Burn injuries represent one of the most severe forms of trauma, constituting a major global public health problem.^1,2 The forensic investigation of a burn fatality extends beyond establishing identity; it is critical for determining the cause, mechanism, and manner of death, which has profound implications for legal accountability.³

A pivotal factor in the prognosis of a burn victim is the Total Body Surface Area (TBSA) affectedThe "Rule of Nines" and the more precise Lund and Browder chart are standard tools used to estimate this percentage, which directly dictates fluid resuscitation needs, nutritional support, and overall survival probability^4,5. Burns exceeding 15-20% TBSA can induce systemic effects, including hypovolemic shock and profound immunosuppression leading to septicemia.^6,7 The cause of death follows a temporal sequence: Immediate deaths are rare, early deaths (within 24 hours) are often due to hypovolemic shock, and delayed mortality (days to weeks) is predominantly attributable to infection, septicemia, and multi-organ failure.^8,9 Therefore, the survival period serves as a crucial proxy for inferring the underlying cause of death in a forensic context.

This study aims to provide a forensic-pathological analysis by systematically correlating categorized burn extent from autopsies with precise survival periods to elucidate the predominant pathways to death in a medicolegal case series.

Aims & Objectives

1. To determine the distribution of fatal burn cases based on the Total Body Surface Area (TBSA) involved.
2. To correlate the percentage of TBSA burned with the subsequent survival period of the victims.

Sample Size: A prospective descriptive study was conducted over a 20-month period (December 2014 to August 2016) using the convenient sampling technique. The study group consisted of 39 cases of death due to burns.

Inclusion/Exclusion Criteria: The study included all consecutive medicolegal autopsies for deaths due to burns performed at General Hospital, Ernakulam. Decomposed bodies were excluded to ensure accurate assessment of burn injuries and survival signs.

Data Collection and Categorization: TBSA burned was meticulously estimated during autopsy and categorized into three groups: Low (L): 40-60%, Medium (M): 60-80%, and High (H):

80-100%¹⁰. The time interval between the burn incident and death was recorded in days. Cases were documented as "Hospitalised" or "Non-Hospitalised" as a key indicator for distinguishing between short-term survival and delayed mortality.

Statistical Analysis: Descriptive statistics (frequencies, percentages, mean, and standard deviation) were used to summarize the data.

The analysis of the 39 fatal burn cases revealed specific patterns in TBSA distribution, gender, and survival time. The majority of fatalities were concentrated in the Medium burn severity group (60-80% TBSA), which accounted for 21 cases (53.8%) of the deaths.(Table.1)

Table 1: Distribution of Fatal Burn Cases by TBSA Category

Observation: The Medium burns group (60-80% TBSA) accounted for the majority of fatalities (53.8%).

Table 2: Gender Distribution of Fatal Burn Cases (n=39)

Observation: Females predominated significantly, accounting for 85% of the victims in this study

The detailed ten-percent interval analysis reinforced this finding, showing that the single highest concentration of fatal cases was in the 60-69% TBSA range (28.2%). This demonstrates that while high-TBSA burns (80-100%) are inherently more lethal, the intermediate-to-high range of 60-80% TBSA was statistically the most represented among the studied deaths (Table.3)

Table 3: Frequency of Fatal Burn Cases by TBSA Percentage (Ten-Percent Intervals)

The highest single concentration of fatal cases was observed in the 60-69% TBSA range (28.2%), reinforcing the finding that the medium burn group (60-80% TBSA) is the most represented among fatalities

A highly significant finding was the pronounced female predominance in the cases. Females constituted 33 cases (85%), while males accounted for only 6 cases (15%). (Table 2)

The overall survival period for the cohort ranged from 1 to 17 days, with an average of 4.92 days. A large majority, 85% (n=33), were hospitalized before death And 15% (n=6) were non - hospitalised (Fig 1). The analysis of survival trends revealed a clear correlation between burn severity and the likelihood of death within 24 hours.The High Burns (80-100% TBSA) group had the highest proportion of early deaths, with 60% (3 out of 5 cases) dying within the first 24 hours, meaning only 40% survived longer than one day.Conversely, the Low Burns (40-60% TBSA) group demonstrated the greatest short-term survival capacity, with 76.9% surviving beyond 24 hours. (Table 4)

Table 4: Survival Trend by TBSA Group and Time Period (n=39)

The overall survival period ranged from 1 to 17 days, with an average of 4.92 days

Overall, two-thirds of the total cases (66.7%, n=26) survived for longer than 24 hours, suggesting that the majority of deaths occurred as delayed consequences of the injury rather than immediate traumatic shock.

Table 4 shows the distribution of the 39 fatal cases based on specific TBSA ranges. The grouping highlights that the majority of deaths occur in the intermediate-to-high TBSA ranges.The highest single concentration of fatal cases was observed in the 60-69% TBSA range (28.2%), reinforcing the finding that the Medium burn group (60-80% TBSA) is the most represented among fatalities.

