Burn Injuries – Forensic Approach -Tom Bennett 1 1

Burn Injuries – Forensic approach -Tom Bennett 1 1

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1 Burns: objectives

• To understand the multiple sources of energy to produce tissue burn injuries. • To recognize the tissue reactions and appearances characteristic of each type of injurious agent. • To differentiate amongst accidental and non-accidental burn injury patterns.

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Treat a fire fatality scene like a crime scene • Remember what you do or touch or move • Document what you do or touch or move • Secure and seal off the scene

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2 At a crime scene, put your hands in your pockets!

•Play with yourself, not the crime scene •Everyone will be happier

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Once the fire victim is found: • If there is any question as to whether a fire victim is deceased, initiate CPR. • If death pronounced, DO NOT allow the body to be moved (unless it at risk of further damage) until Coroner authorizes it.

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3 The six basic questions we must answer for any death (e.g., fire): • Who - Identification of body • What - Determining CAUSE of fire / injuries • When - Time of death relative to time of fire (i.e., are burn injuries premortem?) • Where - Determine where injuries were received, and how positioning of body relates • Why - Can autopsy help identify cause of fire • How - Determine MANNER of death

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ALL burn deaths are Coroner / Medical Examiner cases

• An autopsy is needed in essentially all cases

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4 What tools do we have?

• Autopsy • Toxicology • X-rays • Crime lab … • Scene investigators • History • etc.

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Autopsy of a burned body:

• Gather ALL of the body - may be in pieces • Photography & Diagrams • X-rays • Remnants of clothing, possessions & debris - identify & save • Complete external & internal examination • Toxicology - get blood (liquid), urine, vitreous fluid, muscle, etc. -(any available) – obtain [Alcohol] and [Carbon Monoxide] on all cases

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5 Gather all the pieces

• 1 or 2 (or more) people? • Co-mingled remains

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48wm found in bed, in motel room: - where fire started? -lividity & color? - type of fire? - BAC & [CO]? 12 12

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7 Photography / Diagrams • “A picture is worth 1000 words” • Digital v. 35mm v. Video -(Why not all three?) • Diagrams can be added to your reports, to include measurements, observations, etc.

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Toxicology

• Even in severely burned bodies, it is often possible to obtain blood from the heart or great vessels. • Obtain blood in both grey-top and plain containers. • We need (at least) [EtOH] & [CO].

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8 Toxicology - other fluids

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X-rays • Artifact v. significant findings • Which films to get? – Skull AP & lateral – Chest AP – Abdomen – others?

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9 Artifacts seen in X-rays

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10 SCENE is usually more valuable than BODY, but the autopsy may help direct the investigation of the scene

• Autopsy findings (e.g., homicide) may redirect the search for cause or origin. • Odor of accelerant may be found in lungs or GI gas. • Bomb fragments or other foreign material.

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The six basic •Who? questions: •What •When •Where •Why •How

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11 Who? • Even in mild burns, physical features are altered, and visual identification may be unreliable. • Rely upon: – dental – fingerprint – x-ray – DNA, etc.

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Dental identification

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12 Fingerprints

• Fingerprints may be obtained, even in some severely-burned cases – Pugilistic pose – Skin slippage (stocking-glove) – Dermal prints

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Children? • These two girls (ages 4 & 5), found together in a bed in a fire starting in the bedroom where they were to be taking a nap. • Rare to find dental records, fingerprints, x- rays, etc. • DNA is expensive. • What to do to achieve reliable ID? 26 26

13 eruption of teeth? hair color

?-clothes

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The six basic •Who questions: •What? •When •Where •Why •How

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14 What? -Cause of death: -Trauma -Heat -Lack of oxygen -Burns -Toxic gases -Natural causes?

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Superficial burn injuries

• We need to assess the depth of the burn to understand the nature of the heat.

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Flash flame burns - 18wf

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16 Hair can change color in fire • Gray  brassy blond at 250°C • Brown  red at 400°C • Black hair doesn’t change color • “Singed hair”

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17 20wf, found on gravel road

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20wf, found on gravel road

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18 The six basic •Who questions: •What •When? •Where •Why •How

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When? • Death certificates require we determine time of injury & death. • More important is the time of death relative to the time of fire (-i.e., were they alive in the fire?) –Carbon monoxide level –Soot in airways –Skin burns - reaction of body’s tissues

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19 When? -what time did fire reach body?

• Use any clues you can. • Fires can smolder for hours before their discovery. Smoldering fires produce more CO.

