THERMAL BURNS Formatted: Bottom: 0.

69"

• Thermal burns are injuries caused by exposure of living tissue to high temperatures that
will cause damage to the cells.
• The extent of the damage caused is a function of the length of time of exposure as well as
of the temperature to which the tissues are exposed.
• The minimum temperature required to cause cell damage
• 44°C if exposed for several hours,
• Over 50°C or so, damage occurs more rapidly,
• At 60°C tissue damage occurs in 3 seconds.
The heat source may be dry or wet;
• where the heat is dry, the resultant injury is called a ‘burn’,
• whereas with moist heat from hot water, steam and other hot liquids it is known
as ‘scalds’.
Classification of thermal burns according to sources of heat
1. Flame burns
• In flame burns, there is actual contact of body and flame, with scorching of the
skin progressing to charring.
• Flame burns may or may not produce vesication but singeing of hairs and
blackening of skin is always present.
• Hair singed by flame burns become twisted and curled, breaks off or is totally
destroyed.
2. Flash burns
• Flash burns are a variant of flame burns.
• They are caused by the initial ignition flash fires that result from the sudden
ignition or explosion of gases, petrochemicals or fine particulate material.
• Typically, the initial flash is of short duration, a few seconds at most and
because the thermal conductivity of the skin is low, the burn is superficial.
• All exposed surfaces are burned uniformly.
• Flash burns usually result in partial-thickness burns and singed hair.
• If the victim’s clothing is ignited, a combination of flash and flame burns
occurs.
• Flash burns from methane explosion. Hair singed.
3. Contact burns
• Contact burns involve physical contact between the body and a hot object.
• A heated body when applied to the body for a short period causes a blister or
reddening corresponding to the size and shape.
• For a longer duration causes, trans-epidermal necrosis.
• The hair may be singed or distorted.
4. Radiant heat burns
• They are caused by heat waves a type of electromagnetic wave.
 • There is no contact between body and flame, or contact with a hot surface.
• Initially, the skin appears erythematous and blistered, with areas of skin
slippage.
• With prolonged exposure to low heat, the skin will become light brown and
leathery
• Radiant heat burns with erythema, blistering of skin and skin slippage
Classification of thermal burns according severity of burn injuries:
1. Dupuytrynes
I degree – erythema with transient swelling
II degree –vesication with blister formation
III degree – partial destruction of dermis
IV degree – complete destruction of dermis
V degree – involvement of subcutaneous tissues and also the muscles
VI degree involvement of bones
2. Hebras classification
1st degree - Involves only epidermis
2nd degree - Involves both epidermis and dermis
3rd degree - Involves subcutaneous tissues, muscles and bones.
3. Wilsons Classification
Epidermal - Involves only epidermis
Dermo epidermal - Involves both epidermis and dermis
Deep - Extend beyond dermis.
4. Evans classification
Superficial burn - involves only epidermis
Partial thickness - involves both dermis and epidermis
Full thickness - involvement beyond dermis
5. Muir and Sutherlands classification
Superficial partial thickness burn
Deep partial thickness burn
Full thickness burn
6. Modern day classification
I. First degree (superficial)
o Redness without blister
o Involving only epidermis
o painful
II. Second degree
a. Superficial partial thickness
o Redness with blisters
o Extending into superficial papillary dermis
o Very painful
b. Deep partial thickness
o Yellow or white burns
 o Extending into deep reticular dermis
o Pressure discomfort with no pain.
III. Third degree Formatted: Font: (Default) Times New Roman, 14 pt,
Kern at 12 pt
o Full thickness – white/ brown
Formatted: Centered
o Extending into entire thickness of skin.
o Painless Formatted: Font: (Default) Times New Roman, 14 pt,
Kern at 12 pt
IV. Fourth degree
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o Black, charred with Escher formation Bulleted + Level: 1 + Aligned at: 0.25" + Indent at: 0.5"
o Formatted: Font: Not Bold
o Extending into entire skin, subcutaneous fat, muscles and bone.
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o Painless Kern at 12 pt
Classification of burn injuries according to involvement of body surface area: Formatted: List Paragraph, Indent: Left: 0.3", Hanging:
Wallace rule of nine divides body surface into following regions 0.3", Numbered + Level: 1 + Numbering Style: 1, 2, 3, …
o Head, neck and face - 9 % + Start at: 1 + Alignment: Left + Aligned at: 0.74" +
Indent at: 0.99"
o Front of thorax - 9 %
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o Back of thorax - 9 %
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o Right upper limb - 9 % Kern at 12 pt
o Left upper limb - 9 %
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o Front of abdomen - 9 % 0.3", Numbered + Level: 1 + Numbering Style: 1, 2, 3, …
o Back of abdomen - 9 % + Start at: 1 + Alignment: Left + Aligned at: 0.74" +
o Front of right lower limb - 9 % Indent at: 0.99"

