ThermalInjuries

Thermal deaths
are caused by the systemic or localized exposure to
cold or exposure to heat.The effect of heat or cold
over body may be in generalized form or may have
localized effect to a particular body part..
Due to exposure to cold
1.General effects:Hypothermia.
2.Local effects: such as,
_Frost bite.
_Trench foot.
_Pernio.
Due to exposure to heat
1.General effects:Heat stroke,heat cramps,heat
exhaustion.
2.Local effects:burns, scalds.

. EXPOSURE TO COLD:
Exposure to cold produces hypothermia. Which is defined
as oral or axillary temperature of less than 350C . The body
can tolerate dry cold much better than wet cold.Wetness
increases heatloss considerably.The direct effects of cold
are prominent in fatty tissue and myelinated nerve fibers.
The indirect effects are mostly ischaemic, due to vascular
damage. The ability of hypothalamus is completely lost
below 300C.

Local effects:
1.The cold produces first a blanching and paleness of the
skin, due to vascular spasm. 2.it is followed by erythema,
oedema, and swelling due to the later vascular dilation and
paralysis and increased capillary permeability
3.blister formation is the third more advanced stage which
include skin, subcutaneous tissue,muscles,and nerves
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The localized effects of cold are frost bite, trench foot, and
immersion foot. Trench foot and immersion foot are the
result of prolonged exposure to severe cold (5-80C) and
dampness, such as typically seen soldiers during winter
warfare, especially in trenches. Blister formation with
ulceration and localized dry gangrene occurs.
Frostbite is infarction of the peripheral digits with
oedema, redness and later necrosis of the tissue beyond a
line of inflammatory demarcation , it may affect only the skin
or may extend deeply .In addition to the extremities, it is
frequently affects other parts eg. Nose, ears and the face.
In frostbite, necrosis with blister formation and gangrene
occurs. Skin becomes hard and black in about two weeks.
General effects:
It is manifested in 3 stages:
1. Patient becomes cold and shivers and the body
temperature falls.
2. In the second stage, shivering stops when the
temperature is at or below 320C.The victim is depressed
and with further cooling he becomes lethargic, droesy and
sleepy, which gradually passes into stupor and coma.The
muscles soften and mobility is impaired. If he tries to walk,
he may feel as if drunk.Respiration, circulation, metabolic
and enzymatous processesand oxygenation of all cells are
slowed down
3.The temperature is lowered to 270C or even less,which if
maintained for 24 hours or long is fatal.Death result the
ultimate failure of the vital centres due to anoxia.
Postmortem appearences
External: Pink or brown pink areas with indistinct blurred
margins, particularly over and around joints such as knees,
elbows and hips is characterstic,there may be pink patches
in cheeks, chin and nose. The extremities may be
cyanosed.oedema may be seen in the feet and lower legs.
Internal;The appearance are not characterized.The
subcutaneous tissue’s are relatively vascular.Ice crystals
may be found in blood vessels , heart and interstitial tissue
spaces.The blood is often of a bright red colour due to the
retention of oxygen by haemoglobin at low
temperatures.The stomach mucosa is studded with
numerous brown black acute erosions, ulcerations and
haemorrhages similar to those seen in many type pf pre-
death stress. A variable degree of fat necrosis of the
pancreas is seen in about 50% of cases.
Pulmonary oedema and micro infarcts in may
organs are commom.perivascular haemorrhages I the brain
and small infarcts in the heart is seen. Internal organs are
congested.
Medicolegal importance;
Most deaths are the results of accidents, mountaineering, or
persons lost in snow-driftsand those who have been
immersed in ice cold waters.Infanticide and homicide in
sdults, where un conscious persons are left in freezing
temperature is rare.
The hide and die syndrome: In some cases of hypo thermial
death,the victim who tries to protect himself from the
cold,may hide himself in corners, in cupboard or under piles
or under furnitures.More commonly naked or partly clothed
old person is found amid a sceneof utter confusion
withfurniture pulled over and drawyers and cipboard
emptied out.
Neonatal cold injury: It results from the failure of metabolism
to prevent a fall in temperature in a body kept in an
unsuitable cold environment.The children
becomeincreasingly lethargic and drowsy. Rectal
temperature is usually below 320C.The outstanding feature
is the swelling of the extremities with pitting oedema,
particularly the hands and the feet and the eyelids.Localized
hardening of the skin and the subcutaneous tissue overlying
oedematous parts.The heart rate is slow.Pulsation of
peripheral arteries are absent.Respirations are shallow slow
and irregular. Infants lie still, though conscious.
