XII

SPECIFIC INJURIES

A. INJURIES CAUSED BY EXPLOSIONS

- Classification:
a. Mechanical explosion as seen in air pressure tanks explosion
b. Electrical explosion as seen in lightning
c. Nuclear explosion as in atomic bomb explosion
d. Chemical explosion as seen in gunpowder, dynamite
- Explosions are accompanied by blast waves and flames
- Destructive effects are varied:
Complete disruption or fragmentation of the body
Punctate bruises
Abrasions, lacerations
Peppering kind of injuries
Knockdown effect on the victim
Petechial (pinpoint) hemorrhages (bleeding) on the respiratory mucosa
Reddening of the inner ear
Burns, singeing of hairs
Asphyxia (suffocation) due to lack of oxygen in the surrounding air
Inhalation poisoning (carbon monoxide, nitric gases, sulfur dioxide, etc)
Injuries from flying missiles
Injuries from falling debris
- On-site investigation: search for traces of detonation mechanism, explosive
residues, gas analysis
- Atomic bomb explosion liberates energy equal to a million tons of TNT. It
produces millions of pounds per square inch of gas pressure, with heat
comparable to the sun and light 30 times more brightness as the sun at
noontime, and creates a shock wave in all directions and can be felt one
mile away in 2 seconds accompanied by transient blast winds.
- Rays emitted by atomic explosion:
a. alpha rays- poor penetrating power; can be stopped by a sheet of paper
b. Beta rays- higher penetrating power than alpha rays; travels at very high
velocity
c. gamma rays- greater penetrating power such that it damages the human
body
d. neutron rays- highly penetrating power
- Atomic explosion, unlike conventional explosions, emit thermal radiation
thereby causing skin burns. Such thermal radiation are highly penetrating
and harmful and continues to be emitted over a long period of time.
- Effects of atomic explosion:
Generalized erythema (redness; likened to severe sunburn)
Coma / Death
Nausea, vomiting
Leukemia and other blood defects
Chromosomal aberrations
 Radiation dermatitis (painful reddening of the skin, later with skin peeling
and skin ulcers)
Cataracts
Sterility, abortion, stillbirth

Hiroshima, Japan. After the dropping of the atomic bomb.

Hiroshima, Japan. Due to the heat of the atomic bomb, steel structures collapsed while
cemented structures stood.
 Effects of radiation burns due to the atomic
bomb blast in Hiroshima, Japan. Kiyoshi Kitsukawa had his back facing the blast which
was 1,000 yards away.

B. INJURIES CAUSED BY FIREARMS

- Legal definition: “Firearm” includes rifles, muskets, shotguns, revolvers,
pistols and all other deadly weapons from which a bullet, ball, shot, shell,
or other missile may be discharged by means of gunpowder or other
explosives.
The barrel of any firearm shall be considered as a complete firearm.
-Ballistics- the science dealing with the trajectories of projectiles, the firing
characteristics of firearms, bullets and cartridges usually for identification.
-Medical Ballistics- studies the penetration of the missile or bullet to the human
body, with emphasis on the severity and appearance of the wounds.
-a minimum pressure of 700 kilopascals (100 lb/sq inch) is needed for tissue
damage in humans.

- Classification of Firearm:
a. Low velocity firearm- firearms with muzzle velocity of not more than
1,000 feet per second. Examples: .25 auto, .38 special, Colt 45
b. Medium velocity firearm- firearms with muzzle velocity between
1,000 to 2,000 fps. Examples: .22 LR, 9mm para, .357 magnum,
.44 magnum, shotgun
c. High power firearm- firearms with muzzle velocity of more than 2,000
fps. Examples: military rifles
- Parts of a Cartridge or Ammunition:
a. Cartridge Case or Shell- a cylindrical structure with a base which
houses the powder, the primer, and with the bullet attached at the
tip. Made of brass (70% copper and 30% zinc). A few have nickel
coating.
b. Primer- a chemical compound sealed at the cartridge base by a small
disc of soft metal – usually lead-tin. The most common chemical
constituent of the primer are: lead, antimony and barium. Less
common elements include aluminum, sulfur, tin, calcium,
potassium, chloride, silicon, and mercury-fulminant based primer.
c. Powder or Propellant- when exploded will cause the bullet to be
driven forward towards the gun muzzle. Its explosion will produce
from 200cc to 900cc of gas composed of: carbon dioxide, carbon
monoxide, nitrogen, hydrogen sulfide, unburnt powder, traces
of methane and oxygen.
d. Bullet or Projectile- the metallic object attached to the free end of the
cylindrical tip of the cartridge case, propelled by the expansive
force of the propellant, and responsible in the production of
damages in the target. Bullet cores are often lead and antimony
with a few having ferrous alloy core. Bullet jacket are usually brass
(90% copper with 10% zinc).

- Mechanism of Firearm Action:

A pull on the trigger will cause the firing pin of the hammer to hit the
percussion cap of the cartridge in the firing chamber which is aligned
with the rear portion of the barrel. As the firing pin hits the primer cap
(percussion cap), the primer compound hits the anvil which causes the
generation of a flash which in turn ignites the powder. This causes the
evolution of gases under pressure and temperature up to 5200 degrees. The
marked expansion of the gases will force the projectile forward with
certain velocity. Owing to the presence of rifling at the inner wall of the
bore which are arranged in a spiral manner, the bullet will produce a
spinning movement as it comes out of the muzzle. Together with the bullet
passing out of the barrel are high pressured heated gases, unburnt powder
grains with flame and smoke.
- Things Coming Out of the Gun Muzzle after a fire:
a. Bullet- tissue damage of a bullet of a very high velocity is very much
greater than those with much less velocity.
b. Flame- it is conical in shape with the vertex located at the gun muzzle.
It usually does not go beyond a distance of 6 inches; in pistols and
revolvers, the flame is often less than 3 inches.
c. Heated, Compressed and Expanded Gas- the volume of the gas
generated is dependent on the nature and quantity of the propellant.
Smokeless powder (mixture of cellulose nitrate and nitroglycerine)
generates more gas compared with black powder (mixture of potassium
nitrate, sulfur and charcoal) of the same quantity. In smokeless powder,
the muzzle velocity of the bullet is three times greater than that of black
powder.

d. Smoke (Soot, Smudging, Fouling, Smoke Blackening)- it is black and

lack sufficient force to penetrate the skin. It is deposited on the target and
is readily wiped off. Its presence infers a near shot. Its shape may also be
useful in determining the trajectory of the bullet.

e. Powder Grains- it produces tattooing (stippling, peppering) around the

gunshot wound of entrance. In close range, the powder grains penetrate
the dermal and epidermal layers of the skin and may cause bleeding in
deeper tissue which cannot be removed by ordinary wiping. Its presence
indicates that the gun muzzle when fired is not more than 24 inches.