Table.5  Distribution of Burn Injuries Among 39 Fatal Cases

Table.6 Cause of Death in Fatal Burn Cases (n = 39)

Observation and Comparison:

• The High Burns group (80-100%) had the maximum burn percentage and the highest ratio of victims who died sooner (within 24 hours), accounting for 60% of their group. This suggests rapid demise due to overwhelming, non-survivable injury.
• The Low (40-60%) and Medium (60-80%) groups demonstrated that the majority of victims in these categories died later (after 24 hours), with survival rates beyond this point being 76.9% and 66.7%, respectively. This pattern implicates delayed complications like septicemia or shock, providing a larger window for the development of these sequelae.
• The fact that two-thirds (66.7%) of all fatalities survived beyond 24 hours confirms that delayed death pathways are the predominant outcome in this series. The most common cause of death identified was septicemia (81%), followed by neurogenic shock/circulatory failure (12%) and asphyxia (7%).

This study provides a clear forensic-pathological perspective on the natural history of fatal burn injuries, emphasizing the central role of burn extent and survival time.The finding that over half of the fatalities (53.8%) occurred in the Medium burns group (60-80% TBSA) is significant. This range represents a critical threshold where the injury is universally severe enough to be fatal, yet victims often survive long enough to reach medical care and develop systemic complications. This aligns with clinical data indicating mortality rates rise sharply with TBSA, often exceeding 50% in adults with burns over 60% TBSA11.

Among the 39 fatal burn cases, the head and neck were the most frequently affected region (63%), followed by the upper limbs (50%) and anterior trunk (56%). The lower limbs (39%), genitalia (31%), and back (22%) were less commonly involved (Table.5).

This distribution highlights that exposed and vital areas, particularly the head, neck, and upper torso, are at higher risk in fatal burn incidents, which may contribute to rapid deterioration and mortality.The most common cause of death was septicemia (81%)7, reflecting severe systemic infection following extensive burns. Asphyxia (7%) occurred mainly due to inhalation injuries, while neurogenic shock or circulatory failure (12%) contributed to fatalities in cases with severe trauma or high TBSA burns. (Tabe 6)

The documented mean survival period of nearly 5 days, coupled with the fact that 84.6% of deaths occurred in the hospital, is the most telling finding. It shifts the paradigm of the "cause of death" in a forensic context from the burn itself to its complications. These individuals died days later from the systemic consequences of the injury, not instantaneously from the flames.

The survival trend is forensically logical:

• High TBSA (80-100%) victims often succumb early (within 24 hours) due to irreversible shock from overwhelming tissue damage.
• Low and Medium TBSA victims survive longer, allowing the devastating sequelae of septicemia and multi-organ failure to set in. The predominance of septicemia (81%) as the cause of death underscores this delayed pathway.

These findings have direct implications for death certification. A death certificate listing only "burns" is insufficient. A more precise and accurate certification would be, for example, "Septicemia due to complications of 70% TBSA burns," which is crucial for legal cases and accurate public health statistics.

Limitations: The sample size, particularly in the High burns group, is a limitation, and the survival data relied on existing records which can sometimes be approximate.

Ethical Clearance : Ethical Clearance was obtained from the Thesis Protocol Review Committee, Amrita Institute of Medical Sciences, Kochi, Kerala with Letter No.MD/MS/2014/13 dated 15/12/2014.

This forensic analysis demonstrates that the extent of burn injury is a primary driver of survival time and the ultimate cause of death. In our study, death was predominantly a delayed event, occurring after hospitalization due to complex physiological sequelae

The findings underscore the need for a sophisticated approach in forensic pathology that:

1. Accurately quantifies TBSA during autopsy as a cornerstone of the
2. Meticulously documents the survival period and clinical
3. Seeks and documents pathological evidence of the specific fatal complication (e.g., sepsis, shock) during the internal examination.

By correlating burn extent with survival data, forensic pathologists can provide a more precise and scientifically grounded cause of death, which is essential for the administration of justice, accurate mortality reporting, and improving clinical understanding of burn mortality.

1. Gupta R, Kumar V, Tripathi SK. Profile of the fatal burn deaths from the Varanasi region, India. J Clin Diagn Res. 2012.
2. World Health Organization. Burns (fact sheet). 2016.
3. Knight B, Saukko P. Burns and scalds. In: Knight's Forensic Pathology. 2004.
4. Wallace AB. The exposure treatment of burns. Lancet. 1951.
5. Lund CC, Browder NC. The estimation of areas of burns. Surg Gynecol Obstet. 1944.
6. Monafo WW. Initial management of burns. N Engl J Med. 1996.
7. Sharma BR, Harish D, Singh VP, Bangar S. Septicemia as a cause of death in burns: an autopsy study. Burns. 2006.
8. Umadethan B. Thermal Injuries In: Principles and Practice of Forensic Medicine. 2008.
9. Church D, Elsayed S, Reid O, Winston B, Lindsay R. Burn wound infections. Clin Microbiol Rev. 2006.
10. Yalcin B, Ugur K. Fire related fatalities in Istanbul, Turkey: Analysis of 320 autopsy cases. J Forensic Leg Med. 2009.
11. Bull JP. Revised analysis of mortality due to burns. Lancet. 1971.