It is the method of killing illegitimate and unwanted infants.
Exposure to heat
3 clinical conditions may result from exposure to heat:
1.Heat cramps
2.Heat prostration
3.Heat hyper pyrexia
1.HEAT CRAMPS: They are caused by a rapid dehydration
of the body through the the loss of water and salt in the
sweat.It is seen In workers at high temperature when
sweating has been profuse.The onset is usually
sudden.Painful cramps affecting the muscles of arms, legs
and abdomen occur.The face id flushed, pupils dilated,
patients complaints about dizziness, headache and
vomiting.Intravenous injection of saline gives rapid relief.
2.HEAT PROSTRATION:Heat prostration is a condition of
collapse without increase in body temperature, which
follows exposure to excessive heat. It is precipitated by
muscular work and unsuitable clothing. There is extreme
exhaustion and peripheral vascular collapse,the patient
feels suddenly weak giddy and sick.He may stagger or
fall.The face is pale the skin is cold,
3.HEAT HYPERPYREXIA;A fever above 41.50c is termed
as hyperpyrexia.Heatstroke is a condition characterized by
rectal temperature greater than 410C and neurological
disturbances such as psychosis,delirium, stupor,coma and
convulsions. The term thermic fever or ‘sunstroke’ is used
when there has been direct exposure to the sun.
 TYPES:it is of two types
1.Exertional heat stroke: most commomly occur in athelets,
military personnel or other persons working hard in hot
environment.
2.In old persons usually over 60 yrs during heat waves.In
classic form usually sweating is absent.
Clinical features:Sudden collapse or loss of
consciousness,prodromal symptoms of headache,
dizziness, nausea, vomiting, weakness,
faintness,staggering gait, mental confusion,muscle
cramps,restlessness,skin is dry hot and flushed, pupils are
contracted,pulse is rapid, convulsions occur and patient
becomes delirious and comatose
Postmortem appearences:
CNS:Brain is congested and oedematous and patechial
haemorrhages seen in white matter. Cellular changes with
pyknotic nuclei, swollen dendrites,chromatolytic changes,
degeneration of neurons and diffuse proliferation of
microglia are seen.changes occur in cerebellum which are
more and consistent and consist of oedema of the purkinje
layer and swelling,disintegration and reduction of the
purkinje cells.
 HEART:Dilation of right auricle , flabbiness of muscle,
petechial or confluent subepicardial and subendo cardial
haemorrhage and degeneration of myocardium.
LIVER:Congestion and centri lobular necrosis.
KIDNEYS:Congestion, oedema, increase in weight.
ADRENALS:Pericapsular haemorrhages, engorgement of
sinusoids, cortical degeneration
GENERAL:Petechial and confluent haemorhages and
disseminated intra vascular coagulation.
BURNS
A burn is an injury caused by application of heat or chemical
substances to the external and internal surfaces of the
body.Which causes destrucyion of the body tissues.The
minimum temperature for producing a burn is about 440C for
an exposure 5-6 hours.
Varieties of burns:
1.Burns by highly heated solid body
2.Burns produced by flame.
3.Burns caused by kerosene oil, petrol.
4.Caused by explosions
5.Due to X-ray and radium.
6. Caused by UV rays.
7.Radiant heat burns.
8.Microwave burns.
9.From corrosive substances
10.Electrical burns.
1.Burns by highly heated solid body; When applied to the
body for a short time may produce only a blister and
reddening correspondimg in size and shape to the material
used.It will cause destruction, or even charring of the parts,
when kept in contact for sometime.The epidermis may
found blackened, dry and wrinkled.
2. Burns produced by flame: May or may not produce
vesication, but blackening of skin present. Roasted patches
of skin or deeper parts may be seen. Dry heat causes burns
by direct conduction.
3.Burns produced by kerosene oil ,petrol: Usually severe
and produce sooty blackening of parts and have a
characteristic odour.
4.Burns produced by explosions :In coal mines or of gun
powder are usually extensive and produce blackening and
tattooing due to driving of the particles.
