 p.92, ). The incidence of inflicted burn injury in children has been estimated at between 1% and 16% (Greenbaum et al (2004)).
Burns and scalds are most likely to occur in the home environment, with the Home Office Accident Surveillance System estimating there to be 100,000 burns a year in the home, whilst those occurring at work have reduced.
Alcohol intoxication is related to an increased risk of being burned or scalded.
In the USA, it has been estimated that 2.5 million people get burned each year, 1/3rd of whom are children. The incidence has steadily reduced over the last 50 years, in common with the UK. Approximately 5% require hospital treatment, and there are between 5500 and 10,000 deaths (depending upon sources).
Burns and scalds are the 3rd cause of death due to injury in children, and 10-20% of these are due to non-accidental injury (Children’s Emergency Care Alliance 2003, McClance and Huether 2002 p. 1499).
Burn wounds are coagulative lesions of the surface layers of the skin – usually caused by contact with a solid hot object (contact burn), flames (flame burn), heated liquids (scald), chemicals or physical agents (electricity, radiation, lightening). Some authors make a distinction between ‘wet heat’ and ‘dry heat’ (Wardrope et al 1992 p.187, Cooper 2003 p. 183-186).
'Frost-bite' is the term given for injury caused by extreme cold, and may include contact with cold objects/ substances such as liquid nitrogen etc.
Scald (after 2 days)
Assessment of burns
In making an assessment of the extent of the burn injury, and the depth of burn, one can gain a great deal of information from the history, including the duration of exposure to the causative agent (e.g. flames or chemicals).
In the clinical setting, one should also attempt to evaluate whether there is likely to have been any damage to the airways, and the nature of the environment in which the fire occurred should be determined – was it a closed environment? Has the person been exposed to toxic gases such as carbon monoxide (most fires) or cyanide etc from synthetic materials etc?
Collateral information from friends and relatives, as well as paramedics will be of great value where the injured person is unconscious.
Further history pertinent to their psychiatric state may also be relevant, as well as their tendency to abuse alcohol and smoke – did they accidentally set fire to their flat whilst smoking and in an alcoholic daze? Were they suicidal and set fire to themselves?
Important questions to be answered when faced with a burns victim include:
- how was the burn wound caused?
- was it caused accidentally or deliberately?
Details should emerge during the history taking process, and most burns and scalds turn out to be accidental (Cooper 2003 p.184).
Risk factors for accidental burn injuries include alcohol intoxification, epileptic seizures and psychomotor impairment (e.g. in the elderly etc).
Factors to consider for burns caused deliberately include:
- variable ages to injuries
- injuries other than burns
- characteristic patterns of inflicted burns e.g. cigarette burns
Source: Child protection and the dental team 2009 (funded by the Department of Health)
E.g. bath scalds (may include ‘tide marks’ over the buttocks, perineum and limbs in children immersed in scalding water); tipping hot water over oneself (may include splash patterns on the upper parts of the body with the appearance of burns from ‘running liquid’)
E.g. burns to the hair or skin; burns to the front of the body and hands (especially the dominant arm) where clothes have caught fire at the cooker etc, burning with sparing of skin folds at the axilla and perineum but predominant over the front of the body (self immolation)
E.g. on the hands (accidental), on the buttocks and perineum (non accidental injury e.g. being placed onto a hot grill surface etc), well delineated (e.g. a cigarette burn – small and oval or circular in a deliberate burn as opposed to pear shaped in accidental brushing against cigarette)
E.g. in the mouth/ oesophagus/ airway from inhalation or ingestion of hot fluids or gases
E.g. acid being thrown into the face in an assault or suicidal ingestion (with burns around the mouth and in the oesophagus (e.g. phenol compounds)
Characteristics of burns and scalds (adapted from Cooper 2003)
scald injuries in children
The Welsh Child Protection Systematic Review Group (http://www.core-info.cardiff.ac.uk/about%20wcpsrg.html) carried out a review of thermal injury in children. Of the 257 studies reviewed, 36 met the inclusion criteria.
