BURNS

 Burn Causes and Characteristics:

o Burns result from energy transfer from physical or chemical sources into living tissues,
disrupting normal metabolic processes and causing tissue death.
o Burns can range from superficial to deep charring, affecting muscle and bone.
o Skin can dissipate heat rapidly, but burn injury occurs when heat absorption exceeds
dissipation.
o Local cellular damage occurs with surface skin temperature above 44°C, with significant
damage above 51°C, and full-thickness destruction above 70°C.
 Factors Affecting Damage:
o Degree of damage depends on temperature and duration of heat source application.
o Skin surfaces exposed to temperatures between 44°C to 51°C experience increased damage
with limited exposure time, doubling the rate of cellular destruction with each degree rise in
temperature.
 Types of Heat Sources:
o Heat sources may be dry or wet.
o Dry heat results in burns, while moist heat from hot water, steam, or other liquids causes
scalding.
 Special Cases:
o Certain settings like war zones or terrorist attacks may lead to specific types of thermal injuries
from improvised explosive devices, posing unique management challenges.
 Severity of Burn:
o Historical classification includes:
 First degree: erythema and blistering.
 Second degree: burning through full-thickness of epidermis, exposing dermis.
 Third degree: destruction down to subdermal tissues, possibly with carbonization and
exposure of muscle and bone.
o Some classifications extend to 4th, 5th, and 6th degree burns indicating more extensive tissue
damage.
o Modern classification for treatment options distinguishes between full-thickness and partial
thickness burns (superficial and deep).
 Extent of Burn:
o Assessment of burn danger often considers the size of the burned area.
o Body surface area (BSA) affected by burns is expressed as a percentage of total body surface
area (TBSA) using the Rule of Nines.
o Rule of Nines assigns percentages to different body areas to estimate TBSA burned, crucial for
fluid resuscitation estimation and severity assessment.
o Factors influencing mortality risk include burn area, age, and inhalation airway injury
presence, with multiple risk factors increasing death risk.
o Individual variation exists, and prompt emergency treatment significantly impacts morbidity
and mortality.
 Clothing Protection and Pattern Recognition:
o In dry burns, clothing can provide some protection against heat unless it ignites.
o Scars or burns may reflect clothing pattern or style worn at the time of the burn, aiding in
pattern recognition.
SCALDS
 General Features:
o Similar to burns with erythema and blistering, except charring is rare except with extremely
hot substances like molten metal.
o Pattern of scalding depends on the exposure method: immersion results in upper "fluid level,"
while pouring, splashing, or scattered droplets lead to punctate areas.
o Runs or streams of hot fluid leave characteristic scalding patterns, often indicating the victim's
orientation or position during exposure.
 Impact of Hot Liquid Quantity and Clothing:
o Rapid cooling occurs with small amounts of hot liquid, reducing skin damage.
o Clothing soaked with hot fluid can exacerbate skin damage by retaining heat against the skin
surface.
 Causes and Settings:
o Typically seen in industrial accidents involving burst steam pipes or boilers.
o Toddlers may experience scalds by pulling kettles or saucepans onto themselves.
o Common in child physical abuse, often intentional and the most common form of intentional
thermal injury in children.
 Characteristics of Intentional Scalds:
o Forced immersion in hot water leads to symmetrical glove and stocking injuries to limbs,
sparing skin folds, and buttocks.
o Injuries are of uniform depth and often have a specific distribution pattern.