Gunshot entry wound of the skull. Note the powder grains “peppering” the
skin around the wound. Also note the irregular shape of the entrance
wound and the beveling of the wound- characteristics of skull gunshot
wounds.

f. Powder Burns- blackening of the margin of the gunshot wound of

entrance. It is due to smoke smudging, gunpowder tattooing and burning
of the wound margin.
 Note the powder burns (blackening of the margin of the gunshot wound),
powder grains in the deeper layer of the wound, and the patterned muzzle
due to close range of fire. Also a gunshot wound point of entry wound.

- Abrasion Collar- the pressure of the bullet on the skin will cause the skin to be
depressed and lacerates the skin. A perpendicular approach will produce an even
width of the collar. An acute angle of approach will cause an abrasion collar
wider at one end of the wound.

Gunshot Entrance Wound. Note the powder grains inside the wound, the burns
around the wound, and the smoke blackening farther from the wound.
- Destructive Mechanism of Gunshot:
a. Laceration and Crushing- low velocity bullets that travel less than
1,000 fps do virtually all their damage via crushing.
b. Cavitation- produced by projectiles traveling in excess of 1,000 fps. A
permanent cavity is caused by the path of the bullet itself, whereas
a temporary cavity is formed by continued forward acceleration of
the medium in the wake of the bullet, causing the wound cavity to
be stretched outward.

c. Shock Waves- travel ahead of the bullet as well as to the sides, but
these waves last only a few microseconds and do not cause profound
destruction at low velocity. At high velocity, generated shock waves can
reach up to 200 atmospheres of pressure.
d. Hydrostatic Force- liquid contents in the lumen of body organs such
the urinary bladder, the intestines and stomach, are displaced radially
away from the bullet path producing extensive laceration. The displaced
fluid carries with it the kinetic energy from the bullet which in turn acts as
a secondary projectile causing destruction of tissues not on the path of the
bullet.
e. Fragmentation or Disintegration of the Bullet- a bullet fragments
when it hits a hard object like a bone. Each fragment has sufficient kinetic
energy to cause injuries similar to the mother bullet. Bonded bullets, also
known as frangible ammunition, are composed of bonded fragments of
iron, lead or copper; and they are designed to disintegrate on striking a
hard surface, thus increasing their kinetic energy delivered to the tissue.
f. Fragmentation of Hard Brittle Object in the Trajectory- bones hit by
bullets may fragment and these bone pieces in turn will cause damage to
surrounding tissues and organs.
- Some Characteristics of Bullets:
1. Bullet travel through a gun barrel is characterized by increasing
acceleration as the expanding gases push on it. Up to a point, the
longer the barrel, the greater the acceleration.
2. Greater velocity, greater caliber, or denser tissue gives more drag. The
degree to which a bullet is slowed by drag is called retardation
3. Once the bullet strikes its target, its wounding capacity is directly
related to the kinetic energy at impact. KE= (1/2 mv²). Increasing a
mass only results in a linear increase in energy; however,
increasing the velocity results in an exponential increase in energy
to the second power.
4. The faster the spin, the less likely a bullet will “yaw” or turn sideways
and tumble. Increasing the twist of the rifling from 1 in 7 will
impart greater spin than a typical 1 in 12 spiral (one turn in 12
inches of barrel). A non-spinning bullet is inherently unstable and
has a tendency to tumble through air.
5. Bullets do not typically follow a straight line to the target. Rotational
forces are in effect that keep the bullet off a straight axis in flight.
These rotational effects are diagrammed below:

Yaw- any degree of deviation of the longitudinal axis from the line
of flight.
Mutation- a second motion of higher frequency and lower
amplitude which imparts a rosette pattern of motion to the
bullet
Tumbling- due to the difference in weight of the nose and base of
the bullet, the bullet rapidly rotates on its long axis while
on flight resulting in some instances where the base of the
bullet hits the skin.
Wabbling- the tail of the bullet wags (tailwags); the target can be
hit sideways.
6. The best bullet composition is lead which is of high density and is
cheap to obtain. Its disadvantages are a tendency to soften at
velocities >1,000 fps, causing it to smear the barrel and decrease
accuracy, and > 2,000 fps lead tends to melt completely. Alloying
the lead with a small amount of antimony helps but the real answer
is to interface the lead bullet with the barrel through another metal
soft enough to seal the bullet in the barrel but of high melting
point. Copper works best as this “jacket” material for lead.
7. Air guns, also known as “BB” (ball-bearing) guns, fire .177 or .22
round pellets at muzzle velocities of 200 to 900 fps. The projectile
can penetrate to a depth of 25mm at a range of 1 meter and up to
15mm at a range of 5 meters.
8. No change in shape occurs until impact velocity achieves about 800 fps.
Between 800 and 1,000 fps a slight flattening of the bullet nose can
be expected. Over 1,000 fps real expansion starts to occur and by
1,200 fps the nose is turned over to form a mushroom shape. At
around 1,000 fps there is tendency for the copper jacket to be shed
from the lead. The jacket stops in the subcutaneous tissue and the
bullet will continue to penetrate. At velocities reaching 1,500 fps
the bullet is transformed into a rounded ball of lead and copper.
(Soft-nose and hollow point bullets actually flatten out or
mushroom on impact, which greatly increases the amount of
kinetic energy delivered to the tissue).

Note the changes in shape of the bullet at varied velocities.

9. Shotguns are smooth-bore weapons and thus do not have a rifled barrel
that creates rifling marks. Their effective range is 30-50 meters.
10. Some newer guns use “polygonal” rifling resembling the reversed
image of a twisted square rod. A particular type of gun (.38 Smith
and Wesson, or 9 mm Glock) will impart these class
characteristics.
Varied bullets of varied guns.

- Examination of Bullet Fragments or Bullet Composition:

In many cases, recovered bullets will be too deformed for comparison
studies. The following methods may be employed:
a. Spark Source Mass Spectrometry (SSMS)- this method makes
use of the fact that the “lead” of bullets actually contain up
to 26 common elements, of which 12 can be used for
differentiation. One of the commonest of these is antimony.
b. Dithiooxamide (rubeanic acid) Test- this test detects copper
and nickel, which may be components of the jacketed
ammunition.
c. Scanning Electron Microscopy with Energy Dispersive
Analysis (SEM-EDA)- identifies the presence of lead and
antimony.
d. Proton Induced X-ray Emission (PIXE)- detects the presence
of lead even in a victim buried for several years

- Distinction between Gunshot Wound of Entrance and Wound of Exit:

Entrance Wound Exit Wound

- smaller than the missile. - always bigger than the
missile
- edges are inverted - edges are everted
- usually round or oval - no definite shape
- presence of contusion collar - absence of contusion collar
- tattooing or smudging may be present - always absent
- underlying tissues are not protruding - underlying tissues may be
protruding
- always present - may be absent
- paraffin test may be positive - paraffin test always
negative
Gunshot wound Point of Entry (front and above the ankle). GSW Point of Exit
(below the ankle).

