CHAPTER 14: THERMAL INJURIES OR DEATHS

Thermal injuries are caused by an appreciable deviation from normal temperature and are
capable of producing cellular or tissue changes in the body.
thermal death is one primarily caused by thermal injuries
Exposure to severe cold frost-bite
Exposure to high temperature burning or scalding

I. Death or Injury From Cold

Not common in tropical countries
Primary cause of death: attributed to the decreased dissociation of oxygen from hemoglobin in the
red blood cells and diminished spasm w/c results to anemia of the skin surface followed by vascular
dilatation with paralysis and increased capillary permeability.
Prolonged exposure necrosis and gangrene
Degree of damage depends upon:
1. Severity of the cold
2. Duration of exposure short exposure to cold temperature may not be deleterious to the body as
long exposure to low but not to freezing temperature
3. Area of the body involved
4. Sex women are more resistant to cold than men on account of their greater subcutaneous fat
deposits
5. Humidity cold damp air is more fatal than cold dry air
6. Others children and aged individuals are more susceptible to cold weather on
account of their limited thermotaxic reserve
individuals whose vitality have been diminished by fatigue, lack of food,
alcoholism and previous ill-health are less able to withstand the effects of cold
Action of cold in the body is partly local and partly reflex in the circulatory system.
Exposure to cold will diminish the dissociation power of oxygen from hemoglobin starving the
brain and other nervous center
Effects of Cold:
1. Local Effect (Frostbite, Immersion Foot, Trench Foot)
1st blanching and paleness of skin due to vascular spasm
2nd erythema, edema and swelling due to vascular dilatation, paralysis and
increased capillary permeability
3 in advanced stage of vascular paralysis, there will be blister formation
rd

4th continued exposure to severe cold will later lead to necrosis, vascular
occlusion, thrombosis and gangrene
The cell membrane, tissue and organ may rupture, and the skull may be fractured due to the
expansion of tissue and individual cell in the process of solidification
Microscopically: Vacuolization and degeneration of epidermal cells
Necrosis of the collagen of the subcutaneous tissue
Perivascular exudates of RBCs and WBCs
Occlusion of vessel lumen by clump of RBCs
Proliferation of the endothelium
2. Systematic Effects
Reflex in nature brought about by the stimulation and paralysis of the nerves.
Respiration, heart action, metabolic processes are slowed down on account of cerebral anoxia
There is cold stiffening of the body with blister formation and gangrene of the exposed part of
the body
a. Signs and Symptoms
 - Gradual lowering of the body temperature accompanied by increasing stiffness (cold
stiffening), weariness and drowsiness
- Lethargic, passing the stage of coma to death
- Suffer from delusion, convulsion and delirium
- palpation of the cutaneous surface shows hardening and coldness
b. Post-mortem Findings
o Externally: Nothing characteristic
- Cold stiffening
- Pale body surface
- Frost-erythema reddish patches especially in exposed portions of the body
- Delayed rigor mortis onset
o Internally: Nothing characteristic
- Blood is generally fluid in the heart and blood vessels with a bright red color
- Parenchymatous organs are congested with occasional petechial hemorrhage
- Audible cracking sound on flexing the knee and other big joints apparently due to the
breaking down of the frozen synovial fluid
- Petechial hemorrhage in the lungs, brain, kidneys
- If death occurs after sometime, pathological findings related to complications like
bronchopneumonia, toxemia due to gangrene, etc. may be found
o Body tissue fluid evaporates slowly if the body is frozen, hence, mummification develops
later. However, the individual cell, tissues and organs are well-preserved