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Time/destruction phases for average adult once the fire reaches 650°C (1200°F) • Early - skin slips & peels • 10 min - arms badly charred • 14 min - legs badly charred • 15 min - bones in face & arms start showing • 20 min - ribs & skull cranium begin showing • 25 min - shin bones begin showing • 35 min - thighs & shin bones exposed 40 40

20 Most house fires don’t exceed 650°C • Cremation requires 900-1000°C for over 1- 2 hours to ashen body. • Bones/fragments still remain - if you look you can find them in the remains of a fire.

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• First 8-12 minutes - Temp rises to 500°C Typical house – still survivable fire • “Flashover”, with rapid rise to over 700°C (1300°F) – not survivable • Temp gradually declines as fuel and oxygen consumed. 42 42

21 When? -were they alive in fire?

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22 Inhalation of products of the fire

• Soot in airways and upper GI tract.

• How far can passive diffusion get soot into the body? 45 45

45m • Found in burned car by RR crossing ~0300, 6-18. • No crash. • Fire started inside passenger compartment. • No gross soot in mouth?

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Gross evidence of soot was minimal, but microscopic findings were conclusive. 48 48

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26 Skull fractures • Fractures of the cranial bones (i.e., above the ears) may be from fire or trauma.

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28 Injuries - premortem or postmortem? • Skin - location & magnitude • Pugilistic pose • Skull fractures (cranial v. basilar) • Intracranial bleed – Epidural blood – Subdural / subarachnoid blood • Crush injuries 57 57

21wf, found in apartment:

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29 21wf, wispy soot, [CO]=28%

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Basilar skull fractures

• Fractures of the base of the skull are due to trauma, NOT the fire. 60 60

30 53wm, pilot of experimental plane

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26bm, gasoline truck driver

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31 The six basic •Who questions: •What •When •Where? •Why •How

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Where? -Are the injuries consistent with the history?

• Child found beside mother, both unconscious in their apartment, adjacent to burning apartment. • Fire never got into their apartment. • Baby’s [CO] = 52%. Mom’s [CO] = 38%. 64 64

32 The fire never reached this man…

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25wm, in burned mobile home

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33 The six basic •Who questions: •What •When •Where •Why? •How?

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Why didn’t the victim escape?

• Child - confused • Teen or adult - suspect another contributing factor: – Drugs/alcohol – Trauma/foul play • Elderly - look for a debilitating disease

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34 • Cherry red discoloration of Carbon blood and tissues (rule out cyanide or monoxide - hypothermia) • Look for contributing factors (drugs &/or autopsy diseases) • When two or more people die suddenly and unexpectedly in a home or motor vehicle, be very suspicious of CO

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“Assumption is the mother of all screw-ups”

-Anonymous

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Sources of burn injury

• Flame (most common): – flash, direct, radiant • Solar / sunburn • Scald (hot liquids) • Contact with hot solids • Convection (Hot air or fluids) • Chemical • Friction • Electrical • Microwave

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Sources of burn injury (i.e., how does the heat reach the body?): • Flame (most common): – flash, direct, radiant • Solar / sunburn • Scald (hot liquids) • Contact with hot solids • Convection (Hot air or fluids) • Chemical • Friction • Electrical • Microwave

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39 Hx: 11 month old child was testing the water in the tub as it was filling.

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Skin Burns, partial thickness (1°-2°) from contact with hot liquids or solids (conduction) -from Moritz, AR, Am J Path 1947;23:695. • Temperature • Time – 120°F (48.9°C) – 5 minutes – 125°F (51.7°C) – 1.5-2 minutes – 130°F (54.4°C) – 30 seconds – 135°F (57.2°C) – 10 seconds – 140°F (60.2°C) – 5 seconds – 145°F (62.8°C) – 3 seconds – 150°F (65.6°C) – 1.5 seconds – 155°F (68.3°C) – 1 second – 160°F (71°C) – 1 second to full thickness (3rd degree)

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41 Hx: 8yo boy found in basement

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44 Check the water level and possible splash-marks

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“Stocking sign”

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45 “Donut sign”

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7yo girl

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46 Sources of burn injury (i.e., how does the heat reach the body?): • Flame (most common): – flash, direct, radiant • Solar / sunburn • Scald (hot liquids) • Contact with hot solids • Convection (Hot air or fluids) • Chemical • Friction • Electrical • Microwave

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47 Hx: child ‘brushed’ against lit cigarette

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Dad claims the 11 month-old ‘walked across the stove’.Dad claims the 11 month- old walked across the stove.