- Some Principles Regarding Gunshot Injuries:

1. The higher the caliber of the wounding bullet, the greater will be the
size of the wound of entrance.
2. In most cases, the size of the wound of entrance is smaller than the
caliber of the wounding bullet on account of the retraction of the
connective tissue.
3. The wound of exit is usually larger than the wound of entrance, this is
due to the lack of support beyond the skin and the velocity of the
missile.
4. In cases of an acute angle of approach of the bullet, the wound of
entrance is oval in shape with the contusion or abrasion collar
widest on the side of the acute angle of approach.
5. Conical shape free end bullets have more piercing power without
marked tissue destruction while missiles with hemispherical free
ends are more destructive.
6. No burning, smudging or tattooing is seen in wounds of entrance fired
from a distance of at least 60cm (2 ft.)
7. An exit wound does not show characteristic shape. This is attributable
to the deformity of the bullet in its passage in the body and to the
wobbling and stumbling movement of the bullet during its course
and fragmentation of the missiles.
8. If the number of gunshot wounds of entrance and exit found in the body
is even, the presumption is that no bullet is lodges in the body. But
if the number of gunshot wounds of entrance and exit is odd, the
presumption is that one or more bullets might have been lodges in
the body (Odd and Even Rule). This rule is merely presumptive
evidence which can be set aside when a material and relevant
contrary evidence is given.
9. Injuries which will cause incapacity to do voluntary acts as those
involving the brain and the spinal cord definitely inhibit volitional
acts.
10. The presence of multiple entrance wounds may not exclude suicide.
Usually solitary. Suicide injuries are found at the temple of the
dominant head, the mouth, the anterior neck, the forehead or
anterior chest wall. The entrance wound shows muzzle impression,
burning, smudging, and tattooing. If the distance from which the
bullet was shot was at arm’s length or less than an arm’s length,
then suicide must be suspected.
11. In revolvers, there is a gap between the cylinder and the barrel to allow
the cylinder to move freely, but this also allows gases to escape
laterally, which at close range may deposit gunshot residue on
surrounding structures and allow forensic pathologist to
reconstruct the scene.
12. Youths and youth gang members may attempt to build their own
firearms. Typically, they are crude and adapted to fire available
ammunition. In one study, such guns caused unusual muzzle
imprints, intensive soot deposits at the entrance wounds and on the
hands, intensive carbon monoxide effects burns and in one case a
skin laceration of the hand holding the weapon. The bullets
showed a reduced penetration depth and characteristic marks were
missing.
13. Wounding is an extremely complex situation with variables of bullet
size, velocity, shape, spin, distance from muzzle to target, and
nature of tissue. These factors are interrelated.
14. In shotgun injuries, at close range (< 4 feet), the pellets essentially act
as one mass; the entrance wound would be about 1 inch diameter.
The wound cavity would contain wadding. At intermediate range
(4 to 12 feet), the entrance wound is up to 2 inches diameter, but
the borders may show individual pellet markings. A rough guide is
that the spread of shot in centimeters equals three to four times the
range in meters, i.e. if the spread of shot pattern is 30cm across,
then the distance the gun was fired would be approximately 9-12
meters. Wadding may be found near the wound. Rarely do shotgun
wounds in the chest and abdomen have wounds of exit.
15. The most difficult problem is distinguishing a distant from a contact
wound, especially when:
a. the body is decomposed
b. the victim survived so that healing or repair of the
wound occurred
c. multiple layers of clothing filter the soot and powder of
a contact wound
d. the edges of a small caliber contact wound dry together
16. Entrance wounds into the skull bone typically produces beveling or
coning, of the bone at the surface away from the weapon on the
inner table. In thin areas such as the temple, this may not be
observed.
17. “Shoring” of entrance wounds can occur when firm material is pressed
against the skin, such as when a victim is shot through a wooden,
glass, or metal door while pressing against it to prevent entry of an
assailant. Such wounds have a greater wound diameter and
demonstrate greater marginal abrasion. Stellate radiating
lacerations of some shored wounds could lead to misinterpretation
of distant range of fire as a contact wound.
18. If the exit wound is “shored” or abutted by a firm support such as
clothing, furniture or building materials, then the exit wound may
take on appearance of an entrance wound- i.e. circular defect with
an abraded margin.
19. In a sequence of fire, the first shot may be horizontal (victim upright)
but subsequent shots would be oriented down or to the back of the
victim as he falls or flees.
20. Persons engaged in target shooting, particularly in indoor firing
ranges, are exposed to lead and may develop intoxication with
lead. One study showed half of those tested had blood levels >40
micrograms/dl. Lead poisoning from retained bullets is most likely
with multiple fragments or pellets within one month of injury. One
to five years after injury, there is little risk for lead poisoning.
21. Plastic bullets, replacing rubber bullets (implicated in 3 deaths) used as
“safe” projectiles for riot control, were shown in one study to be
associated with 13 deaths (7 children) by serious head injury;
usually fired at distances less than 25 yard range considered be
“safe”.
22. Evidences in GSW due to Homicide-
a. located in any part of the body
b. does not show a firm contact fire; a short range fire is possible
c. usually multiple
d. presence of struggle wounds or defense wounds
e. evidences in the surroundings of a fight or a commotion
f. firearm is not found near the body
23. Evidences in GSW due to Murder-
a. wounds usually found at the back
b. usually multiple
c. far distance fire
d. vital parts of the body are hit
e. no defense wounds
f. usually from a high muzzle velocity firearm
24. Evidences in GSW due to accidents-
a. wound in any site of the body
b. usually solitary wound
c. fired from a short distance
- Dermal Nitrite Test (Paraffin test, Diphenylamine test, Lung’s test,
Gonzales test):
Paraffin Wax Test- The back of the fingers and of the hand up to the wrist
is coated with melted paraffin. The melted paraffin penetrates the minute
crevices of the skin and when hardened and cooled off, some of the
powder particles will be extracted and embedded in the paraffin cast. The
cast is built with layers of cotton and paraffin, solidified, then removed
and treated with Lung’s reagent. Presence of particles containing nitrate or
nitrite will be indicated by a blue reaction of the particles upon contact
with Lung’s reagent. (This test is no longer in use and not considered
credible.)