II. Death or Injury From Heat

Classifications of Heat Injury
1. General or Systemic Effects
a. Heat Cramps Miners Cramp, Firemans Cramp, Stokers Camp
b. Heat Exhaustion Heat Collapse, Syncopal Fever, Heat Syncope, Heat Prostration
c. Heat stroke Sunstroke, Heat Hyperpyrexia, Comatous Form, Thermic Fever
2. Local Effects
a. Scald caused by hot liquid
b. Burns
i. Thermal dry heat
ii. Chemical (acids and alkalis)
iii. Electrical and lightning
iv. Radiation (x-ray, UV, etc.)
v. Friction
Classification of Burns by Degree (Dupuytrens Classification)
1. First Degree
- erythema or simple redness of the skin associated with superficial inflammation and slight
swelling of the skin which may subside after a few hours or may last for several days
- may be produced by momentary application of flame, or hot solid or liquid much below boiling
point and produced by mild irritant
2. Second Degree
- there is vesicle formation with acute inflammation
- if the burns are caused by flame or heated solid substance, the skin is blackened and the hair
singed at the seat of lesion
- the vesicle can be produced by strong irritants or vesicants
- scars are not present after healing
- the superficial layers of the epithelium are destroyed
3. Third Degree
- there is destruction of the cuticle and part of the true skin
 - the burned area is very painful owing to exposure of the nerve endings
- healing may leave a scar which contains all the elements of the true skin, consequently without
contracture
4. Fourth Degree
- Whole skin is destroyed with formation of slough which is yellowish-brown or parchment-like
- Surface is ulcerated and on healing a dense fibrous scar tissue develops
- Scar may subsequently contract and cause deformity of the part
- On account of thye complete destruction of the nerve endings, this kind of burn is not very
painful
5. Fifth Degree
- There is involvement of the deep fascia and muscles
- This may result to severe scarring effect and deformity
6. Sixth Degree
- There is charring of the limb involving subjacent tissues, organs and bones
- If death does not ensue immediately, inflammatory changes may develop in the surrounding
tissues

Distinction Between Burns and Scald

Burns Scalds
Caused by dry heat Caused by application of moist heat
- flame, heated solid, or radiant heat - liquid, steam at or near boiling point
Occurs at or above the site of contact of the Occurs at or below the site of the application
flame or contact with liquid
Singeing of hair is present Singeing of hair is absent
Boundary of the affected and unaffected area Boundary distinct, usually like a geographical
is not so clear relief map of the affected area
Injury may be severe Usually, limited on account of the dissipation
of heat in the tissue
Clothings are involved Clothings are not usually burned

Factors Influencing the Effect of Burns in the Body

1. Degree of heat Applied
- effect in body tissue by heat varies with the temperature of the heated object causing it
-effect will be more severe, if the heat applied is great
2. Duration of exposure or contact
- the longer is the time of exposure or contact, the greater will be the destruction
- the underlying tissue will be liable to be subjected to the high temperature
3. Extent of the Surface Involved
- involvement of more than 1/3 of the body surface to a second and third degree burns usually
ends fatally
- this is due to pain, hemoconcentration and shock
4. Portion of the Body Involved
- burns of the extremity is not as serious as that of the head, neck and trunk.
- burns of the genital organs and that of the lower portion of the abdomen are usually serious
- burns in serous cavities are graver than in the skin
5. Age of the Victim
- adults can withstand burns longer than the children and the aged individuals
- children can withstand suppuration
6. Sex of the Victim
-men can resist burns better than women
 7. Septic Infection
-this may bring about complication in other parts of the body and may lead to death
8. Depth of Burns
- in the 6th degree burns, whereby the muscles and bones are involved, it is more likely that a
person is terminated due to shock.
Causes of Death in Burns and Scalds:
1. Immediate Fatal Result:
a. Death from shock
b. Death from concomitant physical injuries with burns
c. Suffocation
2. Delayed Fatal Result:
a. Exhaustion
b. Dehydration with hemoconcentration
c. Secondary shock
d. Hypothermia
e. Complications:
i. Septicemia
ii. Pneumonia
iii. Nephritis
iv. Inflammation of serous cavities and internal organs
f. Changes in the blood due to heat
i. Conflagration
ii. Suffocation
iii. Accident in an attempt to escape burning house
iv. Evaporation from skin surface
v. Absorption of toxic materials
vi. Inhalation of fumes
vii. Secondary infection
Time required to completely burn a human body
1. Degree or intensity of heat applied
2. Duration of the application of heat
3. Physical condition of the body
4. Presence of clothings and other protective materials
Age of the burns
1. Very recent- no pus or much healing or edema
2. 36 hours or few days old- with pus and the red inflammatory zone has disappeared
3. 1 week- superficial sloughing in a third degree burn
4. 2 weeks- deeper sloughs, red granulation tissue
Proofs that the victim was alive before burned to death
1. Presence of smoke in the air passage
2. Increase carboxy-hemoglobin blood level
3. Dermal erythema, edema and vesicle formation
4. Subendocardial left ventricular hemorrhage
Proof that death is due to burning
1. Presence of vital reaction at the heated areas
2. Presence of carboxyhemoglobin in the blood
3. Presence of carbon particles in the tracheobronchial lumina
 Distinction Between Ante-mortem from Post-mortem BURNS
Ante-mortem Post-mortem
Abundant albumin and chlorides Scanty albumin and chlorides
With area of inflammation No area of inflammation
Base of vesicle is red Not much change in color
In conflagration, tracheobronchial lumina In conflagration, there is no finding
contain particles of soot
Abundance in carboxyhemoglobin No carboxyhemoglobin

