Burns-The Medical and Forensic Model

Alan Clark

Table of Contents  (Back to book ordering page)

Acknowledgments xv
Preface xvii

Part I: Medical Basics
Chapter 1: Characteristics of Skin Burns 3
Ray Fish, PhD, MD, FACEP
1.1 Introduction 3
1.2 General Appearance of Burns from an Electrical Source 4
1.3 Degrees of Thermal and Electrical Burns 4
1.4 Gross and Microscopic Examination of Electrical Current Marks 5
A. Current marks: may not be present 5
B. Cyanosis 6
C. Easily overlooked lesions 6
D. Electric channels 6
E. Arc burns with sharp demarcation 6
F. Skin metallization 6
1.5 Difficulty of Determining Extent of Deep Injury Related to Thermal and Electrical Burns 7
1.6 Factors Related to the Formation of Burns 8
A. Changes in skin resistance over time 8
B. Enlargement of burns over time 9
C. Firm versus intermittent contact 9
D. High voltage burns 10
E. Postmortem burns 10
1.7 Conclusions 12
References 13

Chapter 2: Pre-Hospital Evaluation and Treatment 15
Paul A. Janson, MD
2.1 Introduction 15
A. Burn characteristics and pre-hospital care 16
B. Burn management considerations in the pre-hospital setting 17
2.2 Initial Assessment 17
2.3 Extent of Injury 18
2.4 Depth of Injury 20
2.5 Site of Injury 21
2.6 Coexistent Injuries 23
2.7 Initial Evaluation and Transport 24
2.8 Smoke Inhalation 26
2.9 Chemical and Radiation Burns 28
2.10 Electrical Burns in the Pre-Hospital Setting 30
2.11 Summary 32
References 32

Chapter 3: Emergency Department Management 37
Alan D. Clark, MD
3.1 The Emergency Department Paradigm 37
3.2 Plane Crash-Major Burn Injury 38
A. History and examination 38
B. Forensic considerations 39
C. Treatment 40
3.3 Childhood Scald and Thermal Injury 44
A. History and examination 44
B. Forensic considerations 45
C. Treatment 46
3.4 Explosion 48
A. History and examination 48
B. Forensic considerations 48
C. Treatment 49
3.5 Electrical Injury 50
A. History and physical examination 50
B. Forensic considerations 51
C. Treatment 52
3.6 Chemical Burn 53
A. History and physical examination 53
B. Forensic considerations 54
C. Treatment 54
3.7 Conclusion 54
References 55

Chapter 4: Critical Care for Patients with Severe Burn Injury 57
Roger E. Huckfeldt, MD
4.1 Introduction 58
4.2 Critical Care Center Design in the Burn Center 58
A. Staffing 58
B. Administration 59
4.3 Ongoing Resuscitation 59
4.4 Abdominal Compartment Syndrome 61
4.5 Oxygenation/Ventilation 62
A. Hypoxemia 62
B. Ventilation 63
C. Non-invasive mechanical ventilation 63
D. Mechanical ventilation 64
4.6 Nutrition 67
A. Carbohydrates 67
B. Protein 68
C. Lipids 68
D. Hyperglycemia 69
E. Micronutrients 69
F. TPN 69
G. Enteral nutrition 70
4.7 Wound Management 70
4.8 Dressings 70
4.9 Analgesia and Sedation 71
4.10 Chemical Paralysis 72
4.11 Complications 72
A. Gastrointestinal hemorrhage 73
B. Pulmonary emboli (PE) and deep venous thrombosis (DVT) 73
C. Nosocomial pneumonia 74
4.12 Summary 74
References 74

Chapter 5: Burn Rehabilitation 79
William R. Reynolds, MD, FACS
5.1 Overview 79
5.2 When Does Burn Rehabilitation Begin? 80
5.3 Burn Surgery 80
5.4 Conclusions 82

Chapter 6: Disaster Planning for the Multiple Burn Injured 83
Alan D. Clark, MD
6.1 Chapter Introduction 83
6.2 The Disaster Mentality 84
6.3 Burn Disaster Experience-The Last Decade 85
A. The Oklahoma City bombing 85
B. The Jahn Foundry Explosion 86
C. September 11, 2001 88
D. The station nightclub fire 92
6.4 Approach To Mass Casualty Incidents 93
A. Surge capacity and surge capability 93
B. Communication 95
C. Patient transport 96
6.5 Conclusions 96
References 97

