Accidents In The Home And Environment

The topic is divided into:-

A- ACCIDENTS IN HOME
a- Trauma from accidental falls in home.
b- Trauma from effect of heat & chemicals
c- Poisoning with house holds chemicals , drugs &
coal-gas.
d- Miscellaneous Starvation

B- ACCIDENTS IN ENVIRONMENT
a- Lightening
b- Effect of Radiation
c- Effect of Heat & cold i.e. Environmental
temperature.
RESPONSE OF HUMAN TISSUES TO THE APPLICATION
OF HEAT & CHEMICALS

DEFINITION
Burning of the tissue, may be defined as a
traumatic lesion caused by the application of
heat or chemical substances to the external or
internal surface of the body. The effect is
destruction of the tissues.

Death due to burning is important from:-

Accidental----------- Blast of oil stove
Suicidal ------------ Self Immolation
Homicidal ------------ Not uncommon
Most thermal injuries occur from structure fires. The most important question to
answer is if the decedent was alive or dead during the fire. The answer to this
question enables the investigator to distinguish between homicide and other
manners of death.
 CLASSIFICATION OF BURNS

I Thermal Burns
Dry Burns
Wet Burns or Scalds

II Chemical / Corrosive Burns

Strong Acids
Strong Alkalis

III Electrical Burns

Electrical lesions / Burns
Radiation Burns
 MANY HISTORIC CLASSIFICATION

I) Duphytrens classification of six degrees:-

i- Reddening of the skin
ii Blistering
iii- Skin partly destroyed
iv Skin completely destroyed
v- Sub-cutaneous tissue burnt
vi Muscles & bones charred

2) This is modified by Hebra & Wilson into three degrees:-

Ist degree -- Reddening & blistering of skin (Epidermal Burn)
2nd degree -- Charring & destruction of full thickness of skin
(Dermo- epidermal)
3rd degree Charring of the tissues beneath the skin
(Deep Burns)

3) This classification has been further reduced to only two

degrees:-
- Superficial or less than full thickness of skin burns
- Deep or full thickness of the skin & all the deeper tissues.
A first-degree burn is similar to a sunburn without blistering. A second-degree burn has
blistering. Neither type will heal with a scar.
This baby has third-degree burns and some charring (fourth-degree) burns. As a rule,
younger individuals can survive more serious burns than older people. Relatively minor
thermal injuries can cause death in the elderly.
Blistering with thickening (induration) of the skin and tissues is a third-degree burn.
This will usually heal with a scar.
This is fourth-degree thermal injury. There is diffuse charring of the body. An autopsy
should be performed in these cases if warranted.
Most people die in fires by carbon monoxide poisoning from inhaling smoke. Smoke in
the nostrils and mouth does not prove the person died from inhalation. The
larynx must be examined to check for the presence of smoke.
Carbon monoxide (CO) poisoning will cause the skin to turn red. Direct thermal injury
may also cause the skin to be red. The larynx and/or CO concentrations still need to be
checked to determine the cause of death.
 THERMAL BURNS

INTRODUCTION

It is the traumatic effect of the

application of physical heat in any form (solid,
liquid or gaseous)to the body.

Depending upon the nature, duration & intensity of

the source of heat responsible, burns may vary from
mere reddening (erythema) through blistering or
vesication & heat coagulation to actual charring of
the tissue.
 IMPORTANT POINT

The total effect of burns irrespective of

the type of heat will depend more on the
total surface area of the body involved by
full thickness skin burn than any other
factor.

The estimation of the surface area of the

body involved is usually calculated by the
Rule of Nine as estimated by Wallace.
Assessment of Extent of Burn
Rule of 9s

The palm of
the patients
hand is approx
1% of TBSA
Assessment of Extent of Burn
Lund and Bowder Chart
 IMPORTANT POINT

LEGAL IMPLICATION

Law is more concerned with effect of burns as compare

to the cause or type. Recognition of the type is essential
for correlation of the allegation only.

Lethal effect depends more upon the surface area

involved as compare to the depth of the burns. Surgical
classification is not important from legal point of view.
Involvement of more than 35% area is considered to be
lethal.
 PROGNOSIS

Prognosis is influenced by:-

Age of the victim: Children & old people succumb if

even less area is involved.

Physical health

Duration, Extent & Part of the body involved. Serious

when trunk is involved

Treatment: Immediate treatment --- good prognosis.

CAUSE / APPEARANCE RELATIONSHIP OF THE
LESIONS.