o Back of left lower limb - 9 % Formatted: Indent: Left: 0.3", Hanging: 0.3"

o Genitals – 1% Formatted: Font: (Default) Times New Roman, 14 pt,

Causes of death in victim of burn injuries:
1. Primary (neurogenic) shock due to pain
2. Secondary shock due to fluid loss ( in 48 hrs )
3. Smoke inhalation – CO, Cyanide, free radicals preventing oxygen entering blood.
4. Biochemical disturbances secondary to the fluid loss and destruction of tissues.
5. Acute renal failure usually occurs on third or fourth day.
Toxemia due to absorption of various metabolites
6. 5.Sepsis occurring after four to five days.
Kern at 12 pt
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+ Start at: 1 + Alignment: Left + Aligned at: 0.74" +
Indent at: 0.99"
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Kern at 12 pt
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0.3", Numbered + Level: 1 + Numbering Style: 1, 2, 3, …
+ Start at: 1 + Alignment: Left + Aligned at: 0.74" +
Indent at: 0.99"
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Formatted: Font: (Default) Times New Roman, 14 pt,
Kern at 12 pt

6.Biochemical disturbances secondary to the fluid loss and destruction of tissues. Formatted ...
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Acute renal failure usually occurs on third or fourth day. Formatted ...
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7. Gastrointestinal disturbances, as peptic ulceration, dilation of stomach, hemorrhage Formatted: Indent: Left: 0.3", Hanging: 0.3"
into intestines. Formatted ...
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 8. OedemaEdema of glottis and pulmonary oedemaedema due to inhalation of smoke Formatted ...
containing CO. Formatted ...
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9. Pyaemia, gangrene, tetanus etc Formatted ...
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10. Pulmonary embolism from thrombosis of veins of legs Formatted: Indent: Left: 0.3", Hanging: 0.3"
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11. Death due to malignant transformation of a burn scar ( Marjolin’s ulcer)
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Postmortem appearance in a deceased died due to burn injuries:
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External
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1. Clothes
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 Cotton fabrics burns faster.
 Nylon, polyester and wool produce less severe burns. Formatted: Font: Bold

 Close fitting garments are safer. Formatted ...

 Portions of body under tight fitting are comparatively unaffected, like belts, Formatted ...
shoes, brassier or buttoned collar. Formatted ...
 All clothes should be sent for examination of flammable substances Formatted ...
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2. Hair changes Formatted ...
 Hairs are singed, twisted, charred, broken off or completely destroyed. Formatted ...
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 In lesser degree of burns, bulbous enlarged of hair ends present. Formatted ...
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 The hairs present in armpits and skin folds are sometimes spared from singeing. Formatted ...
 The color of light hair changes on exposure to heat. Formatted ...
o at 1200C gray to brassy blond Formatted ...
o 2000C for 10 – 15 minutes brown hair to slight reddish. Formatted ...

 The black hair will show no color changes on exposure to heat. Formatted ...
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 Any unburnt or partially singed hair should be sent for examination for flammable Formatted ...
substances. Formatted ...
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External changes: Formatted: Font: Bold
 The face may be swollen and distorted Formatted ...
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 Tongue protrudes and burnt due to contraction of muscles of neck and face. Formatted ...
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 Froth may be present at mouth and nose due pulmonary edema caused by irritation of Formatted ...
air passages.
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1.
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 Formatted: Font: (Default) Times New Roman, 14 pt,
Kern at 12 pt
Heat ruptures
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 In severe burning, skin and underling tissues contracts and bursts to form heat Aligned at: 0.25" + Indent at: 0.5"
ruptures.
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Kern at 12 pt
Can happen before and after death of individual. Formatted: List Paragraph, Bulleted + Level: 1 +
Aligned at: 0.25" + Indent at: 0.5"
 Usually seen in extensor aspects of limbs and joints. Formatted: Font: (Default) Times New Roman, 14 pt,
Kern at 12 pt
 Several centimeters in length and resembles lacerations or incised wounds,
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Aligned at: 0.25" + Indent at: 0.5"
 Differentiated by
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Kern at 12 pt
o Absence of bleeding as heat coagulates the blood in the vessels. Formatted: List Paragraph, Bulleted + Level: 2 +
Aligned at: 0.75" + Indent at: 1"
o Intact vessels and nerves at the floor Formatted: Font: (Default) Times New Roman, 14 pt,
Kern at 12 pt
Irregular margins Formatted: List Paragraph, Bulleted + Level: 2 +
o Aligned at: 0.75" + Indent at: 1"
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Kern at 12 pt
o Absence of vital reactions in the margins.
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 Can happen before and after death of individual.
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2. Pugilistic attitude ...