Chapter 7: Explosions, Including Terrorist Bombings-Part I 99
Ray Fish, PhD, MD, FACEP
7.1 Introduction 99
7.2 Mixed Mechanisms of Injury in Terrorist Bombings. 100
A. Penetrating injury 100
B. Chemical warfare 100
C. Biological warfare 102
D. Nuclear warfare 102
7.3 The Nature of Blast Waves 102
A. Overpressure 102
B. Overpressure and underpressure 102
7.4 Factors Affecting Severity of Blast Injury 104
A. Blast exposure in water 104
B. Nearby structures and enclosed spaces 104
C. Spalling 105
7.5 Specific Blast Injuries 105
A. Ear injury 105
B. Gastrointestinal injury 105
C. Blast lung injury 107
D. Air emboli 107
References 108

Chapter 8: Explosions, Including Terrorist Bombings-Part II 111
Ray Fish, PhD, MD, FACEP
8.1 The Accident Scene 112
A. Phases of care-giving at a mass casualty bombing scene 112
B. Aspects of bombing scene and ambulance treatment 112
8.2 Initial Emergency Department and Hospital Treatment Priorities 114
A. Airway 115
B. Breathing 115
C. Circulation 120
D. Disability-Neurological 120
8.3 Specific Injuries 121
A. Fractures and dislocations 121
B. Open wounds 121
C. Abdominal injury 121
D. Air emboli 122
E. The ear 122
F. Penetrating injury and retained foreign bodies 124
References 125

Part II: Forensic Considerations
Chapter 9: Fire and Arson Investigation 129
Laura Billon, MS, CFI
9.1 Fire Arson Investigation 130
9.2 Fire Behavior and Strategies 130
A. The Incident command system (ICS) 130
B. Preplanning 131
C. Fire tetrahedron 132
D. Fire's natural progression-three burning stages 133
9.3 Initial Investigation Procedures 134
A. Arson fires 135
B. A systematic approach-the scientific method 136
C. Safety of the fire investigator 137
D. Documenting the scene 138
E. The "backwards theory" 138
F. Providing graphic portrayal 139
9.4 Fire and Burn Patterns 139
A. Examples of patterns 140
B. Melting temperatures 141
C. Spalling 142
D. Irregular patterns 143
E. Blistering surface 144
9.5 Injury and Fatal Fire Scene Investigation 145
9.6 Evidence Collection 150
9.7 Arson and the Firesetter 151
9.8 Interviewing and Interrogation Techniques 156
9.9 Legal Issues Pertaining to Arson 159
9.10 Conclusion 161
References 162

Chapter 10: Body Identification of Burn Victims Using Forensic Odontology 165
R. Tom Glass, DDS, PhD
10.1 Introduction to Body Identification by Dental Means 165
10.2 Dental Identification of Bodies Involved in Low-Heat Fires 174
10.3 Dental Identification of Bodies Involved in High-Heat Fires 177
10.4 Dental Identification of Bodies Involved in Fires with Dismemberment 180
10.5 Dental Identification of Bodies Where Minimal Dental Postmortem or Antemortem Findings are Present 185
10.6 Cases of Dental Identification of Fire Victims 189
References 193

Chapter 11: Fire Death Investigation 197
Crystal R. Samborski, BSc
11.1 Introduction 197
11.2 Fire Investigation 198
A. Fire suppression 198
B. Investigation 199
C. Legislation and investigation 199
11.3 The Police 201
11.4 The Medical Investigator 202
A. Role of the medical investigator 202
B. The scene 202
C. The history 203
D. The body 203
11.5 The Experts 211
A. The forensic anthropologist 212
B. The forensic odontologist 212
C. The forensic entomologist 213
11.6 Research 213
References 217
Endnotes 218

