114 Medico-Legal Update January-June, 2013, Vol.13, No.

Carbon Monoxide Poisoning in Burn - A Case Report

Sachin S Sonawane1, Vinod A Chaudhari2, Shailesh C. Mohite3, Dattatray G Ghodke4, Rajesh D. Kharat5, Pawan R. Sabale6 1,2,5,6 Assistant Professor, Dept. of Forensic Medicine, 3Professor and Head, Dept. of Forensic Medicine, 4Resident, TNMC & BYL Nair Ch. Hospital, Mumbai ABSTRACT Carbon monoxide poisoning is an important aspect of most fires - indeed it is the major or even sole cause of death in many victims of conflagrations, especially in house fire. When any combustible material burns in air, most of the carbon in organic material, such as timber, fabric and furnishings, is converted to carbon dioxide. Carbon monoxide is also produced, however, and, where the access of oxygen is limited or exhausted by the ongoing combustion, larger volumes of the carbon monoxide are produced. Slow, smouldering fires with little flame are likely to produce more monoxide, as with burning bedclothes and mattresses. Here one case of burn is discussed, where thirty five year old person was found dead in his closed room. On crime scene visit it was found that only mattress is burnt, rest of the room is normal. On examination the deceased was sustained only 18% superficial burns. The samples were preserved for chemical analysis. Chemical analysis of blood reveals 46% carboxyl haemoglobin. Keywords: Carbon Monoxide Poisoning, Thermal Burn.

INTRODUCTION The actual cause of death from burns is complex and results from the interplay of many factors. In rapid deaths, the directly destructive effects of heat on the respiratory tract leading to asphyxia, the combined toxic effects of carbon monoxide, cyanide and the multitude of other noxious gases (oxides of nitrogen, phosgene etc.) that are inhaled, the release of toxic material from the extensive tissue destruction, and shock due to pain all cause or contribute to death.1 Carbon monoxide poisoning is an important aspect of most fires - indeed it is the major or even sole cause of death in many victims of conflagrations, especially in house fire. When any combustible material burns in air, most of the carbon in organic material, such as timber, fabric and furnishings, is converted to carbon dioxide. Carbon monoxide is also produced, however, and, where the access of oxygen is limited or exhausted by the ongoing combustion, larger volumes of the carbon monoxide are produced. Slow, smouldering fires with little flame are likely to produce more monoxide, as with burning bedclothes and mattresses. At the other extreme, rapid flash fires with flames fanned by moving draughts and those involving volatile fuels, such as petrol or kerosene, produce relatively little monoxide though much depends upon the free access of air. In

many house fires, where the seat of the fire is originally remote from the victim, death may occur from carbon monoxide poisoning long before the flames reach the body. 2 Carbon monoxide is a colourless, odourless gas produced by incomplete combustion of material containing carbon. The most common sources of Carbon Monoxide Poisoning today are motor vehicle exhaust, smoke from fires, engine fumes, and nonelectric heaters.3 CASE HISTORY As per police inquest, accidental death report and statement of witness, the neighbours of deceased noticed large amount of smoke is coming through the partially opened window of his room. They also noticed that the room was locked from inside and accordingly called fire brigade personnel. The fire brigade personnel broke the door and stopped the fire. At the scene incidence it was noticed that the mattress which was left side of the deceased was completely burnt. The mattress on which deceased was slept was not burnt. The deceased was in supine position with left upper and lower limbs, lateral aspect of trunk and face were on the left burnt mattress. The burn injuries were present over left side of body

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including left upper and lower limb. The deceased was brought to hospital where he was declared dead before admission and the body was sent for autopsy. As per statement of sister of deceased he was unmarried, chronic smoker and alcoholic. He was alone in the room at the time of incidence. OBSERVATIONS Scene of incidence: the door was opened from outside. One window was partially opened. The left mattress of double bed was burnt but the wooden bed was not burnt. We also noticed 4-5 butts of cigarettes and same number of unused cigarettes, partially empty whisky bottle and empty glass. There was no smell and evidence of any inflammatory material. AUTOPSY FINDINGS The deceased was 35 years old, averagely built and nourished. On external examination, 1. The post mortem lividity was present over back and cherry red in colour. 2. Cyanosis of fingernails of right hand. 3. Oozing of reddish colored fluid through the nose and mouth. 4. There were superficial burns with blackening of skin and singeing of left eye brows, left eye lashes and left side of scalp and facial hairs. 5. On the left upper limb there was superficial to deep burn with peeling of skin over arm and forearm, subcutaneous tissue was exposed over extensor aspect of left forearm, 4 cm below the elbow joint and multiple blisters were present over extensor aspect left hand over radial aspect of wrist and base of left thumb, margins of blisters were reddish coloured. 6. The middle and distal phalynx of index and middle fingers of left hand were exposed; medial aspect of the nail of index finger was burnt, blackish coloured. 7. There were superficial burns with blackening of skin and singeing of hairs of lateral aspect of left thigh and subcutaneous tissue was exposed .

