Introduction Electricity can be considered the movement of electrons through a circuit. During this movement, electrons attempt to move toward the “ground.” I something is “grounded,” itis connected to the ground, thus allowing the movement of an elect cal current to the ground, If something is “insulated.” a path to ground is prevented Resistance is defined as an objeet’s ability to avoid becoming part of an electrical cireuit. Resistance is measured in “ohms.” Things with a high resistance do not ceasily become part of an electrical circuit, Substances with an extremely high resis- tance, sich a rubber and glass, are used 10 insulate paris of electrical cireuts, lems ‘with low resistance, such as metal wires, are purposely used as the components of aan electrical circuit Voltage is defined 2s the potential difference between two points within an ele is measured in “volts.” Low voltage is defined as <1000 V, while high voliage is defined as >1000 . The common household voltage in the United States is 120 V (Fig. 17.1), while residential power lines (7500 V) (Fig. 17.2) and high tension lines (100,000 V) (Fig. 17.3) are high voltage. 4. Pablow, Forensic Pathoogs for Police, Death Investigators, tome, “0 ‘and Forensic Scientists, DOL 101007/978-1-59745-404-9-17, © Springor Sciences Businass Media, LLC 2010 Fig. 17.2 Residential power lines around 7300 V), Note hain mes instances, these power lines ae nor insulate they are no coated with rater) Current is defined as the number of electrons flowing within an electrical cit. cuit. Current is measured in “amperes” or “amps.” The amount of current flowing within an electrical circuit depends on two things, the voltage and the resistance. ‘The relation between current, voltage, and resistance is defined by “Ohm's law,” ‘which states that the current is equal to the voltage divided by the resistance. ‘There are two basic types of “manmade” electricity, “alternating current” (AC) and “direct current” (DC). Alternating current is a current that alternates its diree- tion within a circuit at regularly occurring imervals. The frequency at which this ‘occurs is measured in “cycles per second” of “hertz.” Most household and indus- trial electricity is AC, with the common houschold frequency measuring 60 herChapter 18 Temperature-Related Deaths When the sun mse, God provided asconching east wind. andthe sun blazed on Jonah’ ica so tothe refi le wanted to eed sai, ‘tend be better forse odie than to live. Tosh 4:8 Abstract Chapter 18 begins by providing a general description of the normal temperature-regulation mechanisms in humans, along with an introduction to the ‘concepts of hyperthermia and hypothermia. The remainder of the chapter is devoted ‘orelatively in-depth examination of hypothermia and hyperthermia, with emphasis ‘on scene investigation, autopsy findings, and death cenification issues. Keywords Temperature - Hypothermia - Hyperthermia wroauction, ve normal human body temperature is between 37.0 and 37.6°C (98.6-99.7°F), th temperatures up to 38.6°C (101.5°F) considered normal in infants and the erly. There are slight daily cyclical variations, with the lowest temperatures curring in the carly morning and the highest in the afternoon, Vigorous exer- se may cause a several-degree increase in temperature. The body temperature is der the control of feedback neural mechanisms involving the brainstem and the pothalamus, Human tissue can survive only within a range of tissue temperatures tween 20 and 44°C (68 and 11°F), Ultimately, body temperature depends on a balance between “heat load” and ‘eat loss.” A body's heat load represents the heat produced by normal metabolism 4s any heat gained {rom the environment. Heat loss occurs via four mechanisms, ch of which involves the transfer of heat from warmer objects to cooler objects. te four mechanisms of heat loss are “conduction,” “radiation,” “evaporation,” and onvection,” Conduction represents the direct