FORENSIC EMERGENCY

MEDICINE
PRESENTER : Dr. Prajwal Rao K
MODERATOR : Dr. Bharathi (CMO)
Dr. Hima Bindhu (CMO)
DATE : 30/09/2021
 OBJECTIVES
FORENSIC ASPECTS OF GUNSHOT FORENSIC ASPECTS OF PHYSICAL
WOUNDS ASSAULT
Perspective Perspective
Blunt force pattern injuries
Clinical features Sharp force pattern injuries
Diagnostic testing Thermal pattern injuries
Management Chemical injuries
FORENSIC ASPECTS OF MOTOR
VEHICLE TRAUMA
Perspective
Evaluation of Motor vehicle
collisions
Evaluation of Pedestrian collisions
 PERSPECTIVE
• Forensic emergency medicine is the application of forensic medical knowledge, techniques, and
procedures to the management of live patients in the emergency department (ED).

• It is a key link through which patients or victims of violence can receive recourse for the actions against
them, such as physical or sexual assault, abuse, or trauma have forensic needs.

• Forensic examinations should be conducted with the consent of the patient, legal guardian, or court or
by implied consent.

• The evaluation should include a history and physical examination in which all wounds are documented
and described in as much detail as possible, as well as photographs and anatomic diagrams.

• Even simple findings, such as contusions or ecchymoses with associated injuries may serve as
important clues as to how the injury was sustained and may be invaluable in future legal proceedings.
 Forensic evaluation of Handgun injuries
• Handguns are the most common firearm available. There are four categories of handguns:

1. the singleshot weapon (usually a target pistol);

2. the derringer (a small, concealable weapon, usually with two barrels);

3. the revolver (a weapon with a rotating cylinder that advances with the pull of the trigger); and

4. the semiautomatic pistol (which fires with each pull of the trigger).

• The semiautomatic handgun is the most popular because its magazine, or clip, can hold up to 17
cartridges, whereas revolvers hold five or six cartridges.
 Semiautomatic pistol

• It is a type of repeating single-

chamber handgun (pistol) that
automatically cycles its action to
insert the subsequent cartridge into
the chamber (self-loading), but
requires manual actuation of the
trigger, to actually discharge the shot.
Handgun ammunition
PART DESCRIPTION MATERIAL USED
Bullet Projectile that is Generally lead or
propelled down steel
the gun barrel
Cartridge case Propelling bullet Typically brass,
down the barrel Others also

Propellant Gunpowder Nitrocellulose OR

Nitrocellulose &
Nitroglycerin

Rim Provides extractor

on firearm a place
to grip casing to
remove it from
chamber once
fired
Primer Ignites propellant Lead, Barium,
Antimony
 Handgun entrance wounds
• Range of fire is the distance from the muzzle to the victim and can be divided into four general categories:
contact, near-contact or close range, intermediate or medium range, and indeterminate or distant range.

• The size of the entrance wound does not correlate with the caliber of the bullet because the entrance
wounds over elastic tissue will contract around the tissue defect and have a diameter much less than the
caliber of the bullet.

• Atypical entrance wounds occur when a bullet encounters an intermediate object, such as a window, wall,
or door, before striking the victim. Ricochet bullets may also cause atypical entrance wounds.

• The intermediate object may change the bullet’s size, shape, or path.

• Such changes can result in entrance wounds with large stellate configurations that mimic close-range or
contact wounds.
RANGE OF FIRE

RANGE INCHES (BARREL TO SKIN) PHYSICAL PROPERTIES

Contact 0 Soot, seared skin, triangular tears
Close 0-6 Soot, abrasion collar (abrasion
collar may be obscured by soot)
Intermediate < 48 Tattooing, abrasion collar
Distant or indeterminate Any distance Abrasion collar (intermediate
objects will prevent soot and
gunpowder from contacting the
skin)
 CONTACT WOUNDS
• There are three subcategories of contact
wounds:

1. tight contact, in which the muzzle is

pushed hard against the skin;

2. loose contact, in which the muzzle is

incompletely or loosely held against the
skin; and

3. contact through clothing.