5. Burns due to X-ray and radium: vary from redness of the
skin to dermatitis, with shedding of hair and epidermis and
pigmentation of surrounding skin.
6. Burns caused by uv rays, and infra red rays: may cause
necrosis of skin.
7. Radiant-Heat burns are caused by exposure to heat
source.
8. Microwave burns are well demarcated, full thickness
Burns without chasing.
9. Burns from corrosive substance show ulcerated patches
and are usually free from blisters. Hair is not
singed and redline of demarcation is absent.Strong acids
produce dark leathery burns upon the skin.
10.Electrical burns: spark burn or injury is due topoor or
intermittent contact with live electrical object/application/
wire.
Degree of burns:
Three degrees of burns by Wilson
1.Epidermal
2.Dermo-epidermal
3.Deep.
 1.Epidermal: The effected part is erythematous. There is
capillary dilation and transudation of fluid to the tissues
causing swelling. A split may occur in the epidermis or at
the epidermal- dermal junction to form a blister.The blister
contains gas and fluid containing protein.
2.Dermo-epidermal:Whole thickness of skin is destroyed
with destruction of dermal appendages.The central zone of
necrotic tissue is surrounded by the first degree
burns.These burns appear as shrivelled, depressed areas of
coagulated tissue, bordered with reddish blistered skin.The
lesion may be brown or black , due to charring and eschar
formation.
3.Deep:There is gross destruction not only of the skin and
subcutaneous tissue, but also of muscle and even bone.
Nerve endings are also destroyed. The burns are relatively
painless.The appearences are almost similar to the second
degree but in a more severe form.
EFFECTS: Effects depend upon :-
1.Degree of heat: the effects are severe if the heat applied
is very great.
2. Duration of exposure: Symptoms more severe if heat
applied for a long time.
3. The extend of the surface
4.The site:Burns of head, neck ,trunk, anterior abdominal
wall ore dangerous.
5.Age:Children are more susceptible.
6.Sex: Women are more susceptible.

POSTMORTEM APPEARENCES:
External:
*Clothes may show singeing of fibers or melting of clothes
or may be completely burnt.
*Cotton fabric ignites easily and burns faster than other type
of fabrics.
*Clothes should be examined for presence of any
inflammable material such as kerosene, petrol
.
General examinations:
*There may be blackening of body due to deposition of soot.
*Due to application of heat, muscles get contracted and
stiffened. It is due to coagulation and denaturation of muscle
proteins.
*Due to this, body occupies a peculiar posture with
generalized flexion of the trunk, upper limbs and lower
limbs.The upper limbs are flexed in such a pattern with
fingers appear curled inwards similar to the attitude pose of
a boxer. Such a body appearance of body called boxer’s
attitude or pugilistic attitude.
*Contraction of the paraspinal muscles often cause a
marked opisthotonos.
*Hairs are either singed or completely burnt away. In lesser
degree singeing pattern may be obvious and ends appear to
be clubbed.
*Burns may vary from more reddening to charring.Dermo-
epidermal burns are much commoner.
*In severe burns or sustained application of heat, the
muscle or even bone may be charred.
* If death occurs some days after incident, there may be
presence of pus and necrosis in burnt areas.
*Heat ruptures may be evident over body and may be
confused with antemortem incised wounds.
Internal findings:
*Blood may be brightif death is associated wiyh CO
inhalation
*Substances such as lacquered wood have been burnt.The
fire victims could have high levels of cyanide in their blood.
*Internal organs are congested or may show partly cooked
or cooked appearance or coagulated and firm.
*Soot particles or carbon particles may be seen in the
respiratory passage due to smoke inhalation.Presence of
such soot particles I the lower respiratorytract indicates
person was breathing during the fire and suggests
antimortem nature of burns.
*Evidence of inhalational burns may be evident with burns
and oedema of oral cavity, tongue, glottis or larynx.
*Bones may show heat fracture or thermal fracture.
It may be of following types:
1.Bursting type.
2.Surface fracture.
3.Curved fracture.
Heat hematoma-This occurs in the head of the victim has
been sustained to intense heat for longer duration
-Heat hematoma appears in extradural space and has
resemblance with extradural hematoma.
-The clot is soft, spongy from gas bubbles, friable and has
honeycomb appearance.
-The heat hematoma is usually tawny or chocolate brown in
colour.
-The parieto-temporal region is the common site of
occurrence of heat hematoma.