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Contact burns • 48wm, found dead in bed. Complained of back pain before he went to bed. • Describe: – (Notice back scar) – the scene (?fire) – cause of burn – [CO]? – cause of death – manner of death 98 98

49 Sources of burn injury (i.e., how does the heat reach the body?): • Flame (most common): – flash, direct, radiant • Solar / sunburn • Scald (hot liquids) • Contact with hot solids • Convection (Hot air or fluids) • Chemical • Friction • Electrical • Microwave

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50 Gasoline may cause 2°-3° burn, without fire

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Chemical burns

• 3% of burn center admits • Body surface area: – ~18% BSA burned in admissions – ~1% BSA burned for outpatient • Most common chemicals: – Sulfuric acid, gasoline, NaOH, KOH, phenol, etc. • Alkali more damaging than acid

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51 Other chemical injuries: • Phenol & other organic compounds: – Used to make plastics, dyes, fertilizer & explosives. – May actually penetrate through the skin. • Anhydrous ammonia: – Strong desiccant, which combines with water on the airway surfaces, drying them and also heating up through the chemical reaction. • Gasoline can cause 2° & 3° burns through contact alone.

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Response by the body to injury: • The severity of any burn injury (irrespective of source/type - thermal, chemical, etc.) is a function of: – the nature of the agent, – intensity/concentration of agent, and – duration of exposure. • If the person lives, the damaged tissues are repaired or removed through digestion of damaged tissues, synthesis of new structures, etc.

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52 Inhalation injury: • Thermal injury - excessive heat damages the upper respiratory tract, down to the larynx. • Inhalation injury due to noxious products of combustion - the lower respiratory tract is more at risk of damage from inhaled chemicals and toxins, especially those which are more fat- soluble, or those entering while the person is unconscious.

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Cytotoxic inhalants - skin & lungs • Anhydrous ammonia • Pathophysiology: • Chlorine gas – Coagulation necrosis • Mustard gas – Dehydration/drying – Desiccation • Phosphorus oxides – Heat of reaction • Petroleum distillates – Liquefactive necrosis (may not elicit (strong alkalis) cough) – Delipidation (petroleum distillates) • Polychlorinated – Vesicle formation biphenyls (mustard gas, methyl bromide, etc.)

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53 Pulmonary effects of inhaled chemicals:

• Airway edema • Mucosal desquamation • Agent-specific bronchospasm • Diffuse lung fibrosis/scarring, with restrictive changes 107 107

• Pulmonary hemorrhage • Cardiac arrhythmias • Kidney - injury to glomeruli & prox. tubules • Hepatocellular damage (e.g., CCl4) Petroleum distillates - systemic effects: 108 108

54 Other examples of systemic effects: • Polychlorinated biphenyls: – Bronchospasm – Immunologic dysfunction & suppression – Teratogenesis • Mustard gas: – early - nausea & vomiting, shock – late - chromosomal damage

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Local results of Acid ingestion:

• Mouth burns & dental caries. • Severe esophageal injury is uncommon. • Distal stomach (antrum & pylorus) scarring and stenosis common • Acids tend to wall themselves off or become neutralized by denaturing proteins. • Acids are used in metal plating processes and in fertilizers. • In home, found in car battery acid (H2SO4), rust removers, swimming pool (HCl), etc.

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55 Local results of Alkali ingestion: • Esophageal stricture or perforation common. • Strong bases (alkali) do not effectively wall themselves off by denaturing. proteins, so burns tend to be deeper and much more serious. • Found in drain cleaners, oven cleaners, soap manufacturing, etc.

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• 46wf, found in garage. • [CO] = 67%

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56 Sources of burn injury (i.e., how does the heat reach the body?): • Flame (most common): – flash, direct, radiant • Solar / sunburn • Scald (hot liquids) • Contact with hot solids • Convection (Hot air or fluids) • Chemical • Friction • Electrical • Microwave

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58 Friction burns

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• What was the source of heat to What? injure the tissues of the body

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Visit the scene

• Note he’s barefoot • Note the alcohol --?

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60 Sources of burn injury (i.e., how does the heat reach the body?): • Flame (most common): – flash, direct, radiant • Solar / sunburn • Scald (hot liquids) • Contact with hot solids • Convection (Hot air or fluids) • Chemical • Friction • Electrical • Microwave

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Lightning

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62 Electrical injuries - high voltage • More than purely thermal • SSx may be delayed <2 years after injury – Vascular injury - occlusive – Neurologic - severe weakness or paralysis (spastic, not flaccid) – Heart - ventricular fibrillation – Eye - early-onset cataracts – Bone - soft tissue ossification – GI - hypermotility

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