A Kit to determine presence of gunpowder particles in the hand.

- About Paraffin Test:
1. Fertilizers, cosmetics, cigarettes, urine and other nitrogenous
compounds will give a positive reaction.
2. The test usually gives a positive result even after a lapse of 3 days or
even though the hand has been subjected to ordinary washing.
3. The test is not conclusive, it may be a corroborative evidence in the
determination as to whether a person has fired a gun.
4. Residue on the palm may simply indicate a defense posture or
alternatively that the suspect handled the gun after it was fired.
Residue on the back of the hands can indicate the suspect recently
fired a weapon.
5. In practice, residues are detectable in 90% of persons who have fired
handguns, but only 50% of persons who have fired rifles and shotguns.
6. In suicide, residues are often detected on the non-firing hand used to
steady the muzzle against the body.
7. Residues of barium alone may be the result of contamination with
barium rich soil.

- Modern Methods of Detection of Gunshot Residue:

The major methods for detection of primer residues are:
a. Neutron Activation Analysis (NAA)
b. Atomic Absorption Spectrophotometry (AAS)
c. Scanning Electron Microscopy with Energy Dispersive
Analysis (SEM-EDA)
The collecting device in the field has a gummed surface and a
holder. The gummed surface is applied to the skin or other material
to be tested for residues. With electron microscopy, actual surface
details of particles are examined for comparison with known
samples of gunshot residue, and pictures can be taken.

Other methods (chemical tests):

a. Modified Griess Test- utilizes a chemical color reaction to help
distinguish obscure or faint gunpowder patterns. This test
detects nitrites by reacting with acetic acid to form nitrous
acid which combines with alpha-naphthol to produce an
orange-red color.
b. Dithiooxamide (DTO) Test- effectively used in determining the
physical characteristics of bullet holes including the
determination of entrance vs. exit holes. Detects presence
of copper and cobalt.
c. Sodium Rhodizonate Test- effectively used in determining
entrance and exit holes. It utilizes a chemical color reaction
that is specific for lead.
 - Basic Principles Involved in Firearm Identification:
1. The quality of metal in the manufacture of the firearm is very much
harder and resistant to deformity as compared to the metal quality used
in the manufacture of the cartridge. The surface condition of the barrel
of the gun can easily be impressed on the shell or bullet.
2. Firearms have certain physical characteristics of certain type of caliber
which differentiate it from others- number of lands or grooves,
direction of the twist, width of the individual lands and grooves, style
of the cannalure, etc.
3. No two firearm can be manufactured with identical surface
characteristic.

- Injuries in Different Parts of the Body:

1. Injury of the cerebral hemispheres is as a rule not immediately fatal,
however, a bullet course which includes the medulla, pons and other
vital centers causes immediate death.
2. Gunshot wound to the heart as a general rule does not prevent the
victim from running, walking, climbing stairs or do other forms of
volitional acts for death is not usually instantaneous.
3. Abdominal gunshot injuries are not limited to one organ but to several
organs.
4. Injuries to organs may not be found slong the course of the bullet.
5. Bullet wounds of the stomach and other hollow organs are usually
small on account of the contractility of walls.
6. Injury of the upper cervical spinal cord may cause immediate death
because the vital nerve tracts may be involved. Lower spinal cord
injury may cause motor or sensory paralysis.

C. INJURIES CAUSED BY HEAT.

Heat Heat Heat
Cramps Exhaustion Stroke
Etiology excess sweating lead heart failure direct sun exposure
to loss of chlorides
and dehydration

Signs sudden muscle cramps syncope congested face

flushed face (dizziness) full & pounding
abdominal pain pale face pulse
dilated pupils dilated pupils contracted pupils
diarrhea leg weakness
weak pulse

Result not fatal fatal fatal

Treatment saline solution IV remove from heated remove from heated

area; medical Tx area; medical Tx
Difference between Heat Exhaustion and Heat Stroke.

Heat Index- a quantity expressing the discomfort felt as a result of the combined
effects of the temperature and humidity of the air.
Rise in humidity, pushes up the heat index

- Burns.
Types of Burns:
1. Scald burns- caused by hot water, hot liquids and food.
Usually involves children. Often has a “geographical” lesion
distribution. There is neither burning of the hair, deposit of
carbonaceous material nor clothing involvement. Death usually
due to infection complication.
 Scalding burns. Note the “geographical” lesion.

2. Flame burns- due to gasoline, kerosene, LPG, burning house

or building. Lesion varies from simple erythematous (redness)
to complete carbonization of the body.

Complete carbonization of the body due to flames.

3. Chemical burns- occurs usually in laboratories and industrial

firms. Due to strong acids and alkalis. Character of lesion-
absence of vesiculation, ulcerative skin lesions, and
“geographic” appearance.
 4. Electrical burns- electric current travels through the body and
may stop the heart and / or depress the respiratory center in the
brain. The depth of damage is worse than other types of burns.
Main cause of death is shock. Amperage and voltage are the
factors causing the injury. A person suffering from cardiac
disease is predisposed to death from electrical shock.
In electrical burns, the entry point of the current is the area of
contact; the exit point is often an area of damp skin such as the
sweaty areas of the axilla, the sole of the foot, the elbow and
the hands. The severity of the burn is directly proportional to
the duration of the contact, although even extremely short
exposure to high-voltage current can cause massive tissue
damage. The pathway of the current is unpredictable but
usually follows the blood vessels, as these offer least
resistance.

5. Mechanism of death:
a. Ventricular fibrillation- irregular heartbeat
b. Respiratory failure due to bulbar / brainstem paralysis
c. Mechanical asphyxia (strangulation) due to violent and
prolonged convulsion
6. Radiation burns- results from x-ray and radioactive / nuclear
bomb exposure. Lesions vary from reddening to blister
formation, ulceration and obliteration of blood vessels.

- Depth of Burns.
1. Partial thickness burns
- First and second degree burns
- First degree burns: erythema (i.e. redness, sunburn)
- Second degree burns: blister formation and pain
- Involves the epidermis and varying layers of the dermis

First degree burn- sunburn. Note the redness (erythema).

 Second degree burn- note the blister formations on the fingers.

When blisters are punctured and the covering removed, the

underlying raw skin is exposed.
2. Full Thickness Burns.
- Third and Fourth degree burns
- Third degree burns-No epithelial remnant, hair follicles, sweat
and sebaceous glands remain
- Painless
- Fourth degree burns- underlying fascia, muscle and or bone is
burned.
 Third degree burn.