 The characteristic posture of a body which has been exposed to high heat. Formatted: Font: Bold

o Legs – flexed at hips and knees Formatted ...

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o Arms – flexed at elbows and wrists, held out in front of body Formatted ...
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o Head – slightly extended Formatted ...
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o Fingers – hooked like claws. Formatted ...
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o Trunk – Opisthotonus due to contraction of para spinal muscles. Formatted ...
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 The attitude is similar to boxers defending position, pugilism( sport of fighting with Formatted ...
fist) and so the name. Formatted ...
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 This stiffening is due to coagulation of proteins of the muscles and dehydration.
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 The flexor muscles being bulkier than extensors their contraction causes this attitude.
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  It occurs in both alive and dead at the time of burning. Formatted: Font: (Default) Times New Roman, 14 pt,
Kern at 12 pt
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Aligned at: 0.25" + Indent at: 0.5"
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Internal changes
1. Heat hematoma Formatted: Font: (Default) Times New Roman, 14 pt,
Bold, Kern at 12 pt
 Whenever Hhead when is exposed to intense heat., there will be collection of clotted
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blood in extradural space of1.5 mm to 15 mm thickness
0.3", Numbered + Level: 1 + Numbering Style: 1, 2, 3, …
1. + Start at: 1 + Alignment: Left + Aligned at: 0.25" +
 Soft, friable clot of brown/ pink color due to presence of carboxy hemoglobin. Indent at: 0.5"
Formatted: Font: (Default) Times New Roman, 14 pt,
Kern at 12 pt
Resembles extradural haemorrhage.
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Aligned at: 0.25" + Indent at: 0.5"
Head when exposed to intense heat.
Formatted: Normal, Indent: Left: 0", First line: 0",
Bulleted + Level: 1 + Aligned at: 0.25" + Indent at: 0.5"
No signs of external injuries. Formatted: List Paragraph, Bulleted + Level: 1 +
On cut section of clot, Aligned at: 0.25" + Indent at: 0.5"
Soft, friable clot of brown/ pink color. Formatted: Indent: Left: -0.25", Bulleted + Level: 1 +
 Honeycomb appearance is presentof clot due to bubbles of stream produced by heat. Aligned at: 0.25" + Indent at: 0.5"

 Parieto- temporal region is the most common site. Formatted: List Paragraph, Bulleted + Level: 1 +
Aligned at: 0.25" + Indent at: 0.5"
 Mechanism of development is due to contraction of meninges and expansion of blood
in venous sinuses expulses the blood in extradural space.
 Resembles extradural hemorrhage but with no signs of external injuries.
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1.5 mm to 15 mm thickness