transfer of heat from one object to an object, Radiation is heat loss via the emission of infrared rays. Evaporation rahlow, Forensic Pathology for Police. Death Investigators, Attomeys 499 1 Forensic Scientists, DOV 10.1007/978-1-59745-404-9.18, Springer Sciences Business Media, LLC 2010an 1s Iemperature-Ketated Deaths is heat loss that occurs when liquid water vaporizes from the body. Convection is heat loss that occurs when air currents moving around the body foster heat loss via conduction and evaporation. ‘The primary means by which an overheated body cools itself is evaporation, and there are Vo ways in which evaporation occurs in the body. The most obvious is via the process of sweating. Sweat represents water that is expelled from sweat glands within the skin; as the sweat evaporates from the skin surface, heat loss occurs, A. ‘human can sweat up to approximately 700 ml/h. The second type of water Joss that allows heat dissipation via evaporation is referred to as “insensible water loss,” and refers to water loss through the skin and lungs via simple diffusion. In skin, this is distinct from sweat production. Approximately 600 mL, of insensible water loss ‘occurs daily. ‘As long as heat gain and heat loss are balanced, normal body temperature will bbe maintained. If heat gain exceeds heat loss, hyperthermia can result, If heat loss exceeds heat gain, hypothermia can result, Increased heat gain ean occur with exer- cise, infection-induced fever, any other cause of increased metabolism, and a very ‘warm environment, When environmental temperature execeds body temperuture, the body actually begins to gain heat via radiation and conduction. Decreased heat gain occurs when metabolism slows. [nereased heat loss ean occur in a variety of settings, including decreased environmental temperature, increased convection, wet skin surface, and increased blood flow to the skin. Decreased heat loss can ‘occur with increased skin insulation (fat, clothing, blankets), high humidity (whieh interferes with evaporation). and increased environmental temperature. When envi: interferes with evaporation), and increased environmental temperature. When envi- ronmental temperature exceeds body temperature, evaporation is the only means by which cooling (heat loss) can occur If the temperature of localized tissues becomes markedly elevated, actual ther- ‘mal tissue injuries (burns) can result. Various types of thermal injuries can occur, including scalding injuries (from hot liquids or gases), dry burns (From hot solids), radiant bums ({rom radiant heat sources, including fires), and fire burns. Burns are discussed in the next chapter (Chapter 19). Hypothermia General Features Hypothermia may occur when heat loss exceeds heat load. Clinically, hypothermia is defined as body core temperature of less than 35°C (95°F). A variety of factors are associated with an increased risk for hypothermia, including low environmental temperature, extremes in age (very young and very old), immersion in water, wet clothing, certain pre-existing diseases, such as hypothyroidism and atherosclerosis, dementia, inadequate nutrition, and ethanol intoxication, which leads to excessive heat loss via dilation of skin blood vessels. The human body has a variety of defense mechanisms that come into play when facing the threat of hypothermia, The blood vessels of the skin and skeletal musclescmapun as 3urns and Fire-Related Deaths 0 all she men ci branches and followed Abimeleclh. They piled ‘them against the stronghold and set it on fire over the people inside. So all the people in the tower of Shechem, about a thousand men and women, also died. Judges 9:49 hstract This chapter addresses deaths related to burns, as well as fire-related caths. It begins by describing the various types and extent of burns that can be ncountered in such cases, along with specific sub-types of burns, including dry ums, radiant burns, scald bums, chemical burns, and