Suicide:Occasionally, women commit suicide by pouring
kerosene on their head and clothes before setting fire to
themselves due to domestic worries. Extensive second and
third degree burns ,ore concentrated in the front are seen
over the whole of the body, only on the skin folds, such as
axillae, perineum, and soles being spared.

SCALDS
A scald is an injury which results from the application of
loquid above 600C or from steam, it is the tissue damage
caused by the application of moist heat.
Classification: 1.First degree: Characterized by erythema
formation of affected part.
2.Second degree:characterized by blister formation with
increased vascular permeability.
3.Third degree:Characterized by drying and desiccation of
underlying tissues with necrosis.
Features:- -Scalds doesnot cause charring, carbonization or
singeing of surface hairs.
-Shape of scalds may vary but have sharply demarcating
edge; corresponding to the limits of contact of fluid or water.
-When hot water is splashed,the water or fluid runs under
due to gravity causing trickle pattern.If hands are immersed
in hot water, a horizontal level may be made by hot water.
-Occasionally, the steam may be inhaled and causes
scalding of oral cavity, nasal mucosa, epiglottis and larynx,
-The wearing apparel or clothes may either minimize the
damage caused due to spurting of water or liquid as may
causes contact with skin for a long period.
Differential diagnosis
The scald has to be differentiated from: dry burns, toxic
epidermal necrolysis, drug eruptions.
Causes of death: shock, Hypovolemic shock,Electrolytic
disturbance.
MEDICOLEGAL IMPORTANCE:
1.Scalds are usually accidental injury often involves infants
toddlers or children.
2.Scalding may be intentional when someone with malicious
intention throws hot water or liquid over someone else’s
body.
3.It may be one pattern of battered baby syndrome.
4.Suicide is very rare; one case of suicide scalding where a
person immerses himself in a soup cauldron after attempted
suicide by hatchat blows.
Injuries due to electricity:Electrical energy is obtained from
chemical energy, mechanical energy or light
energy.Electrical burns constitute a unique type of thermal
injuries. The tissue damage associated withan electric injury
occurs when an electric energy is converted into thermal
energy or heat.
Sources:
1.Domestic; 2.Industrial/commercial; 3.Electrical distribution
system; 4.Lightning.
Physical factors:Voltage is a fundamental force or pressure
that causes electricity to flow through a conductor and is
measured in volts.
Types of current: There are two types of current namely:-
1 Alternating current(AC).
2. Direct current(DC).
-Diect current is less dangerous than alternating current.
-In DC the electricity flows constantly in the same direction
where as in AC alternatively in opposite direction.
-The usual frequency of AC -50 cycles/sec.
-The AC between 40 to 150 cps is most dangerous.
-Ordinary household supply of current is around 50 cps and
that of commercial supply is between 25 to 50 cps.Less
than 10 cps or more than 100 cps is harmless for the body.
Electrical injury consists of:- 1.Contact injury.
2.Spark burn / injury.
3.Flash burns.

1.Contact injury: Contact injuryis due to close contact with

an electrically live object such as wire with domestic
voltage.The damage varies from a small superficial injury or
burn to charring depending upon the time of contavt that is
maintained with the object. A characteristic electric injury
may be present at the point of entry and may be at the point
of exit.(exit wound).
2.Spark burn/ injury: Spark burn/ injuries due to poor
intermittent contact with line electrical object/ wire. Here the
resistance offered by tissue/skin is also important. The
lesion is caused by such intermittent contact may be a pitted
area or nodule due to arching of current from the conductor
to the skin. A yellowish parchment like scab may be noted
with a pale halo round the lesion. It is due to melted keratin
that fuses on cooling.
Flash burns: Flash burns are due to contact with very high
voltage and usually seen in lines-man working on grid
system and not frequently in thieves stealing wires from
those overhead lines. Here there may be actual arching of
the current, occur on the man approaching towards wire
without actual contact. Sometimes heat may cause ignition
of clothes and person sustains burn injuries.
Postmortem appearance:
External:The examination of the scene may be much more
important than the postmortem of the body.The clothing,
including shoes,gloves and headgear should be examined
for burns.In cardiac arrhythmia victim will be pale, and in
respiratory paralysis cyanosed.The eyes are congested and
the pupils are dilated.Rigor mortis appear early, postmortem
lividity is well developed.In about 50- 60% cases there
areexternal marks of electric burning, and contusion or
laceration at the point of entrance and exit of the body.