 Charring of surrounding outer table of vault. Formatted: List Paragraph, Bulleted + Level: 1 +
Aligned at: 0.25" + Indent at: 0.5"
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Parieto temporal region is the most common site.
Mechanism of development may be due to contraction of meninges and expansion of
blood in venous sinuses and in skull diploe
2. Thermal fractures of skull
 Two mechanism of causation
o Increase in intracranial pressure bursting the non- united sutures and producing
widely separated bony margins.
o Due to rapid drying of the bone causing contracture of the outer table.
 Usually seen on either sides of template region.
 Usually stellate shaped
 May crosses the suture line.
 Fractures of long bones are also seen in cases of intense heat
 Due to excessive shrinkage of muscles attached to bones.
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0.3"
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Kern at 12 pt
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0.3", Numbered + Level: 1 + Numbering Style: 1, 2, 3, …
+ Start at: 1 + Alignment: Left + Aligned at: 0.25" +
Indent at: 0.5"
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Bold, Kern at 12 pt
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Kern at 12 pt
Formatted: List Paragraph, Bulleted + Level: 1 +
Aligned at: 0.25" + Indent at: 0.5"
Formatted: List Paragraph, Bulleted + Level: 2 +
Aligned at: 0.75" + Indent at: 1"
Formatted: Font: (Default) Times New Roman, 14 pt,
Kern at 12 pt
Formatted: Indent: Left: -0.25", Bulleted + Level: 2 +
Aligned at: 0.75" + Indent at: 1"
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Aligned at: 0.75" + Indent at: 1"
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Aligned at: 0.25" + Indent at: 0.5"
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  CCompletely burnt bones will be greyish white in colour.
3. Inhalational injuries
 Carbon monoxide levels will be more than 10% and can govaries up to 70 to 80 %

 Children and old people die at 30 to 40 %

 Aspirated blackish coal particles are seen in nose, mouth, larynx, trachea, bronchi,
esophagus and stomach.
 When mouth is open, passive percolation of soot particles may present up to pharynx
but not beyond vocal cords.

 Inhalational injuries can occur due to other poisonous gases like cyanides and oxides
of nitrogen

 Presence of carbon particles and an elevated CO level are absolute proof of patient
being alive at the time of burns.

If flame or super heatedsuper-heated air is inhaled, burns are seen interior of mouth,
nasal passages, larynx with .

 vocal cord epithelium destruction, edema of larynx and lungs are seen.

Hemoconcentration is also seen.

4. Brain and Meninges
 Usually shrunken.

 Firm in consistency.

 Yellow to light brown in color.

 Dura matter becomes leathery.

 Dura matter may split with brain matter oozing out forming frothy paste.
5. Pleura and Lungs
 Pleura are congested and inflamed.

 Lungs are usually congested and edematous.

 Heavy, airless and consolidated.

 Blood vessels of lungs may contain a small amount of fat due to physio chemical
alteration of already fat present.
6. Heart and Pericardium
 Petechial hemorrhages present in pleura, pericardium and endocardium.

 Heart is usually filled with clotted blood.

 Interstitial edema and fragmentation of myocardial fibers are also seen.

7. Gastro intestinal tract
 Inflammation and ulceration of peyers patches and glands of the intestines.

 Curlings ulcer
o Seen in less than 10% cases
o Usually seen after 10 days of survival
o Sharp punched out lesions in duodenum
o May be superficial or deep

 Gastric ulcers may occur within a day.

 May erode vessels leading to fatal haemorrhagehemorrhage

8. Spleen
 Enlarged and softened

9. Liver
 Enlarged and congested
 May develop jaundice

10. Kidneys
 Enlarged with capillary thrombosis and infarction

11. Adrenals
 Enlarged and congested
Time of death in burns cases
The features from which time since death were assessed are altered in a case of complete
burns.

 Rigor mortis cannot be assessed as most of muscles tissues are destroyed.

 Heat rigors may be present in the muscles.

 Postmortem hypostasis cannot be assessed in completely burnt bodies, as skin over

the body are usually charred and destroyed.

 Body temperature will also be altered in complete burns.

Thus its always difficult to assess the time since death in burns cases.

Establishment of identity
 Weight and height are unreliable in complete burns

Due to drying of skin,

Skeletal fractures
Pulverisation of intervertebral discs

 Moles, scars and tattoo marks are usually destroyed

 Dental charts should be prepared and used.

 Postmortem x rays can be compared with previous x rays of suspected individual.

 DNA typing and identification will be useful

 Sex can be identified by presence of uterus or prostate, which resist burning to marked
degree.

 Personal belongings like key chains, watch, buttons, belt buckle and cuff links are also
useful

Antemortem and Postmortem burns

Line of redness

 5 to 20 mm in width.
 Surrounds the burnt area.
 Involves whole thickness of skin
 Permanent and persist after death
 Absent when whole body is burnt.

Antemortem Blisters:

 Raised dome with gas or fluid

 Contains serous fluid with proteins

 Base and periphery shows red and inflamed areas.

 Surrounding areas show increase in enzymes like acid mucopolysaccarides.