PATHOPHYSIOLOGICAL CONSEQUENCES OF THERMAL INJURY

 Inflammatory Response:
o Tissue exposed to burn or scald trauma triggers an acute inflammatory response.
o Increased capillary permeability occurs at the injured site.
 Fluid Loss and Shock:
o Thermal injury leads to severe tissue fluid loss, causing dehydration, electrolyte disturbance,
and hypovolemic shock.
o If burn area exceeds 20% of the Total Body Surface Area (TBSA), systemic inflammatory
mediators are released.
 Systemic Effects:
o Systemic inflammatory response may lead to acute lung injury and multiple organ
dysfunction/failure.
o Burned skin lacks protection against infection, increasing the risk of sepsis in survivors.
EXPOSURE TO HEAT/HYPERTHERMIA
 Hyperthermia Definition:
o Hyperthermia is when the core body temperature exceeds 40°C (100°F), resulting from
ineffective dissipation of heat.
 Causes:
o It may be triggered by certain prescribed drugs like anti-psychotics, illicit stimulants such as
cocaine and amphetamine, or some novel psychoactive substances.
o Medical conditions like hyperthyroidism or resistance to restraint can also lead to
hyperthermia.
o Exposure to high ambient temperatures, known as heat stroke, poses a significant risk of
mortality or morbidity.
o Hyperthermia can occur in exertional heat stroke during intense physical activity or non-
exertional heat stroke, affecting the elderly and infirm as well as the young and fit.
o Children trapped in hot cars are also at risk.
 Autopsy Findings:
o Autopsy findings in hyperthermia cases are nonspecific but may include diffuse petechial
hemorrhages of serosal membranes, lung congestion, and features indicative of shock and
multiple organ failure in those who survive for a short period despite resuscitative efforts.