fire-related thermal burns. lext, the chapter discusses issues of importance when dealing with a body found 1a fire scene. It concludes by addressing other important issues, including autopsy aittnde:onerbian tee of Aeth aidedh Porttinatiinn i sods alt Introduction ‘The tissues of the body, including the skin, can sustain burn injuries by several mechanisms. The most common types of burns are related (o thermal damage, which ‘occurs when a tissue’s cooling ability fails to compensate for externally applied heat ‘The extent of damage depends on the applied temperature, the ability of the issue (© ‘conduct away excess heat, and the time for which the heat is applied. With these con- cepts in mind, it should be evident that thermal bums can oceur very quickly when contact is made with very hot objects/substances. Conversely, objects/substances that are hot, but not extremely hot, ean still cause thermal burns so long as contact, ‘with the object is long enough to overcome the tissue’s ability to coo! itself. Another important concept is that skin surfaces of different body regions, and skin from indi- ‘viduals of different ages, can vary greatly in their ability to withstand thermal insult ‘The classic example involves infant skin being burned by hot water that does ot readily burn adult skin, J Prahlow, Forensic Pathology for Police, Death Investigators, Attorneys asi ‘nl Forensic Scientists, DOL 10,1007/978-1-59745-404-9_19, (© Springer Science+Business Media, LLC 2010Besides thermal injury, burns can result from comtact with chemical substances (or as a result of exposure to various forms of radiation. In each of these situations, a thermal component may play a role in tissue damage, but other mechanisms are also present. Blur evety ‘as son on the sin sarfce may be catgotinnd ne follows: Fist degree burns demonstrate a red discoloration of the skin surface. Physicians may frequently describe this as “erythema.” Such burns are limited to the epidermis (Fig, 19.1). Second degree burns damage not only the epidermis, but also the upper dermis. These burns are characterized by blisters and skin “slippage” (Fig. I In third degree burns, full-thickness skin injury occurs (Fig. 19.3). Fourth degree bums are characterized by charring of the skin and underlying subcutaneous tissues (Fig. 19.4), If one considers the skin as an organ, it represents the largest organPENERBIT BUKU KEDOKTERAN | i EGC | Stef a SABISTON LIT UND Bagian 1SABISTON'S ESSENTIALS OF SURGERY ‘ranlaio and daptaon ofthe Ft Engsh language eon (©1987 WB. Saunders Co. Piaelpia PA 19105 BUKU AJAR BEDAI ‘Alban dr. Petrus Anda dan Tian Bor fost Orwar Diarang mengup.mempetayak dan menenenahkan scbagian 0 selurah is bak in tanga icin eis dar peer ‘Ceakan aha: 1992 (Cenk than: 1995 ‘Perpustakaan Nasional: Katalog Dalam Terbitan (KDT) ‘SABISTON, David C ‘Bok jr teda = Sabon esemls surgery) /leh David C Sabon, slit tase, Pres Anda, Turn 15. er, Jonata Onwa~ daha cc. 1995. "4, 593m. 2h; 20.5427 em, {SBN 979-44.170-X (no. lenghap) 1SBN979-48.171-8 (i | 1. Blah tims 1 dl Andiamo, Powe 1S. Tian.feksi_yang jelas jarang dljumpal pada Tuks kurang ari 20-30%, namun Iuka yang besa lebih sensitif terhadap pertumbuhan bakteri yang berlebihan, bah- an dengan terapitopikal yang tepat, Bila tandatanda pperubahan Iuka sebagian teal kalit menjadi Iuka se. Juruh tebal lit mola terthat (pengeringan, perubab an warna) atau timbul daerah baru berwara kecoklat an, maka biops selauh tebalkulit pada luk haus d- Jakukan, Is diakukan untuk mengevaluasitingkat bak- teri di dalam luka dengan teknik biakan-kuantitatif Biakan permukaan tidak dapat diandalkan sebagai has! Kehadiran agen antibakterttopikal pada permu- aan luka dan Kemungkinan adanya infeksi intra dan subeskar, Bla Kultur kuantitatif menunjukkan jumlah 100,000 organisme bakteri per gram jaringan atau le- bih, maka mungkin ada infekst Iuka bakar yang luas. Diagnosis ini mengharuskan segera dilakukan per. ubahan