- Causes of Death in Burns.

a. Immediate Causes:
1. Shock- early death is due to neurogenic shock following painful
irritation of the multiple nerve endings in the skin.
2. Concomitant physical injuries
3. Suffocation- inhalation of fumes cause inflammatory reaction of
the respiratory passages. Carbon monoxide competes with
oxygen in the blood.

b. Delayed Causes:
1. Exhaustion
2. Dehydration- loss of body fluids from the raw surfaces of burn
areas secondary to evaporation.
3. Complications
Infection / Septicemia
Pneumonia
Nephritis – kidney complication

- Proofs that Victim was Alive before Burned to Death.

1. Presence of smoke in the air passages- grayish black or black

material adherent to the mucosa (inner lining) of the air passages (i.e.
larynx, trachea, bronchi)
2. Increase in carboxy-hemoglobin blood level- carbon monoxide
enters the body through the respiratory tracts and competes with
oxygen in the blood. Cherry red color of the blood is due to carbon
monoxide.
 3. Dermal erythema / redness, edema / swelling, vesicle / blister
formation- these reactions indicate that blood circulation was present
when heat was applied.
4. Subendocardial left ventricular hemorrhage- bleeding along the
walls of the chamber of the heart.

- Findings that prove that Death is Due to Burning:

1. Presence of vital / inflammatory reaction at the heated areas- i.e.

erythema / redness, edema / swelling, fluid, antibodies / neutrophils
2. Presence of carboxyhemoglobin in the blood
3. Presence of carbon particles in the tracheo-bronchial lumina

- Distinction between Ante-Mortem and Post-Mortem Burns:

Ante-Mortem Post-Mortem
Burns Burns
Blister Contains albumin & Scanty albumin &
chlorides in abundance chlorides

Inflammatory Present None

Reaction

Vesicle base Red No color change

Soot or carbon Present None

in tracheo-bronchial
lumina

Carboxy-hemoglobin Increased None

level in the blood

- The absence of signs of vital reactions at the site of the burns does not
necessarily indicate that the lesion is post-mortem. Death may have occurred
too quickly for these changes to develop or the injuries might be ante-mortem
but the body resistance was so diminished to produce the vital reaction.
- Heat Rupture- splitting of the soft tissues of the body, like the skin, due to
exposure before or after death of the body to considerable heat. May be
mistaken for an incised or lacerated wound.
- Heat Stiffening- heat coagulates the albuminous materials inside the muscle
making it stiff and contracted (shortened). Since flexor muscles are stronger
than extensors, the limbs become flexed and the fingers clenched (“pugilistic”
position of a boxer).
- Spontaneous Human Combustion (SHC)
o definition: the ignition and burning of the body independently of
contact to any burning body
o first documented case of SHC was reported in 1662
o Features of cases of SHC:
▪ Burning is never spontaneous. There is always an ignition
source present in the room nearby the victim
▪ The burns are not distributed evenly over the body; the
extremities are usually untouched by fire, whereas the torso
usually suffers severe burning
▪ 80% of cases are female, overweight and alcoholics
▪ Combustion is localized to the body
▪ The floor around the deceased is often covered with a viscous,
foul smelling, oily yellow liquid
▪ All cases occur indoors
o The human body is approximately 80% water. Excess fats are usually
distributed in the torso and thigh

- Mechanism of Human Combustion

The victim usually drinks a lot of alcohol before going to sleep in front of
a fire or other naked ignition source. During the course of the night, the
victim comes into contact with the ignition source which sets a portion of
the victim’s clothing alight. This burns the skin and melts the
subcutaneous fat. The fat will burn and so the body will fuel its own
combustion. The body continues to burn until there are no more fatty
tissues left. Parts of the body which are not covered by clothing will not
burn. Clothing of the body serves as a wick for the melted fats to burn.
Burning fat produces large amounts of smoke and soot. Melted fat would
run off the victim and pool on the floor where it remains unburnt (due to
lack of wick).

Human combustion. Note clothed parts of the body are burnt.

D. INJURIES BY LIGHTNING AND ELECTRICITY
- Direct electric current amounting to one million volts and about 2,000
amperes
- Human body especially its nerves is a good conduction of electric current.
- Effects of lightning:
- in objects:
a. metallic articles fuse and become magnetized
b. glass materials fuse
- in the human body:
a. spasmodic contraction of blood vessels in the brain resulting to anemia
(lack of blood supply) to the brain and loss of consciousness; in the
extremities this may cause gangrene.
b. certain degree of neurological disturbance; concussion; personality
changes; paralysis
c. external lesions- burns of the skin; singeing of hair; wounds of almost
any description
d. fracture of bones; hemorrhages / bleeding in the organs
e. cataract formation
f. ruptured tympanic membranes
- Death is usually due to cardiac arrhythmias. They occur as current travels
across the chest. AC current usually is associated with ventricular
fibrillation and DC current with asystole. In some cases arrhythmias are
delayed for up to 12 hours.
- In electrical burns, the entry point of the current is the area of contact; the exit
point is often an area of damp skin such as the sweaty areas of the axilla,
the sole of the foot, the elbow and the hands. The severity of the burn is
directly proportional to the duration of the contact, although even
extremely short exposure to high-voltage current can cause massive tissue
damage. The pathway of the current is unpredictable but usually follows
the blood vessels, as these offer least resistance.

E. INJURIES DUE TO ATMOSPHERIC PRESSURE CHANGES

- Effect of Depth
a. When a person descends beneath the sea, the pressure around him
increases tremendously.