I DRY HEAT / FLAME

Erythema to coagulation to roasted patches of the
skin / deeper tissues.
Burning of clothes & singeing of hair
Carbonaceous material deposits externally &
blackening or Soot particles in the air passages or
in the stomach due to inhalation or swallowing.
Minimal Vesication
Vital reaction (red line) at the junction of injured &
healthy tissue.
Pugilistic or Boxers attitude due to coagulation /
stiffening of the protein of the muscles condition
also called as Heat Rigor.
Depth of the coagulation of the tissues will
indicate the duration of exposure to heat.
The abundant amount of smoke on this mans face suggests he died from inhaling
smoke. His face is covered with smoke because of the smoke in the fire. This does not
prove he died from smoke inhalation.
This is the larynx (upper arrow) and the trachea (windpipe). The lower arrows point to
carbon material in the trachea from inhaling smoke. The presence of smoke in the lower
larynx and trachea proves the decedent was alive during the fire.
CAUSE / APPEARANCE RELATIONSHIP OF
THE LESIONS.
II Scalds or Wet Burns

Erythema --- Coagulated patches.

Extensive vesication (bullae formations) Rupture of
blisters leaves a pink surface from which fluid oozes
out.
The pattern of lesion caused by splashing & running
of the hot liquid is characteristic.
Absence of singeing of hair / burning of clothes. In
turn hair & clothes may show matting & soiling with
type of fluid / material involved.
Absence of Carbonaceous material deposit externally
as well as internally in the air passages.
Vital line at the periphery i.e. at the junction of
injured & healthy tissues.
CAUSE / APPEARANCE RELATIONSHIP OF
THE LESIONS.
III Corrosive or Chemical Burns
Redness --- inflammation & ulceration at the surface due to
chemical digestion of the tissues.
Absence of vesication.
Discoloration of skin & clothes. Discoloration is characteristic of
different type of corrosives :-
HCL ----------------- Greyish becoming black
H2SO4 ----------------- Brownish becoming black
HNO3 ----------------- Yellow becoming brown
Alkalis ----------------- Whitish becoming grey
Phenols ----------------- Dark brown
Litmus reaction at the periphery of the lesion.
Vital reaction at the base of the lesion i.e. surface of the dermis
instead at the periphery.
Vitriolage --- Throwing of vitriol on human face for
disfiguration.
Apart from local effect, some corrosive have remote effects like
Phenols.
 CAUSE / MODE OF DEATH

Death may occur at once or be delayed for days or

weeks.

Factors affecting fatal outcome are:

i- Age of the victim,
ii-Total area of the body effected
iii-Depth of the burns.

When 35% of the body area is involved, then the

chances of dying equals those of surviving.
CAUSE / MODE OF DEATH

Death may be :-
a)- Immediate :-
i) Neurogenic shock (Severe pain)
ii) Asphyxia Suffocation or toxic effects from
gases like Co, HCN, Ammonia, H2S
.
b)- Within 24 48 hrs.
Due to circulatory collapse / loss of fluid.
c)- Delayed
i)- Sepsis ---Septicaemia
ii)- Haemorrhage --- from wounds / from
curling ulcers of G.I.T.
iii)- Acute tubular necrosis --- Renal failure
iv)- Acute respiratory distress syndrome
ADDITIONAL POINTS OF MEDICOLEGAL IMPORTANCE
ON AUTOPSY EXAMINATION

I Identity of the Victim :

By subjective & objective methods
II Cause of Death other than Fire :-
i- Due to some coincident natural disease like
myocardial infarction
ii- Trauma due to falling masonry
iii- Due to inhalation of gases like CO, HCN, NH3, NO3
or H2S from various combusting materials like silk,
wool, leather or Sulphur containing compounds.

Complete autopsy examination & collection of viscera

for chemical analysis is necessary in doubtful cases.
Differentiation between Ante-mortem & Post-mortem
Burns

On external Examination

i Vital Reaction: In the skin adjacent to a burn there is

normally a well marked vital reaction in the form of
reddening of the skin as observed on naked eye
examination. This red line is about 0.6 cm in breadth,
although it may be broader where several burns are in
close proximity.
The vital reaction is observed at the periphery at the
junction of burns & healthy skin in case of dry & wet
burns while it is observed at the base of the lesion in
case of corrosive burns.

ii Pink Colour Hypostasis present if CarboxyHb level

is increased in blood.
Differentiation between Ante-mortem & Post-mortem
Burns

iii Blister Contents:

a) Blister fluid is rich in protein even to the extent of
becoming solid on heating.
b) Polymorphoneuclear leucocytes may be present even
in the absence of infection.
c) Increase in chloride contents
d) Presence of pus indicate their ante-mortem formation
.
Post-mortem blisters have scanty albumin and
practically no W.B.C. and chloride ions.

iv Sepsis: Sure sign of ante-mortem burns appear

within 36 hrs.
Differentiation between Ante-mortem & Post-mortem
Burns

V Histological & Histo-chemical Examination :-

- Leucocytic infiltration 6 hrs after burns.

- An increase in staining reaction for:
Acid phosphatase is detected at 3 hrs,
Leucine amino peptidase at 2 hrs,
Estrases at 3/4 hrs before death at the junction of
burn & healthy tissue.