Table-1 Percentage and distribution of burns

Sr. No. Area 1 2 3 4 5 6 7 Head, neck, face Right Upper limb Left Upper limb Anterior Trunk Right Lower limbs Left Lower limbs Total area of burns Percentage 2% 0% 9% 4% 0% 3% 18 %

On internal examination 1. On opening trachea and laryngeal mucosa were congested and soot particles were seen admixed with the mucus. 2. Blood was in fluidity in consistency and cherry red in color. 3. Both lungs were congested and edematous. 4. All organs were severely congested on cut section. Material preserved 1. Routine viscera for chemical analysis 2. Blood with layer of liquid paraffin in air tight container for carboxy haemoglobin. 3. Scalp hairs and piece of skin for detection of inflammatory material. 4. Tissue for histopathology examination Results of chemical analysis 1. Chemical analysis examination of blood under paraffin showed 46% carboxy haemoglobin. 2. General and specific chemical testing for blood reveal 90 mg% alcohol 3. Test for detection of inflammatory material (petroleum hydrocarbons) were negative in skin and scalp hairs. On the basis of autopsy, history, scene of incidence, chemical analysis and histopathological examination report the final cause of death was given as Asphyxia due to suffocation as result of carbon monoxide poisoning in a case of 18%superficial thermal burns. DISCUSSION For the victim of a fire whose body shows no or minimum evidence of thermal injuries, the cause of

8. There was a patch of superficial burn was present over flexor aspect of left leg, 5cm below the popliteal fossa, reddish coloured.

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death is often attributed to smoke inhalation. This is often used synonymously with carbon monoxide poisoning. Examination of individuals overcome by smoke inhalation will usually reveal soot in the nostrils and mouth as well as coating the larynx, trachea, and bronchi. At autopsy, it is usually relatively easy to determine whether the individual died of carbon monoxide intoxication. The livor mortis, the muscles, and internal organs, as well as the blood, will have a cherry-red coloration4 In house-fire victims, carbon monoxide and hydrogen cyanide, singly or combined, are probably not solely responsible for the deaths that occur in badly burned victims (a minority of fire victims). In fact, the significantly higher carboxy-haemoglobin in unburned or scarcely burned victims (most fire victims) indicates that carbon monoxide alone or combined with hydrogen cyanide plays a major role in the cause of death. Carbon monoxide levels of 30% or 40% and even 20% may cause death if the victim suffers from an underlying disease such as severe coronary atherosclerosis. In a typical fire the complete exothermic reaction is: C + O2 = CO2+ heat If the conditions of the fire are altered such that there is an overabundance of fuel (increased carbon) and/or a relative/absolute lack of oxygen, incomplete combustion results: 2C + O2 = 2CO + heat The latter is the typical scenario in most fires; therefore most fire-related deaths are directly attributed to smoke inhalation, primarily from the contained CO therein5 Carboxy haemoglobin detection from the victims blood is the most important laboratory finding to differentiate ante mortem and post mortem incidence of burning. More than 10% blood haemoglobin saturation with carbon monoxide in bodies recovered from fire usually indicates that the victim inhaled smoke and hence was alive at the time of fire.6 The combustion reaction in the fire may sometimes be incomplete, resulting in the production of a great deal of smoke, composed of gases and of condensed and solid products. Carbon particles, by-products of sulphurous compounds, and carbon monoxide, together with other toxic gases, are also present in smoke. 7

Similarly in this case the deceased sustained less burns (18%) due to slow smouldering fires with little flame. It produced more carbon monoxide due to burning of bedclothes and mattresses. The room was closed and there is no space for escaping the smoke which resulted asphyxia due to carbon monoxide. The deceased was under the influence of alcohol and smoking cigarette. He slept with burning cigarette in the left hand which resulted into the burning of left

Fig. 1. Showing burnt and unburnt cigarettes.

Fig. 2. Showing left burnt and right unburnt mattress.

Fig. 3. showing cherry red pm lividity on back.

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CONCLUSIONS The type of fire provides valuable information regarding how a case should be worked up. A fire that begins in bedding or clothing in a case with a history of alcohol and/or drug use in a cigarette smoker may suggest an accidental origin. In this case of burns was less hence the investing authorities were in dilemma regarding the cause and manner of death. It was very important to visit the scene of incidence, proper history, meticulous autopsy, collection evidences. This was very helpful in this case to conclude the cause and manner of death. The cause of death was Asphyxia due to suffocation as result of carbon monoxide poisoning in a case of 18%superficial thermal burns. The manner of death and type of fire were accidental. REFERENCES 1. 2. 3. 4.
Fig. 5. showing burnt nail of left index finger, at typical position of cigarette holding.

Fig. 4. minimum burn on left lower limb and upper limbs.

5.

mattress. The middle and distal phalynx of index and middle fingers of left hand were severely burnt. The type of fire was accidental and the manner of death was the same.

6. 7.

Richard Shepherd. Simpsons Forensic Medicine 12th edition. p 109-110. Bernard knight, pekka saukko. Knights Forensic Pathology 3rd Edition. p 322-23. Reddy KSN. The Essential of Forensic Medicine and Toxicology. 27th edition p 553. Vincent J. Di Maio , Dominick Di Maio. Forensic Pathology 2nd edition. p 390-91. Jason Payne, James Roger Byard , Tracey Corey , Carol Henderson. Encyclopedia of forensic and legal medicine. p 222-223. Krishan Vij. Textbook of Forensic Medicine and Toxicology 3rd Edition 2005. P 255-256. Viegas D.X., Fire behaviour and fire-line safety. Ann. Medit. Burns Club. 1993;6: pg 179185.)