Postmortem Blisters:

 Dry, hard and yellow

 Contains air and thin Clear fluid

 Base is not inflamed.

 Peripheral zone doesn’t shows increase in enzymes.

Circumstances of burns
Accident:
 Women’s clothes may caught in fire while cooking.

 Injuries are concentrated in front of thighs, chest, abdomen and face.

 Hands also shows injuries as they will try to douse the fire.

 Feet and ankles are spared.

 While lying on a flat surface, the skin resting is spared

Suicidal burns:
 Extensive burns present all over the body.

 Only the skin folds such as axillae, perineum and soles are spared.

 Sometimes person use to keep clothes in mouth to suppress the cries.

 Inflammable substances are usually present in high amounts in head.

Homicidal burns:
When inflammable substances are thrown and lighted, then the burns are found more on.

 Sides of neck.
 Sides of trunk.
 Between the thighs.

 Attempts may be made to burn the body after the homicide to conceal the crime.
So in all cases of burns, during postmortem the presence of any other fatal injuries should be
identified.
Sometimes chemicals, irritating substance, hot boiling liquids are thrown over the victims
with the criminal intension.
Effects of high environmental temperature
 Heat cramps
 Heat exhaustion
 Heat stroke
1. Heat cramp – fireman’s cramp/ miner’s cramp
 Occurs in person working in hot atmosphere and sweating Profusely.
 It is due to rapid dehydration with loss of water and salt through sweat
 Characterised by severe painful cramps of voluntary muscles.
 Muscles of arms, legs and abdomen are usually affected.
 Face will be flushed, pupils dilated
 Complaints of dizziness, tinnitus, headache and vomiting - rare.
2. Heat Exhaustion- Heat Prostration/Heat Syncope
 It is a condition characterised by collapse without increase in body temperature.

 Due to exposure to excessive heat and aggravated by muscular work and unsuitable
clothing.
 Leading to extreme exhaustion and peripheral vascular collapse
 Patient may feel sudden weakness and giddiness.
 Face will be pale, skin cold, subnormal body temperature, Pupils dilated, small and
thready pulse with shallow respiration
 Death rarely occurs by cardiac failure due to cardiac overload.
3. Heat Stroke – Heat Hyperpyrexia/ Sun Stroke
 Hyperpyrexia is fever above 41.5o C
 Heat stroke is characterised by rectal temperature above 41.5o C and neurological
disturbance like psychosis, delirium, stupor, coma and convulsion on exposure to sun.
 Due failure of thermo-regulatory mechanism of thalamus.
 Onset is sudden with sudden collapse and loss of consciousness, skin will be dry, hot
and flushed with complete absence of sweating
 Pupils contracted, rapid & irregular pulse(>130), rapid and deep breathing(130)
 Convulsion occurs leading to delirious and comatose state.
 Death occurs in five minutes due circulatory collapse and cardiac failure.
 Predisposing factors – high temperature, increased humidity, minor infections,
muscular activity, lack of acclimatisation, old age, unsuitable clothing.