 Handgun Exit wounds
• Exit wounds are the result of a bullet pushing and stretching the skin from the
inside out.

• The skin edges generally are everted, with sharp but irregular margins.

• A shored exit wound is a wound that has an associated false abrasion collar.

• If the skin is pressed against or supported by a firm object or surface at the

moment the bullet exits, the skin can be compressed between the exiting bullet
and supporting surface, such as belts, floors, walls, doors, chairs, and mattresses.
 CLINICAL FEATURES
• Patients with firearm injuries have varying presentations, depending on the anatomic location of
the injury and type of weapon used.

• Patients with injuries to the head and neck often present in critical condition due to the
abundance of vital neurovascular structures in this area. Patient can present with altered mental
status and signs of impending herniation and Neck injuries can present with the Symptoms that
can range from asymptomatic to active bleeding (from trauma to the vasculature), dysphonia or
hoarseness (due to pharyngeal or tracheal injuries), or hemiplegia or hemiparesis (if the internal
carotids are disrupted).
• Gunshot injuries to the thorax can result in damage to the cardiac musculature,
cardiac tamponade, pneumothoraces or hemothoraces, or other mediastinal
pathology.

• Injuries to the extremities could result in fractures, vascular (DVT) or nerve injury,
and compartment syndrome, because bullet tracts do not necessarily
decompress fascial compartments.

• Gunshot wounds to the perineum can cause bowel or bladder injury where the
patients can present with gross hematuria or gross blood on rectal examination.

• Shots fired from air rifles may result in cardiac injury & traumatic brain injury.
 DIAGNOSTIC TESTING

• The imaging modalities used will differ, depending on the location of the injury.

• A noncontrast CT scan of the head can show associated skull fractures,

intracranial hemorrhages, or retained missiles.

• CT angiogram of the neck is useful to evaluate for injuries to essential

neurovasculature or aerodigestive structures.

• Thoracic injuries often mandate a CT chest scan to assess for injuries to the lungs,
heart, and mediastinum, as well as to define the bullet trajectory.
• Abdominal or genitourinary injuries will also require CECT of the abdomen
and pelvis to identify the tissues injured.

• CT urogram or cystogram may be indicated if there is a concern for upper

tract or bladder injury respectively.

• Spinal cord or vertebral injuries are well visualized by MRI or CT, respectively
—but note that the metallic nature of most bullets may preclude imaging with
MRI.
MANAGEMENT
Resuscitation, crystalloid(s), blood, ABC
 Head and neck injuries
• Resuscitative measures.

• Emergent operative procedures may be required to evacuate intracranial hematomas in patients

in whom there is significant mass effect, shift, or other evidence of increased intracranial
pressure.

• Neck injuries are managed with emergent intubation, as needed, and control of active
hemorrhage.

• Vessel ligation might also be required if unable to control the hemorrhage with direct pressure.

• Damage to vital structures may necessitate emergent operative intervention.

 Thoracic injuries

• Decompression of pneumothoraces, hemothoraces, and hemorrhagic

pericardial effusions.

• ED thoracotomy is performed for patients who present in cardiac

arrest within 15 minutes of their injury or on arrival to the ED.

• Tension pneumothoraces or pericardial tamponade should be

decompressed emergently, prior to advanced imaging.
 Abdominal injuries
• Gunshot wounds to the abdomen can be managed expectantly if the patient is stable with no
injuries to the peritoneal cavity or with moderate solid organ injuries (grades 1–3 liver or splenic
lacerations) and Unstable patients with bowel injuries (including evisceration) or severe splenic or
liver lacerations (grade 4 or 5) will require emergent exploratory laparotomy.

• Urethral injuries are managed with Foley catheter placement before or after the appropriate
diagnostic modalities have been performed (retrograde urethrography or retrograde
cystourethrography).