Distinction Between Ante-mortem from Post-mortem BLISTERS

Ante-mortem Post-mortem
Abundant albumin and chlorides Scanty albumin and chlorides
Heating the fluid contents will cause Heating the fluid contents will show slight
solidification cloudening
Base of vesicle is reddish with signs of Not much change in color
inflammatory changes in the periphery
Abundant fluid content Scanty fluid content

Differential Diagnosis of Blister due to Heat

Putrefaction Disease Friction
Fluid content is blood stained Differentiated by the size, History and absence of signs
watery fluid distribution and absence of of application of heat
other signs of heat
application

Differential Diagnosis of Heat rupture

Incised wound Lacerated wound
Absence of blood with regular margins Contusion and other vital reactions at the margin

Investigation of death in a conflagration

1. Identity
a. Clothing
b. Property in pockets
c. Height, sex, age, color of hair
d. Natural disease or stigmata
2. Whether the person was alive in the fire
3. Cause of death
4. Information indicating a possible cause of the fire
a. Alcohol intoxication
b. Natural disease
c. Site of origin of fire
d. Demonstration of injuries
Medico legal aspects of burns and scalds
According to the Revised Penal Code (Art. 248)
1. Killing a person by means of fire is a murder
2. The setting of a building on fire must be an intentional means to kill the person inside
the building to make it a murder
 The actual design to kill with the use of fire that is purposely adopted as a means to that end (People v.
Burns 41 Phil. 418).
1. Spontaneous Combustibility
2. Preternatural Combustibility
3. Chemical Burns (Corrosive burns)

Distinction between Thermal and Chemical burns

Thermal Burn Chemical Burn
Presence of blister Absence of blister
No staining in the skin and clothing The skin and clothing may be stained with
chemical
No possible analysis of the lesion Analysis of the substances around the lesion that
will show the chemical causing the corrosion
Lesion is diffused Borders are distinct and simulate a geographic
appearance

Characteristic Lesions by Different Chemicals

1. Sulphuric Acid (oil of Vitriol)- blackish-brown sloughs
- splash marks where the acid has fallen
- lines of ulceration
- clothing will be destroyed
2. Nitric Acid- yellow or yellowish-brown sloughs
- spot of yellow will be seen on the skin
- clothing is destroyed and the color becomes brown
3. Hydrochloric Acid- intense irritation and localized ulceration of a red or reddish-gray color
4. Caustic Soda and Potash- bleached appearance
- greasy feeling to the skin
- skin becomes brown and parchment-like

Types of Electrical Burns:

1. Contact burns- due to close contact with an electrically live object
2. Spark burns- due to poor contact and the resistance of dry skin
3. Flash burns- due to a high voltage flash

Radiation Burns:
1. Burns from X-ray
a. Slight exposure- reddening and inflammation of the skin that will pass away leaving a
bronze color on the skin
b. High degree of over-exposure- blister, atrophy of the superficial tissue and obliteration
of the superficial blood vessels
2. Ultraviolet Light Burns
Severe and persistent dermatitis