They noted that scalds are the commonest intentional burn injury recorded (Ayoub and Pfeifer 1979), and apart from head injury, intentional burns are the most likely injury to cause death or long-term morbidity.
(Daria et al 2004; Hobbs 1986; Ofodile et al 1979; Bang et al 1997; Ayoub and Pfeifer 1979; Sheridan 1996)
- majority are from hot beverages/ liquids pulled off a table top or stove etc
- they are predominantly 'spill' injuries
- few are from immersion
- only 2 studies addressed location of injury - head, face, neck, trunk and upper body
A single study (Titus et al 2003) looked at 'accidental flowing water' injuries and noted:
- a lack of circumferential 'stocking' distribution
- an irregular margin
- an irregular burn depth
- lack of 'splash' marks
- with an asymetric distribution affecting the lower limbs
(Ayoub and Pfeifer 1979; Daria et al 2004; Hobbs 1986; Ofodile et al 1979; Caniano et al 1986; Heaton 1989; Purdue et al 1988; Brinkmann and Banaschak 1998; Deitch and Staats 1982; Durtschi et al 1980; Galleno and Openheim 1982; Grosfeld and Ballantine 1976; Hashimoto et al 1995; Holter and Friedman 1969; Lung et al 1977; Patscheider 1975; Philips et al 1974; Russo et al 1986; Schlievert 2004; Stratman and Melski 2002; Yeoh et al 1994; Titus et al 2003; Hight et al 1979; Hultman et al 1998; Johnson et al 1990; Leonardi et al 1999; Gillespie 1965; Hammond et al 1991; Kumar 1984; Russo et al 1986; Dressler and Hozid 2001; Potokar et al 2001;Sheridan 1996; Hultman et al 1998; Keen et al 1975; Showers and Garrison 1988)
- the majority of scalds are from hot tap water - forced immersion being the most common mechanism
- scald margins have clear upper limits
- scalds are symmetrical
- skin fold sparing is found e.g. in the popliteal area
- central sparing of the buttocks, sometimes referred to as a 'doughnut ring' pattern may be found in immersion injuries
- circumferential ('glove and stocking' distribution) scalds to the upper or lower limbs may be seen
- scald depth is uniform
- distribution - usually lower limbs (bilateral); buttocks and perineum (or combination of these)
- associated features
- previous burn injury
- development stage inconsistent with mechanism of injury
- associated neglect
- passive/ fearful child on examination
- old fractures on skeletal survey
- other injuries
- history incompatible with injuries
- historical/ social features
- lack of parental concern
- unrelated adult presenting child for medical attention
- domestic violence
- differing accounts of the mechanism of injury
- history of prior abuse
- 'trigger event' e.g. bed wetting, misbehaviour etc
- prior social services contact/ involvement
- scald commonly attributed to sibling
- numerous previous accidents reported
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- WebPath image - scalding to the hand
- Derm Atlas image - hot water (tea) scald to child's face (accidental) and child's chest
- Derm Atlas image - hot water burn to child's chest (accidental)
- Derm Atlas image - hot water splash burn
- Derm Atlas image - probable hot water scald to buttocks (unproven)
- Derm Atlas image - diaper area hot water burns (abusive)
- Derm Atlas image - cigarette burn on forearm
- Derm Atlas image - cigarette burn
- WebPath image - electrocution injury to hand
- Derm Atlas image - erythema ab igne
- Derm Atlas image - abusive hot water burns to genitals
- The skin (Wikipedia)
- Burn injury (Wikipedia)
- Online Journal of Burns and Wounds - Managing the burn wound 1
- 'Frost bite' (Wikipedia)
- Erythema ab igne
- WebPath The Internet Pathology Laboratory
- Fire (Wikipedia)
- Welsh Child Protection Systematic Review Group (http://www.core-info.cardiff.ac.uk/about%20wcpsrg.html)