At sea level = 1 atmosphere

33ft below 2
66ft 3
100ft 4
200ft 7
300ft 10
500ft 16
b. When a person descends beneath the sea, gases are compressed to
smaller and smaller volumes.
- Three gases to which a diver breathing air is normally exposed are: Nitrogen,
Oxygen, and Carbon Dioxide. Four-fifths of the air is Nitrogen; Nitrogen
is 5 times as soluble in fats as in water
-Trimix- breathing gas consisting of oxygen, helium and nitrogen
-for deep commercial diving, 330 feet
-Helium reduces proportion of nitrogen and oxygen (10% oxygen, 70%
Helium, 20% Nitrogen); diminish nitrogen narcosis and oxygen toxicity
-Helium of low molecular weight enters and leaves tissues more rapidly
than nitrogen; of low solubility, does not load tissues heavily as nitrogen
-Helium is faster to saturate and desaturate
-Heliox (Helium + oxygen with 0% nitrogen)
- Nitrogen narcosis- also called Martini’s Law, “raptures of the deep”
-not noticeable at depths less than 30 meters (100 ft)
-state similar to drunkenness; resemble effects of marijuana and
Benzodiazepine
-chemical toxicity disrupts nerve conduction at receptor sites
-affects coordination of sensory, cognitive processes and motor activity;
impairment of judgment, multi-tasking and coordination, loss of
decision-making activity and focus; vertigo; visual and auditory
disturbances
-Martini’s law- narcosis results in the feeling of one martini every
10meters (33ft) below 20meters (66feet)
- Oxygen toxicity
-affects CNS, lungs, eyes
-chemical toxicity affects capillary and alveolar endothelium leading to
pulmonary damage and atelectasis
-chemical toxicity affects enzymes and cells in CNS leading to destruction
of neurons and eventual convulsions and coma
-disorientation, breathing problems, visual changes (myopia; retinal
detachment)
- Decompression Sickness
When a diver breathes air under high pressure, the blood flowing through
the pulmonary capillaries become saturated with Nitrogen to the same
pressure as that in the breathing mixture. Over several hours, enough
Nitrogen is carried to all the body tissues to saturate them. Since Nitrogen
is not metabolized by the body, it remains dissolved. Several hours are
required for the gaseous pressures of Nitrogen in all the body tissues to
come to equilibrium with the pressures of Nitrogen in the alveoli. If a
diver has been beneath the sea long enough so that large amounts of
Nitrogen have dissolved in his body, and then he suddenly comes back
to the surface of the sea, significant quantities of Nitrogen bubbles will
develop in his body fluids and then will cause serious damage in almost
any area of the body.
 Atmospheric pressure increases as the depth increases.

1. Sea Level. As depth increases (2,3) nitrogen and oxygen pressures increase.

- Signs of Decompression Sickness

Local pain in the legs and arms Shortness of breath
Dizziness Extreme fatigue and pain
Paralysis Collapse & unconsciousness
- The rate at which a diver can be brought to the surface depends on:
1. The depth to which he has descended
2. The amount of time he has been there
- Effects of High Altitudes:
At a higher altitude, the atmospheric pressure becomes lower and more
gas will be liberated by the body fluid. The release of gases will cause:
1. “Bends”- joint and muscular pains
2. “Chokes”- non-productive coughing and breathing difficulties. This is
due to bubble formation in the lung blood vessels or bubble formation
in tissues near the lungs
3. Substernal emphysema- accumulation of bubbles beneath the skin
with associated crackles / crepitations under the skin on palpation
4. Trapped gas in hollow viscus like the stomach and intestines resulting
into a doubling of their sizes
5. Anoxia- lack of oxygen. At higher altitudes, the oxygen content of the
atmosphere becomes lesser and lesser. This is especially felt between
8,000 to 15,000 feet level.
6. Cold temperature- at high altitudes, the temperature falls sometimes
causing frostbite or freezing of the body.

Decompression Chamber. Divers suffering from decompression sickness

are brought into this chamber for gradual atmospheric pressure
adjustments to normal.

The inside of a bigger decompression chamber.

F. INJURIES DUE TO ASPHYXIA

Asphyxia is the medical term applied to all forms of violent death which results
primarily from the interference with the process of respiration or the condition in
which the supply of oxygen to the blood or to the tissues or both has been reduced
below normal level. In layman’s terms this is suffocation. Examples: hanging,
strangulation, drowning.

- Phases of Asphyxial Death:

a. Dyspneic Phase- humans breath in oxygen and expel carbon dioxide.
With asphyxia, there is lack of oxygen intake and retention of
carbon dioxide. The blood responds by rapid and deep breathing,
increased pulse rate, rise in blood pressure. Consequently, the
fingers and hands turn bluish.
b. Convulsive Phase- with persistence of asphyxia, the retained carbon
dioxide stimulates the brain resulting to convulsions. Small
pinpoint hemorrhages (bleeding) known as Tardieu Spots are
evidenced in body organs; this is due to the increasing pressure in
minute blood vessels.
c. Apneic Phase- this occurs due to the paralysis of the respiratory center
in the brain. Breathing becomes shallow and gasping and the rate
becomes slower till death.

- Mechanism of Death in Hanging:

Upon suspension of the body, the weight causes the noose or band to
tighten, producing pressure at the region of the neck. The pressure of the
band will cause the air passage to constrict, the hyoid bone and tongue are
pushed upwards and backwards against the laryngo-pharynx, the larynx is
pushed backwards and its opening is closed. Likewise there is
compression of the jugular veins, carotids and the nerves producing
anoxia. Ordinarily, breathing may persist one or two minutes and the heart
action for 15 to 30 minutes so that artificial respiration may successfully
revive the victim.
 Tongue Blood vessels
Epiglottis
Adam’s apple
Trachea

The epiglottis closes during the tightening In hanging, tightening of the noose also
of the noose in hanging thereby stopping presses on the large blood vessels in the
the passage of air into the lungs. neck, thereby stopping the flow of blood
to the brain.

- Mechanism of Death in Drowning:

In water, the body sinks due to its greater specific gravity compared to
water. Later the body is buoyed because of the instinctive movements of
the individual, coupled with the air beneath the individual’s clothing.
Upon reaching the surface, there is an attempt to breathe. Air and water
enters the mouth and nostrils. He alternately surfaces and sinks in the
water; and every time he attempts to breath, water enters. The entrance of
water to the lungs causes violent coughing, which expels the air in the
lungs which creates an imperative desire to breathe, during which more
water enters. A vicious cycle ensues. Water fills up the air passages and
then the lungs. Death occurs in 2 to 5 minutes.

During diving, submerging the face into the water, especially cold water,
triggers the mammalian diving reflex. In this reflex, the body compensates
by slowing body functions as well as diverting blood only to the heart,
lungs, and brain. Bradycardia (slowing of the heart) and peripheral
vasoconstriction (blood flow to the skin and extremities is restricted)
ensues.
 - Findings in Drowning:
Skin is puckered, pale and contracted (goose-skin)
Penis and scrotum are contracted and retracted
Washerwoman’s hands and feet
Post-mortem lividity marked in the hand, neck and chest
Lungs are swollen like balloons (emphysema aquosum)
Whitish foam accumulates in the mouth and nostrils (Champignon
d’ocume); indicates victim was alive
Plenty of fluid in the stomach
Water presence in the middle ear
- If drowning took place in salty water, the blood chloride content in the left
heart chamber is greater than in the right chamber; but if drowning took
place in fresh water (approx. 0.5% salinity), the blood chloride in the right
chamber of the heart is greater than in the left.