A no. of greyish- white circular spots, which are firm to the
touch and free from zone of inflammation, may be found at
the site of entrance and exit. Current marks may be hidden
inside the oral cavity, from putting live wires into the mouth
or from drinking at a water fountain in contact with electric
current. Any metallic objects on the body will produce
corresponding burns on the skin because it becomes
heated by the passage of the current.
INTERNAL: Appearance usually that of asphyxia.The lungs
are congested and oedematous, brain, meninges and
parenchymatous organs are congested.Petechial
haemorrhages are found along the line of passage of
current, under the endocardium, pericardium, pleura, brain
and the spinalcord.
High amperage has an explosive effect and
may produce injuries resembling bullet, stab or cut wounds.
Small balls of molten metal’s, derived from the metal of
contacting electrode, so called current pearls, may be
carried deep into the tissues. There may be bone necrosis,
and zig-zag microfractures.Focal petechial haemorrhages
are found in the brain and spinalcord. In some
cases,irregular fissure in the brain tissue and rupture of
walls of arteries are seen. Occasionally, no lesions can be
found either externally or internally. Death in these cases
may be due to vagal stimulation
Medicolegal aspects:-
-Death due to electric currents are usually accidental from
defective electrical appliances or negligence in the use of
equipment, flying kites or short circuit.
-In industry death may result from live overhead cables or
from handling of charged lamps, tools or switch gears.
-Rarely death may occur during convulsive therapy to
mental patients but cases of suicide and even homicide
have occurred. The viscera may be analyzed to know
whether the victim was impaired at the time of accident.
-Suicide is rare.

Lightning stroke:
Death from lightning are not uncommon and
occasional tragedies occur where no. of people are killed or
injured in a single episode. A flash or bolt of lightning is due
to an electrical discharge from cloud to earth.
Sources:Thunder storms, snow storms,dust storms,sand
storm,volcanic eruptions,nuclear explosion.
Dry skin and dry clothesare bad conductors, where as wet
skin and wet clothes are good conductors.A lightning bolt
may injure or kill a person by a direct strike a side flash, or
conduction through another object. In a direct strike or
sideflash strike the current passes through the surface of
the body; enter it or follow both routes.
Due to electric current:Lightning is a very high voltage
electric current between 10 million and 100 million volts.A
person may die instantaneous due to electrocusionor may
remain unconscious.
Due to heat effect:Any degrees of burn may be sustained in
lightening depending on the proximity of flash.the burn
injuries varies from singeing to superficial burns and deep
burns.Usually the exposure of lightning stroke is extremely
short, because of victims exposure is so brief, no burns only
minor singeing of hair is seen.
AUTOPSY FINDINGS:
Circumstances:At the scene of lightning strike there may be
damage to near by trees such as splitting or removal of
bark.Ground may display a fern pattern in the grass
resembling the cutaneous discoloration seen on some
victims.
Clothes:The clothes may show singeing of fibres or melting
or may catch fire and burn.At times, the clthed may be
completely torn off the body and tear ends may be
scorched.The boots or shoes and the waist belts may also
burst open.
Examination:It is said that rigor mortis appear soon after
death and passes off quickly. The patterns of injuries may
vary from case to case.Ther may be injuries of destructive
kind in one body and there may be no external mark in
another.The skin may show clusters of burns caused by
electrical arcing or may show singeing of hairs.There is
congestion of internal organs and pulmonary oedema.
-Spencer grouped external marks of lightning into three
classes as:-
1.surface burns.
2.linear burns.
3.Arborescent burns.
Surface burns:These are tissue burns and are usually
related to metallic object worn or carried by the victim.some
times secondary burns from ignition of clothing are
noted.There may be blisters, fissures or charring of deeper
tissues and bones.
Linear burns:Are of size 1 to 12 inches long may found on
body area where theskin of that part offers less
assistance.The usual sites are moist and folds of the skin.
Arborescent marks:These are also called as filigree burns or
feathering or fern leaf pattern.Arborescent markings are
characteristic of lightning.Arborescent markings are
multiple,superficial,irregular,tortuous markings on the skin
resembling branches of tree.These injuries fade overtime.It
was reported that the mark completeky disappears.