Chapter 12: Interaction Between Toxicology and Burn Victim Physiology 221
John Brick, PhD, MA, FAPA
12.1 Introduction 221
12.2 Epidemiology and Consequences of Intoxication in Burn Patients 223
A. Alcohol: the socially acceptable drug 223
B. Stimulants and other drugs 226
C. Heroin, sedative-hypnotics and other drugs 227
12.3 Other Physiological and Medical Complications 228
12.4 Immune System 233
12.5 Pharmacokinetics and Pharmacodynamics 239
A. Acetaminophen 240
B. Alcohol 241
C. Benzodiazepines and imipramine 242
D. Barbiturates 244
E. Opiates and other pain management medications 245
12.6 Direct Thermal Injury from Drug Use 249
12.7 Summary and Conclusions 250
References 251

Chapter 13: Hidden Toxic Dangers In Burn Injury 257
Alan D. Clark, MD
13.1 Introduction 257
13.2 Overview of Smoke Inhalation Effects 257
13.3 Hidden Factors in Acute Inhalation Injury 258
A. Thermal injury 258
B. Carbon monoxide 259
C. Hydrogen cyanide 261
D. Chemical irritants 264
E. Methemoglobin 264
13.4 Chemical Exposure and Chronic Toxicity 265
13.5 Overview of the Management of Smoke Inhalation 267
13.6 Conclusions 268
References 268

Chapter 14: Advanced Forensic Considerations In Electrothermal Burns-Part I 271
Ray Fish, PhD, MD, FACEP
14.1 Overview 271
14.2 Electrothermal Burns 272
14.3 Arc Burns 273
14.4 Conduction by Streams of Liquid 274
14.5 Conduction Through Shoes and Truck Tires 274
14.6 Electric Cord Injuries 274
14.7 Conduction by Moisture, Surface Contamination, Insulation Breakdown and Tiny Holes 275
14.8 Holes In Rubber Overshoes And Kinetic Energy Of A Loose Powerline-Case Report 276
14.9 Conclusions 280
References 280

Chapter 15: Advanced Forensic Considerations In Electrothermal Burns-Part II 283
Ray Fish, PhD, MD,FACEP
15.1 Introduction 284
15.2 Myoglobinuria 284
A. Pathophysiology 284
B. Incidence 285
C. Laboratory investigation 286
D. Treatment 287
E. Arterial (not Urine) pH should guide bicarbonate therapy 288
F. Other problems related to rhabdomyolysis 290
15.3 Gastrointestinal Injury 290
A. Direct injury of intra-abdominal organs 290
B. Treatment of intra-abdominal electric injuries 291
C. Indirect effects on the gastrointestinal system 292
15.4 Vascular Insufficiency 294
A. Compartment syndromes may compress arteries, leading to vascular compromise 294
B. Detecting vascular insufficiency. 294
C. Treatment of vascular insufficiency. 295
D. Case example of an unusual treatment for delayed vascular occlusion: streptokinase 295
E. Progressive tissue necrosis over days is sometimes a sign of vascular insufficiency 295
15.5 Disseminated Intravascular Coagulation 296
15.6 Burns 296
A. Wound management 296
B. Oral burns 297
15.5 Microwave Oven Injury 298
A. Comparison of microwave and other types of burns 298
B. Treatment of microwave burns 299
15.6 Progressive Tissue Necrosis Following High Voltage
Contact 299
A. Description of progressive tissue necrosis 299
B. Case studies 302
15.7 Conclusions 305
References 305

Chapter 16: Advanced Forensic Considerations In Electrothermal Burns-Part III 309
Ray Fish, PhD, MD, FACEP
16.1 Introduction 309
16.2 Basic Electrical Terms 310
16.3 Basic Concepts Regarding the Flow of Electric Current 311
16.4 Capacitance 314
16.5 Primary versus Secondary Injury 317
16.6 Power 317
16.7 Thermal Injury 318
16.8 Voltages Involved in Electrical Injury 319
16.9 Skin Impedence 319
16.10 Stimulation of Excitable Cells 321
16.11 Simplified Resistance Model of the Human 322
16.12 Current Path 325
16.13 Amounts of Current Carried by Various Tissues 326
16.14 Injury Without Burn Marks 326
16.15 Death Occurring Without Skin Burns 326
16.16 Effects of Various Amounts of Current 327
References 327

About the Author 329
About the Contributors 331
Index 335

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