IPLab:Lab 12:Burns

Clinical Summary

This 45-year-old back female was involved in a house fire which killed her husband. Upon admission to a local emergency room she was found to have approximately 80% body surface area burns including 1st, 2nd, and 3rd degree burns. Burns were most severe around the head and neck. The patient was intubated and transferred to a tertiary care center. Upon arrival, the patient had a blood pressure of 71/25 mmHg, a heart rate of 121, and was responsive to deep pain but had few spontaneous movements. Both eyes were swollen shut, her nasal hairs were singed, and carbonaceous deposits were present in her nares, throat, and posterior pharynx. Despite aggressive fluid resuscitation and ventilatory support, she remained hypotensive, and became progressively hypoxemic and hypercapnic until she died approximately eight hours after the fire.

Autopsy Findings

The degree and severity of body surface burns were documented. Carbonaceous material was noted in the throat and posterior pharynx as well as in the trachea and main stem bronchi. The liver was soft, yellow and greasy. Results of premortem blood work showed a blood alcohol level of 147 mg/dL.

Images

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  This photograph taken at autopsy demonstrates the severity of the surface burns on this patient.

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  This closer view shows the burned skin peeling off to expose the underlying tissue. The various depths of the burn can be appreciated by the color and character of the underlying tissue.

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  This photomicrograph of the burned skin depicts an area of third degree burn. There is some residual epidermis (arrow) but in the majority of this section the epidermis is gone. Also note the severe subcutaneous edema.

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  This high-power photomicrograph shows the denuded surface of the skin with thrombosed blood vessels (arrows) and necrosis of the dermis.

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  This medium-power photomicrograph of the burned skin demonstrates blister formation. The vessels in the dermis are congested (arrows).

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  This high-power photomicrograph of the burned skin shows the blister and the thrombosed vessels in the dermis.

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  This photomicrograph of the burned skin depicts an area of first degree burn. Note that there are no blisters and no damage to the dermis. There is mild damage to the superficial epidermis and some hyperemia (arrow).

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  This medium-power photomicrograph of the burned skin shows the mild damage to the superficial layers of the epidermis.

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  This photograph demonstrates the black carbonaceous material in the trachea.

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  This photograph of the lung again shows the black carbonaceous material in the trachea as well as in the main stem bronchi. The lungs are mildly congested and hyperemic. The patient lived for less than 8 hours after the burn injury so there was not enough time to develop a full-blown pneumonia.

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  This closer view of the lung shows the black carbonaceous material in the trachea as well as in the main stem bronchi.

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  This photomicrograph of the trachea shows sloughing of the tracheal epithelium and the black carbonaceous material contained therein (1). This degree of tracheal epithelial damage is indicative of severe inhalation injury. The tracheal cartilage rings can be seen in cross-section (2).

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  The damage to the tracheal epithelium and the black carbonaceous material is present down to the level of the terminal bronchioles.

Study Questions

• What was the immediate cause of death (COD) in this patient? What other factors played a role in this patient's demise?

The immediate cause of death for this patient is thermal injury involving 80% body surface area. This large body surface area of burn injury is very severe and has a poor prognosis. The gross and microscopic evidence of smoke inhalation and burn injury to the nose, throat and lungs are indicative of severe lung injury. Inhalation injury is seen in over 80% of patients with a burn size of 85% or more of the total body surface area. Carbon monoxide poisoning also contributes to the early death in inhalation injury. The manner of death in this case would have been accidental - unless someone deliberately set the fire.

This additional factor of the severity and the extent of the body surface area burn would likely have lead to death of this patient. Clinical management of a patient with burns this severe would be very difficult. Shock and sepsis are common problems in these patients.

• What is the significance of the fatty liver and the blood alcohol level noted in this patient?

The fatty liver and the elevated blood alcohol level indicate that this patient was severely incapacitated by alcohol prior to the fire. The patient was likely in an alcoholic stupor when the fire broke out and could not escape.

Additional Resources

Reference

• eMedicine Medical Library: Thermal Burns
• eMedicine Medical Library: Emergent Management of Thermal Burns
• Merck Manual: Burns

Journal Articles

• Fukuzuka K, Rosenberg JJ, Gaines GC, Edwards CK 3rd, Clare-Salzler M, MacKay SL, Moldawer LL, Copeland EM 3rd, Mozingo DW. Caspase-3-dependent organ apoptosis early after burn injury. Ann Surg 1999 Jun;229(6):851-8; discussion 858-9.
• Robert L. Sheridan, M.D.Fire-Related Inhalation Injury. NEJM 2016 Aug;375:464-469.

Images

• PEIR Digital Library: Burn Images