- Diatoms or Bacillariophyceae, single celled algae, are found in natural bodies

of water. During drowning, diatoms could enter the blood via the lungs. If
detected in the body tissues are the most reliable indicator of a freshwater
drowning. Even when there are only skeletal remains, diatoms can be detected
in the bone marrow of drowned victims. Twenty diatoms per 100 microliters
of pellet from a 10 gram lung sample, or five complete diatoms from other
organs, are normally required for a positive diagnosis. Their absence raises the
possibility that drowning took place in a sink, or bathtub, since diatoms are
filtered from households during water treatment. Diatom population varies
seasonally with a major peak in the spring and a less pronounced peak in
autumn.
- The presence of wood or any floating material in the hands of the dead in
water, may show that the victim was still alive before he ultimately died in the
water.

- Presence of live fleas in clothing- in death by drowning, a flea can survive for
about 24 hours submerged in water. After 24 hours submersion in water, the
fleas die.

G. INJURIES IN CHILD ABUSE.

RA 9262- Anti-Violence Against Women and Their Children Act of 2004.
Children refers to those below 18 years old or those over but are unable to fully
take care of themselves or protect themselves from abuse, neglect, cruelty,
exploitation or discrimination because of a physical or mental disability or
condition.
Child Abuse/ Shaken Baby Syndrome/ Battered Child Syndrome- refers to
maltreatment, whether habitual or not, of a child which includes:
 1. Psychological or Physical Abuse, neglect, sexual abuse or emotional
maltreatment
2. Any act by deeds / words which debases, degrades or demeans the
intrinsic worth and dignity of a child
3. Unreasonable deprivation of his basic needs- food, shelter
4. Failure to immediately give medical treatment

- Classification of a Child Abuser:

a. Intermittent Child Abuser- Periodically batters a child with periods of
proper care between battering. They have no intention to hurt the
child but panic or compulsion drives them into abusive behavior.
They become sincerely remorseful afterwards.
b. One-Time Child Abuser- Manhandle the child for a time and never
repeats the act. There is more likelihood for a one-time abuser to
repeat the act until the child is killed.
c. Constant Child Abuser- Actually hates the child and callously and
deliberately beats the child. Parent has the intent to hurt the child.
Parents often have personality disorders and are coolly indifferent
to the destructive nature of their actions.
d. Ignorant Abuser- Parents ‘mean’ well, but their attempts at rearing
result in permanent injury or death of the child. They are ‘truly
sorry” when the child dies.

- Medical Evidences in Child Abuse:

Skin imprints
Multiple bruises and / or scars
Multiple burns
Multiple fresh healing fractures
Injuries to the genitalia, peri-rectal, peri-vaginal areas
Signs of malnourishment, poor hygiene, infection, poor growth and
development
Boxed by the parent. Note the swelling and hematoma on the eyelids.

- Forms of Child Abuse:

Child prostitution
Sexual abuse
Child trafficking
Working children
Obsence publicity and indecent shows

- One suspects child abuse in the making with the following:

1. Some discrepancies between severity of the injury and the parent’s /
relative’s explanation
2. Injuries appear unusual
3. Injuries suggest infliction in separate occasions
4. Delay in reporting
5. Unexplained sibling death in the family
6. Child becomes sick under parent’s custody but becomes well in care of
another.
7. Suspect parent is emotionally distant from spouse

- On Child Abuse:
1. There are often no witnesses to the abuse, therefore it requires a high
index of suspicion to detect one.
2. Abusers seldom have the intent to kill the victim. Death happens usually
accidentally.
3. In any form of Child Abuse, the physician is mandated to report to the
authorities.
5. Doctrine of Parens Patriae- “father of the country”; where the
state, as sovereign, exercises powers of guardianship over persons
under disabilities. The state may interfere in affairs of child if it so
deems for child’s interest. Article II, Section 12 of the Constitution
provides that the State shall protect and strengthen the family as a
basic autonomous social institution.
6. Child is not obligated to follow parent’s tenets. Child is too young to
 have found his own religion convictions and should not be bound
by religious beliefs.
7. Parental Authority- granted rights to parents. In case of
disagreements, father’s decision prevails, unless there is judicial
order to the contrary.
8. Mauchausen Syndrome by Proxy- parent creates an emergency
situation and attempts to revive / rescue the child.

-On Working Children:

Anti-child Labor Law provides that children below 15 years of age, if
working in non-hazardous conditions, may work for not more than 20 hours a
week, at most 4 hours a day. The Law limits children 15-17 years old to work not
more than 8 hours a day or 40 hours a week. Night work from 8pm to 6am is
prohibited.
Not more than 20% of the child’s income may be allotted for the
collective needs of the family. There must be a trust fund from at least 30% of the
earnings of the child whose wages and salaries and other income amount to at
least P200,000 annually. Employers must provide the working child access to at
least primary and secondary education.

H. TRANSPORT INJURIES
Pedestrian Injuries:
1. When there is little or no visible bumper injuries, the pedestrian was probably
struck by the side of the vehicle.
2. If there is fracture of the long bone (tibia) of the lower leg, this is often
wedge-shaped or triangular, with the base representing the site of impact or
blow and its apex the direction in which the vehicle was traveling.
3. The height of the bumper is usually about 22 inches above ground level.
Sometimes it has protruberant parts which go as high as 18 to 19 inches .
4. Bumper injuries are usually below the center of gravity, that is, below the
brim of the pelvis at the level of the waistline.
5. When the injury is as low as the ankle of the victim, the driver of the car may
have seen the pedestrian and applied the brakes causing the front end of the
vehicle to dip and hit the pedestrian at a lower level.
6. In speeds less than 40 kph, the pedestrian may be carried by the vehicle for a
considerable distance. When the vehicle stops, the victim drops to the ground.
7. In speeds between 41 - 48 kph, the pedestrian can be thrown upwards and may
land on the hood of the vehicle. When the vehicle stops, the victim rolls to the
ground, incurring other injuries.
8. In speeds of about 80 – 96 kph, the victim may be thrown higher and may
land on the trunk or on the road behind the vehicle in such case he is in danger
of being hit by another passing vehicle.
 9. If the victim is hit by a bus or truck, the impact is above the center of gravity.
The victim is thrown forward, sidewards or into the radiator grill and falls to
the ground when the vehicle stops.
10. Ones head or body may be completely amputated due to the vehicle’s impact.

Occupant’s Injuries:
1. Incur injuries from 2 sources, namely:
a. Primary impact- refers to the vehicle hitting any objects on the road. As
a result, the occupant-passenger or driver may be expelled partially
or completely from the vehicle or thrown through the windshield.
b. Secondary impact- occurs when as a result of the first impact, the
occupant is thrown in any direction and even expelled from the
vehicle, resulting in injuries.
2. In head-on collision, more than 50% of the accidents result in death to its
passengers.
3. Certain injuries sustained by an unrestrained occupant suggest a head-on
collision such as dashboard injuries resulting in displacement or fracture
of the femur or dislocation of the knee cap.
Driver’s Injuries:
1. One can sometimes tell who is the driver based on injuries sustained:
a. One is often crushed against the steering wheel
b. One may be impinged against the windshield of the car
c. Ones foot is wedged under the front seat resulting in laceration and
fracture of the ankle of the foot.