Electrical injuries
 Electrons, the outer particles of an atom, contain a negative charge. If electrons collect on
an object, that object is negatively charged.
 If the electrons flow from an object to another, the flow is called electric current.
 Voltage is the fundamental force or pressure that causes electricity to flow through a
conductor and is measured in volts.
 Resistance is anything that impedes the flow of electricity through a conductor, which
is measured in ohms.
 Current is the flow of electrons from a source of voltage through a conductor, which is
measured in amperes
Factors Influencing Electrical Injuries
1. The type of current:
 Alternating current is 4 to 5 times more dangerous than the direct current of same
voltage.
2. The amount of current:
 Amount of current that flows through the body is given by the formula Ampere(A)
= voltage / resistance. So a current of high voltage and body of low resistance will
cause more damage.
3. The path of current:
 Death is more common if the brain stem or heart are in the path of current.
4. Duration of current:
 Severity is directly proportional to the duration of flow of current.
Effects of Current on living tissues.
1mA- Tingling of the fingers
5mA- Tetanic muscle contractions and so grab the power conductor (no-let-go threshold),
Leading to increase in the duration of contact with current.
15mA- control over muscles is lost
50mA- loss of consciousness, severe muscles contractions, leading to fractures in bones.
Paralysis of respiratory muscles and respiratory arrest.
eg. Bilateral scapular fractures, Bilateral humeral fractures, Bilateral neck of
femur fractures, T12- L1 fractures.)
70mA- Fatal
Local effects:
 Current passing through skin produces heat causes burns in skin and underlying
tissues, also boiling and electrolysis of tissue fluids.
 Depends on Resistance (R)–
If increased-
o increased local injury due to more heat generation,
o but decrease the entry of ampere amount and decrease fatality.
If decreased-
o decreased local injury due to less heat generation
o but increase the entry of amperes and hence the fatality.
Well moistened skin reduces resistance and so no electrical burn marks in comparison
to dry skin which shows well marked skin.
Electric Mark – Joule Burn
  It is thermal burns caused due to heat generated by passage of electric current
through body.
 Theses marks are round or oval in shape, 1 to 3 cm in diameter with shallow crater
with a ridge of skin raised around part or whole of circumference.
 The skin surrounding the mark are some times blanched often with hyperaemic
border.
 As the duration of contact increases, the skin in the mark will become brown and
then charred.
 If the conductor contains copper, the electric mark will have a green colour.
 Occasionally the electric mark resembles the shape of conductor.
 It is specific and diagnostic of contact with electricity found at the point of entry of
current.
Histopathological findings of electrical burns:
 Coagulation of dermis
 Cells of epidermis is elongated and arranged in parallel rows at right angles to
dermis
Flash or Spark Burns or arc burns
 When the body comes in close range of a high tension wire, electrons jump from
wire to skin even though there is no contact, which results in arc burns.
 These arc burns are multiple in number and usually pinpoint in nature.
 They have a central nodule of fused keratin of brown or yellow colour surrounded
by areola of pale skin.
 Confluence of arc burns over a large area produce crocodile skin/ crocodile
flash burns.
Cause of death in electrocution
1. Ventricular fibrillation
2. Respiratory failure due to spasm of respiratory muscles
3. Cerebral anoxia
4. Delayed death due to complication of burns.
Autopsy Findings & Medico Legal Importance
 Entry wound and exit wound helps to find out the pathway of current
 All the organs will be congested with petechial haemorrhage
 Usually accidental, however there are cases of suicide and homicide
 Judicial electrocution is followed in some states of US
LIGHTNING
 Natural, high voltage direct current (DC) in the atmosphere is called lightning or
lightning flash.
 Usually seen with thunderstorms
 Sometimes when it is not raining.
 Lightning is attracted to
o Trees, Metal fences, Gates,
 o Tall light poles, Power lines
o Open areas such as grounds, swimming pools (unless properly grounded)
Lightning power
 Voltage- 10-100 million V
 Current 10,000-100,000A
 Temperature- 15,000-50,000 F
 But the duration is extremely small. (1/10,000sec),
Due to phenomenon called flashover, majority of energy travels over the surface of the
victim’s body therefore, no burns at all or very small burns- pin head sized or scratches
like, minor singeing of hair Pinhead sized exits
Mechanism of Injury
1. Direct strike-
 Current strikes directly, affect metal objects worn,
2. Side flash or splash-
 Current jump ricochets from adjacent object to the victim and transient fern-like
(Lichtenberg/ arborescent burns) marking may be seen. May remain or disappear
with time, associated with singing of adjacent hair. Haemolysis due to heat along
the BVs may be the cause
3. Ground strike-
 Current conducts from ground to the victim, can enter through one leg and exit
through the other.
4. Contact strike-
 when in contact with a electrical conductor
Post Mortem findings
1. Melting of metallic objects – eg coins, wrist watches, ornaments- contact burns
2. Magnetization of objects- eg coins, wrist watches, ornaments
3. Metallization- small metal particles travel into the body with current. (could be
demonstrated by histopathology)
4. Blast wave effects- blast of shoes, tearing of clothes etc tearing of internal organs such
as lungs, bowels etc.
5. Burns. Could be surface burns beneath metallic object.
6. Linear burns – along skin creases. Eg. on palm. Due to dampness on creases.
7. Fern like/ arborescent burns-
 Superficial, thin, irregular torturous markings like a branch of tree.
 Due to rupture of smaller blood vessels.
 Transient disappears in few hours
 Diagnostic of burn injury due to lightening.
Explosive effect can cause
 Rupture of eardrums.
 Multiple foci of SAH
 Throws the victim away, and fall
 May rip clothing and shoes. Clothes can get shredded, or burnt