terapi, Terapiantibiotika.sstemik yang tepat untuk organisme tersebut harus dilakukan, dan pera- watan luka harus dirubah. Bila digunakan agen topikal non-absorpi, maka agen ini harus diganti dengan ma- fenid asetat, Karena dapat menembus eskar. Pada daerah invasi lokalista, dapat dipertimbangkan infus antibjotka_ yang tepat subeskar, Bia mengenalseluruh Iuka, maka eksisi operasi dan pemutupan Iuka dengan balutan biologi sering diperukan untuk mengkontrol- aya, Infeksi subeskar Karena jamur-membutubkan cksisi lokal yang lebar dari daerah tersebut dengan ‘penutupan luka yang tepat. Dalam menghadap inva Juka bakar dan sepsis genealsata yang telah terjadi, semua metode terapi buruk dan angka kematian tinggi."” LUKA BAKAR LISTRIK Lewatnya tenaga listrik bervoltase tinggi melalui jaringan menyebabkan perubahannya menjadi tenaga ppanas.° a menimbutkan Juka bakar yang tidak hanya ‘mengenai kulit dan jaringan subkutis,tetapi juga semua jatingan pada jalur arus listriktersebut, Tahanan listrik jaringan bervarasi, dengan twlang, tendo dan kulit ‘yang paling tahan sedangkan darab dan jaringan saraf ‘memiliki tahanan yang rendah. la menyebabkan arus lisrik Hebth suka berjalan melalu cairan jaringan dan sepanjang berkas neurovaskular Ia bisa menyebabkan tak dengan sumber fenaga bervoltase tinggi seperti yang terjadi pada petugas listrik yang bekerja di dekat sum- ber listrik yang kuat. Anggota gerak merupakan tempat Kontak yang terlazim, dengan tangan dan lengan yang lebih sering cedera daripada tungkai dan kaki, Kontak LUKABAKAR 159 sering menyebabkan gangguan jantung dan/atau per- rapasan, dan resuitas kardiopulmonerserng diperu- kan pada saat kecelakaan tersebut terjadi, Luke pada daerah masukaya aus listrik Biasanya gosong dan tam- = pak mencekung. Luka mungkin dikelilingi dengan daerah-daerah juka bakar yang khas atau jaringan yang. tampak normal. Laka Keluarnya arus sama seperti Taka tembak arena peluru,berkecepatan tinggi. Kontak rus listrike dengan sendi dapat menimbulkan luka bakar kulit pada daerahdaerah yang tidak berkontak etka arus keluar atau maguk ke jarngan, Ukuran Iuka ‘Kulit biasanya membingungkan dan dapat membuat ‘ita salah menentukan kerusakan pads otot,saraf dan _. pembuluh daerah. Anggota gerak dengan loka bekar liste mudah terkena komplikasisindroma kompar. ‘temen karena adanya luka otot yang dalam atau vas- ‘ular, Dengan rusaknya otot, pengeluaran mioglobin ke aliran darah dan timbulnys mioglobinuria sexing — terlihat pada luka bakar listrik. Sekuestrasi cairan dan berkurangnya aliran darah ginjal akan menambah ‘kemungkinan kerusakan ginjal karena pengendapan ‘mioglobin di dalam tubulus ginjal. “Terai luka bakarlstrikdiarahkan Ke bagiankulit trauma suhu permukaan dihitang dengan cara yang s- 1a seperti untuk ka bakar standard, Cairn dibeikan seperti pada luka bakar permukaan dengan penambah- an volume untuk kerusakan otot. Tindakan ini dila- kukan seperti pada penderita ka remuk, yang mir ‘dengan Juka bakar listrik bervoltase tinggi. Pada luka bakar listik yang hus, penggantian cairan yang cukup banyak diperlukan untuk menghindari komplikasi. Jumlah ini (di atas dan di bawah kebutuhan untuk luka bakar ult) tidak dapat ditentukan dengan rumus apa pun. Penderita dengan sejumlah besar mio- slobin di dalam urina akan mengeluarkan urina ber \warna merah anggur dan reusitas pasen ini menghs- ruskan pengeluaran urina 75100 ml per jam. Seain itu, urina harus drubah menjadi basa dengan natrium bikarbonat intravena, yang menghalangi pengendapan rioglobin, Bila urina tidak sogera bening atau penge- Iuaran urina tetap rendah, walaupun sudah diberikan sejumlah besar cairn, maka harus diberikan diuretik yang kat beruuma manitol Pada penderita cedera otot yang masif, dosis manitol (12,5 gm per dosis) ‘mungkin diperiukan selama 1224 jam. Pasien yang sigal untuk berespon tethadap dosis di atas mungkin ‘membutuhkan amputasl anggota gerak gawat darurat atau pembersihanjaringan nonviabel. Bila meragukan, jaringan