2. The sternum (midline chest bone) especially in the area of the manubrium
(upper midline chest area)may be fractured.
3. The lower portion of the steering wheel may cause extensive tears of the
internal organs- i.e. liver, heart, lungs, aorta- causing exsanguination and
death
4. It is possible that the driver and occupants may have internal injuries without
any apparent external injuries.
5. Whiplash injury due to severe hyperflexion and hyperextension of the neck
may cause transaction of the spinal cord usually at the level of 5th and 6th
vertebrae. Such injury may cause instant permanent paralysis of the parts
of the body below the site of injury.
6. Even if the driver or occupants survive the crash, post-operative complications
can occur- i.e. prolonged immobilization together with fracture of bones and
soft tissue injury may expose the patient to fat and bone marrow embolism.

Motorcyclist Injuries:
1. Due to sudden deceleration, whiplash injury may occur.
2. Internal organs injury may occur due to sudden violent turning of the
handlebar.
3. In front and rear collisions, he is likely to be thrown forward and upward over
the top or on top of the vehicle hit.
 4. In intersection collisions, the cyclist’s body moves forward, his pelvis is lifted
from the motorcycle’s seat and his head strikes the side of the vehicle near its
roof.

Seatbelt injuries:
Compression injuries to the lung and intra-abdominal organs.

I.SPORTS INJURIES

1. Traumatic Brain Injury (TBI) is the leading cause of death and serious injury
in sports and recreational related accidents.
2. TBIs account for 5% to 20% of injuries with higher proportions among
children, adolescents, and young adults.
3. The most common head injury or TBI in sports is concussion.
4. Symptoms of Concussion:
Early Late
Headache, dizziness Memory disturbances
Vision changes Poor concentration
Confusion Irritability, Fatigue
Tinnitus (ringing in the ears) Sleep disturbances
Nausea, Vomiting Personality changes
 5. Compilation of Concussion Guidelines:
Symptom Guideline Grade First Second Third
Complex Concussion Concussion Concussion
Concussion <15 Roberts MILD Return to play if Return to play if Return to play if
minutes. No asymptomatic for asymptomatic for 1 asymptomatic for
Post-Traumatic 20 minutes week 2 to 4 weeks
Amnesia (PTA)
Cantu 1 Return to play if Return to play in 2 Terminate season.
asymptomatic weeks if May return next
asymptomatic for 1 season.
week

Colorado 1 Return to play if Return to play if

Medical Society asymptomatic for asymptomatic for 1
15 minutes week. If second
concussion is on
same day,
terminate activity
that day

PTA <30 Roberts 1 Return to play if Return to play Return to play if

minutes. No asymptomatic for after 2 weeks, if asymptomatic for
Loss of 1 week asymptomatic for 1 3 to 6 months
Consciousness week
(LOC)
Cantu 1 Return to play if Return to play Terminate season.
asymptomatic for after 2 weeks if May return next
1 week asymptomatic for 1 season
week. Consider
terminating season

Colorado 2 Return to play if Return to play if Terminate season.

Medical Society asymptomatic for asymptomatic for 1 May return next
1 week month season

American 2 Return to play if Return to plat if

Academy of asymptomatic for asymptomatic for 2
Neurology 1 week weeks

PTA >30 Roberts 2 Return to play if Return to play Return to play if

minutes <24 asymptomatic for after 1 month if asymptomatic for
hours; LOC <5 1 week asymptomatic for 1 3 to 6 months
minutes week

Cantu 2 Return to play if Return to play Terminate season.

asymptomatic for after 1 month if May return next
1 week asymptomatic for 1 season
week. Consider
terminating season

Any LOC Colorado 3 Transport to Terminate season.

Medical Society hospital. Return Discourage return.
to play 1 month
after injury if
asymptomatic for
2 weeks

(LOC for American 3 Transport to Return to play

seconds) Academy of hospital. Return after 1 month.
Neurology to play when
asymptomatic for
 1 week

PTA >24 hours. Roberts 3 Return to play 1 Return to play No return

LOC >5 minutes month after after 3 to 6 months
injury, if
asymptomatic for
2 weeks

Cantu 3 Return to play 1 Terminate season

month after
injury, if
asymptomatic for
1 week

(Any LOC) Colorado 3 Transport to Terminate season.

Medical Society hospital. Return Discourage return
to play 1 month
after injury, if
asymptomatic for
2 weeks

(LOC lasting American Return to play if Return to play if

more than a few Academy of asymptomatic for asymptomatic for 1
seconds) Neurology 2 weeks month

6. Evaluation of athlete after injury:

-Basic life support (airway, breathing, circulation)
-Determine if LOC occurred
-Determine injury to the spine (tingling sensation of extremities, numbness
of extremities, movement of fingers and toes, pain in neck or back)
-May be moved to the sideline
-Test cranial nerves, coordination and motor function
-Test long- and short- term memory (three word memory, serial sevens,
questions on recent events- who is the opponent, what the score is, who
the team played the previous week, who scored most recently)
7. Reassess frequently so that any deterioration or continuation of symptoms can
be noted.
8. Second-Impact Syndrome- occurs in players who return to competition before
the symptoms of a first concussion have completely resolved. A second blow
to the head, even a minor one, can result in a loss of autoregulation of the
brain’s blood supply; this leads to a vascular engorgement and subsequent
herniation of the brain that is usually fatal.
9. Repeated concussions can result in cumulative neurologic damage, even when
injuries are separated by months or years. Punch-drunk syndrome in boxers.
10. Postconcussion syndrome- characterized by fatigue, headaches, equilibrium
disturbances or difficulty in concentrating that may persist for weeks to
months after the initial injury.
11. An athlete should not return to play while concussion symptoms are present.
Even if symptoms are absent at rest, the patient should be tested during
exertion.
12. The use of helmets will instill a false sense of security and lead to more
aggressive risk taking behavior. With the increased utilization of protective
 gear, there appears to have an associated increase in the level of aggressive
play and a concomitant rise in the occurrence of concussions and spinal
injuries.
13. Other injuries sustained with sports and recreational activities:
Spinal injuries
Cranial hematomas
Ocular injuries
Dental injuries
Fractures
Sprains and strains
Dislocations
Soft tissue injuries
14. Athletes or participants must always play in a safe and responsible manner.
They should proper instruction and should always stay within the ones limit of
ability.