Vi Pugilistic or Boxer Attitude :-

No role
 ON INTERNAL EXAMINATION

i) Carbonaceous Material or Soot Particles in the

respiratory tract due to act of inhalation & may be
in the oesophagus & stomach indicating the act of
swallowing the material before death.

ii)- Carboxy - Hb in the blood indicates the ante-

mortem burns. Level of 10% or above of CoHb
indicate the ante-mortem burns.
 ARTIFACTS IN BURNED BODIES-

Any structure or change introduce into a body after

death that is likely lead to misinterpretation of
medicolegally significant ante-mortem findings.

a Heat Ruptures : In badly burn bodies heat ruptures

may be produced.
- These are splitting of the skin & soft tissues caused by
coagulation of the protein.
- The resultant breaches are of considerable length &
may resemble lacerated or incised wounds.
- Distinction is by the absence of vital reaction &
hemorrhage around the rupture & also running of intact
vessels & nerves in the bed of the wounds.
Fire will cause the joints to contract. The arms and legs may be bent. This pugilist
(boxer) appearance makes the decedent appear as if she were fighting at the time
of her death. These contractures are all postmortem.
The heat will cause bones to break and skin to split. The presence of postmortem
thermal fractures (arrow) should not be confused with antemortem injuries.
 ARTIFACTS IN BURNED BODIES

b Heat Hemotoma:
- Extra dural hemorrhage
- Un-accompanied by any sign of injury to the
head.
- Occurs only in circumstances when the head is
exposed to intense heat upto the extent of
charring.
- soft
- friable
- chocolate colour
- Not uniformly solid but present a Honey comb
appearance.
The possible source of this hemotoma is due to
rupture of the superficial blood vessels of the
membranes.
Thermal fractures may be very difficult to distinguish
from antemortem fractures. The pathologist should
be conservative when making this distinction.
Skin splitting is a common artifact of thermal injury.
The splits may be confused with sharp force injury.
Heat will cause the skull to fracture and come apart. The underlying brain may be
fragmented and cooked. This should not be confused with antemortem trauma to the
head.
There was a marked amount of hemorrhage
just under the skull. This epidural hemorrhage would be suspicious
of blunt trauma injury if the child had not died in a
fire. This particular type of hemorrhage is an artifact of the
fire.
A closer look shows the hemorrhage distributed over the entire surface of the dura
mater. An antemortem epidural hemorrhage is thicker and more of a discrete entity.
Subsequent examination of the brain in this case revealed no
injury to the brain.
No matter how badly damaged a body, a blood
specimen can usually be obtained. The redness of the tissues in
this case suggests the person died of carbon monoxide poisoning.
The blood test will confirm this opinion.
The splitting of the skin and tissue may cause
organs to become exposed. This evisceration of organs should
not be mistaken for antemortem injuries.
This body has charring, skin splits, and the pugilistic
attitude in the upper extremities.
 ARTIFACTS IN BURNED BODIES

c Heat Fractures : In Skull bones two types of

thermal fractures:-
i Fracture resulting from a rapid increase in intra-
cranial pressure due to heat & the fragments are
displaced outwards.
ii) The 2nd type of fractures appears to be due to
rapid desiccation of the bones with contraction &
involvement of the outer table of the skull bones
only.
iii- In long bones the post-mortem fractures may be
observed at the ends due to severe flexion at the
joints due to heat rigors.
Close examination of the fractures & absence of
adjacent hemorrhages & injury to the brain &
surrounding soft tissues differentiate these fractures
from ante-mortem fractures.
 ARTIFACTS IN BURNED BODIES

d Toxicological Artefacts :

Combustion of body tissues & other materials associated

with the burn bodies & present at the scene of incidence
produces several gases like HCN, NH3 H2S etc.

Some of these gases may be detected in the body

tissues.

In such cases the results of toxicological analysis may

raise false alarms. It is important to make accurate
determination of blood levels.
 ARTIFACTS IN BURNED BODIES

Collar Mark: The simulation of a strangulation mark

may be observed on the body of a person who has
sustained burnes when the skin of the neck is protected
by clothing like ( tight collar or muffler).

Fat Embolism : Droplets of fat are frequently observed

in the Pulmonary vessels of severely burned bodies.

These occur independent of ante-mortem injuries &

should not be confused with traumatically induced
ante-mortem pulmonary fat embolism.
Differentiation of Thermal Blisters From Putrefactive
Blisters

The putrefaction bullae are incompletely filled with

watery, blood stained fluid having putrid odour, burst
easily & leave slippery pink surface. Absence of albumin
& chloride contents.
 EXAMINATION OF CLOTHINGS

The clothing of a person who has been removed from a

burned out structure should be examined for
combustible substances & also for distribution of burns.
Burns due to ignition of clothing are less severely burns
over the parts of the body where the garments are
tightly applied or if they are present under the lying
body. Clothes have double role depending impervious or
absorbent

Such an examination have considerable value to confirm

the allegations.