PATHOLOGICAL INVESTIGATIONS OF BODIES RECOVERED FROM FIRES

 Caution in Fire-Related Fatalities:
o Fire-related fatalities should be approached cautiously due to the potential for concealing
homicide.
 Investigation and Safety:
o Specialist investigators with expertise in fire causes and accelerant identification are essential.
o Pathologist attendance aids in interpreting post-mortem findings.
o Safety of investigators, especially after events like gas explosions, is crucial.
 Fire Scene Examination:
o Specialists examine the fire scene to determine the cause and origin of the fire.
o The victim's position at the scene provides clues about their movements and state during the
fire.
 Pathological Investigation:
o Objectives include confirming identity, determining whether the victim was alive during the
fire, establishing the cause and manner of death.
o Visual identification may be challenging due to heat damage, necessitating reliance on dental
records or DNA analysis.
o Post-mortem radiography aids in identification, detecting fractures, and excluding projectiles.
o Presence of soot in airways and carboxyhemoglobin levels help determine if the victim was
alive during the fire.
DEATHS OCCURING DURING A FIRE
 Causes of Death in Fires:
o Most fire-related deaths result from exposure to combustion products like smoke and carbon
monoxide, rather than direct burns.
o Complications of thermal injury, such as shock, infection, respiratory failure, renal failure, or
bleeding, can lead to death.
 Determining Manner of Death:
o Forensic pathologists often provide opinions on the manner of death in fire-related fatalities.
o Interpretation is complicated by post-mortem artefacts related to fire exposure.
 Post-Mortem Artefacts:
o "Pugilist attitude": Heat-related muscle contraction leads to flexion of limbs.
o Splitting of burnt skin, heat-related fractures, and extradural hemorrhage are common artefacts.
o These artefacts may be misinterpreted as signs of pre-mortem violence.
 Distinguishing Artefacts from Trauma:
o Careful examination is needed to differentiate post-mortem artefacts from pre-mortem trauma.
o Lack of evidence of vitality (e.g., erythema, blistering) helps distinguish artefacts from ante-
mortem trauma.
 Manner of Death:
o Deaths in fires can be classified as homicide (e.g., arson), accident (e.g., cooking accidents), or
rarely, suicide (self-immolation).
COLD INJURY
 Cold Injury and Hypothermia:
o Hypothermia, defined as core body temperature below 35°C, can lead to death, especially in
cold environments or water immersion incidents.
o Exposure to cold causes heat loss through various mechanisms, including radiation,
convection, conduction, respiration, and evaporation.
o Vulnerable individuals include those in extreme weather conditions, homeless people, heavy
alcohol or drug users, and trauma patients.
 Physiological Responses to Cold:
o Initial responses to cold include shivering and vasoconstriction to conserve heat.
o Prolonged exposure may lead to decreased heart rate and loss of shivering ability.
o Alcohol consumption exacerbates hypothermia by dilating blood vessels.
 Clinical Presentation and Diagnosis:
o Hypothermia is diagnosed based on symptoms and environmental conditions, classified as
mild, moderate, or severe.
o Symptoms worsen as core body temperature drops, with unconsciousness occurring below
30°C.
 Treatment and Management:
o Controlled rewarming under medical supervision is crucial for severe cases.
o Other therapeutic interventions, such as dialysis, may be necessary.
 Forensic Aspects:
o Hypothermia deaths can occur even in moderately cold weather, particularly affecting the
elderly and children.
o Certain death scene findings, such as paradoxical undressing and "hide and die" syndrome,
may indicate hypothermia but could be misinterpreted.
ELECTRICAL INJURY
 Electrocution Overview:
o Electric current passing through the body can cause injury or death, with the current
measured in milliamperes (mA).
o Resistance of tissues (ohms) and voltage of the power supply (volts) determine the current,
following Ohm's Law.
 Factors Influencing Harm:
o Public power supplies typically deliver electricity at 110 V or 240 V, with death rare below
100 V.
o Entry point of current is often a hand touching a conductor, with exit to earth, passing
through the thorax, posing cardiac and respiratory risks.
 Effects on the Body:
o Pain and muscle twitching occur at about 10 mA; muscle spasms at 30 mA may cause the
"hold-on" effect, dangerous due to prolonged contact.
o Current across the chest exceeding 50 mA for seconds can lead to fatal ventricular
fibrillation, more common with alternating current (AC).
 Impact of Conditions:
o Skin resistance varies, decreasing when wet, significantly increasing current flow, relevant in
wet environments or when sweating.
 Modes of Death:
o Ventricular fibrillation, often reversible upon current cessation, is the primary cause of death,
while primary brainstem paralysis is rarer.
o Scene of suspected electrical death should be reviewed to identify causative agents and
mitigate risks per health and safety legislation.
THE ELECTRICAL LESION
 Identification Challenges:
o Difficulty in determining if a victim was in contact with electricity, especially with brief
exposure or low voltages.
o Extensive burns may result from high voltages or prolonged contact, while minimal signs
may be present after short exposure.
 Focal Electrical Lesions:
o Typically, a discrete focal point of entry exists, often on the hands, which should be
examined carefully.
o Entry points may be multiple and obvious or single and inconspicuous, resulting in thermal
lesions.
 Types of Electrical Lesions:
o Blister: Formed when the conductor is in firm contact with the skin, characterized by a
raised rim with a concave center, often accompanied by an areola of pallor.
o Spark Burn: Occurs when there is an air gap between metal and skin, presenting as a central
nodule of fused keratin surrounded by pale skin.
 Internal Findings:
o No specific findings internally in fatal electrocution cases.
o Diagnosis often based on circumstances of death and morphological findings, particularly the
current mark.
o Skin lesions are mainly thermal, with varying opinions on whether histological appearances
are specific to electricity.
 Advanced Techniques for Diagnosis:
o Metallisation of the skin may serve as a marker of electrocution.
o Scanning electron microscope equipped with an Energy Dispersive X-Ray Spectroscopy
(EDS) probe can assist in detecting and identifying embedded metals in the skin, aiding
diagnosis.
DEATH FROM LIGHTNING
 Lightning-Related Deaths:
o Hundreds of deaths occur annually from atmospheric lightning, particularly in tropical regions.
o Lightning strikes from clouds to earth may affect property, animals, or humans, involving
immense electrical forces generating millions of amperes and high voltages.
 Injuries from Lightning Strikes:
o Direct or near lightning strikes cause a range of injuries:
 Electrical Injuries: Including burns, explosive effects of compression waves, ruptured
tympanic membranes, pulmonary blast injury, and muscle necrosis/myoglobinuria.
 Burns and Trauma: Severe burns, fractures, and gross lacerations are common.
 Clothing and Metallic Object Effects: Victims may experience partial or complete
clothing stripping, magnetization, or fusion of metallic objects in clothing.
 Lichtenberg Figures: Described as fern- or branch-like patterns on the skin, but other
marks like red streaks along skin creases or sweat-damped tracks are also observed.
 Variability in Appearance: Some bodies may lack visible marks despite lightning
strikes.
 Appearance and Suspicion:
o The stripping of clothing or bizarre injuries may raise suspicions of foul play.
o Lichtenberg figures are a textbook description, but other marks like red streaks are more
commonly observed.
o Disagreement regarding the presence of these marks is unlikely after viewing typical images.