yang terkena luka bakar lstik bervoltse tings harus sgera diperika untuk menentukan vibi- ltas otot di bawabnya, Pada saat pemeriksaan, dapat dialukan pembershan jaringan nonviabel seta fasio tomi, Salah satu Komplikas lanjut uke ba160 BUKUAJAR BEDAH BAGIAN 1 ‘adalah terbentaknya katark, Katarak dapat unidateral atau bilateral dan biasanya terihat setelah Kontak list pada atau sitar kepala, Katarak Karena fuk liste dapat tertat beberapa hari atan bulansetelah ‘Ott jantong, juga rentan trauma ars srk. Blek- twokardiogam harus iakukan untuk mengetahui dary kerumkan jantung dan pemantauan jantung ‘Yang terus menenss diperiukan untuk mendingnoss dan meravataritmia, Keruakan neurolog joga ering fered, terutama pada medula spinal, tetapi sat dithat, Kecuai bila diakskan tes clektrofsiolog. Penganstan cermat atas abdomen peru diakukan ‘pda tahap segerasetelah cedera Karena aus yang me- Tewati cavtas pestonealis dapat menyebabkan ker sakan aluran pencemann PerawatanTuka baka stk yang tepat mengikut eins perawatan urmum fuka bakar atau ka yang besa Dengan kehlangan jringan yang masf stas amputas Jaringan yang besa, mungkin dipertskan rekonstruks dengan Map ott atau miokuts LUKA BAKAR KIMIA Laka Heli Karena bahan Kimia berbeds dengan ks Karena panas yaitu derjat luka beshuburgan Jangsung dengan lama Kontak. Karena itu, dokter dapat langsung. merubah kedalaman Iuka dengan perawatan yang cermat. Semua pakaian yang terkena harus se- tera dees dan halt diperkan untuk melhat darah Iuka. Karena kedalaman Iuka juga ditentulan oleh ‘onsentras agen yang ada pada kulit, maka pengeceran ‘dengan pembelan yang banyak menjadi tahap berikut ‘ds penatalksanaan pasion, Ada berbagal agen nev- (rales yang sidah dhuubkan untuk berbaga zt ki- smi, tetapi tak stupun menawatkan banyak Keuntung- an darpada irigas ka segera dengan lic bervolune bear. Beberapa di antaranya malah dapat memperpa- ‘ah Iuka oleh pengluaranpanas dengan nevralist!ba- han kimia. Lk bakar kaena bas serngkall Kurang d- ‘pengaruh oleh tiga, bla Tuka sudah berumur lebih lari 1 jam. Pertambahan kedalaman luka mungkinte- What dengan iigasi Karena dipermudah masoknya ion droll ke lapisan Kulit yang lebih dalam. Riwayat penting dalam menentakan Komposist zat kina sebe- farnys Karena ia dapat menentukan terapi setelah pengenceran dengan biasan ais. ‘Laka bakar karenafenol,asam hidrofluorida dan fosfor memeriokan pethatian Khusis. Fenol kurang Jarut dalam alr dan iigast harus dikuti dengan peng- ‘les pelart seperti pollen giko, propilen eikol, lierol, minyak sayur atau lrutan’air dan sabun, Kontentrai absorp fenol yang tinggi dapat menim- Dulhan efek pada sisi Jantung, ginjal dan susunan sannf put seta pasion periu dimanta untuk methat fungi-fungs ini Asam hirofluorat menembus kalit TRAUMA INHALASI Celera uh muni pada stim perapasan, jrang tevihat pada penderia Iuka bakar, Karena satosatunya cara tedokumentad untuk "membakar” batang tra Keobronchus dengan inhalad batang pernapasn, ‘Korban kebakaranterpaparasxp yang banyak mengan- dung bahan kimia berbahaya, ermal sulfur dioksda, raitrogen dioksda,asum hidroklorida, hidrosinida, kar bon monoksida dan karbon dioksida. Inhaled agen jenis ini menyebabkan Keruskan para yang parah dan bertanggung jawab bagi Komponen Iuka bakar tungzal yang paling mematikan. Banyak pasen yang mening. tal spera di tempat Kejadan Karena trauma inhalas, act semua pasin Iuka bakar yang dibawa ke rumah skit, cederainhalalterthat pada lebih dari 30%. Se ‘agian beaae pasion cedera inhalsi menderita Iuka bakar di sekitar kepal dan leber sera serng terbakar dalam ruang tertatup.Tetapi pening diketahui baw sebagian besar pasion Iuka Dakar kepala dan leer tidak smenderitacedea pau Pertolongan pertama untuk Korban dengan ke ‘mungkinan cedera ihalas terri dari pemindahan penderita dart sumber gas becbahaya dan membe- fikan oksigen. Ketka pertama diperksa éi rumah ‘abit, semua penderta ka bakar yang bert than dalam ruang tertutup dan penderta dengan Woks