• Intraperitoneal bladder injuries are managed operatively, whereas extraperitoneal injuries are
managed with Foley catheter placement and decompression.
 Extremity injuries

• Management of these injuries involves irrigation, débridement of devitalized

tissue, and traction or splinting of broken extremities.

• Bullet removal is only required in certain cases.

• Operative intervention is required for patients with unstable fractures, fractures

with exposed bone, compartment syndrome, or vascular injuries requiring repair.

• Transabdominal injuries with pelvic fractures also mandate prophylactic

antibiotics.
 Soft tissue injuries
• Soft tissue wounds are managed with irrigation, but wounds are left open.

• However, because high-energy injuries and shotgun wounds produce a significant amount
of devitalized tissue, they often require operative débridement.

• Tetanus vaccinations should be updated and tetanus immunoglobulin given to those

without prior immunity.

• Indications for prophylactic antibiotics are grossly contaminated wounds, abdominal

wounds with hollow viscus injury, intraarticular injuries, intracranial injuries, and high-
energy gunshot injuries.
FORENSIC ASPECTS OF
ASSAULT IN EMD
 PERSPECTIVE
• Rates of violence vary by age, gender, ethnicity, and geographic location.

• Differences in child maltreatment rates, as well as other forms of violence, are attributable to underlying
risk factors, such as poverty.

• Urban areas have higher homicide rates than suburban or rural areas.

• Accurate documentation of their shape, precise body location, and measured size makes it easier to
determine the implement, tool, or weapon responsible for producing each wound, which can be called
pattern injuries of abrasions or contusions.

• These injuries are classified into major categories according to their source—blunt force, sharp force,
thermal, and chemical.
 Blunt force pattern injuries
• The most common blunt force injury is the contusion, along with abrasions and lacerations. A weapon with a
unique shape or configuration may stamp a mirror image of itself on the skin.

• COMMONLY INFLICTED PATTERN INJURIES:

1. Slap marks with digits delineated

2. Looped or flat contusions from belts or cords

3. Circular contusions from fingertip pressure

4. Parallel contusions with central clearing from linear objects

5. Contusions from shoe heels and soles

6. Semicircular contusions and abrasions from bite marks

 Sharp force pattern injuries
• An incised wound is longer than it is deep, and a stab wound is defined as a puncture wound that is deeper than it is wide.

 Characteristics of Self-Inflicted Knife Wounds:

• Multiple superficial incisions located on the anterior trunk, arms, and face

• Multiple superficial stab wounds located on the anterior trunk, arms, and face

• Parallel incisions, in close proximity to each other, on the nondominant side of the body

• Sparing of sensitive body areas

• Linear or curved incisions toward the hand inflicting the wound

• Intact clothing covering the wound

• Evidence of prior wounds in repeat offenders

 Thermal pattern injuries
• A thermal pattern injury is a common form of abuse, particularly in pediatric patients. They comprise
about 5% to 22% of all physical abuse, 41 and pediatric burns represent 6% to 20% of all abuse cases.

• The location of the burn may also be helpful in delineating the intent of the burn; burns to the gluteal
area or perineum are very rarely accidental, whereas burns to the hands and upper trunk are common
with unintentional injuries.

• Intentional burns tend to be deeper and well demarcated and are often due to hot objects, such as
curling irons, cigarettes, or hot liquids.

• In contrast, splash burns are characterized by an irregular or undulating line or by isolated areas of
thermal injury, usually round or oval in shape, caused by droplets of hot liquid.
• The severity of thermal or scald injury
depends on the length of contact time
and the temperature, which causes skin
damage and cellular damage. It is
important to be attentive to
concomitant injuries in burn patients,
particularly those who are victims of
significant violence.
 Chemical injuries

• The victims tend to be female, often following domestic disputes.

• The most commonly used agents are those found around the home, such as car
battery acid, which is usually thrown at the victim.

• The head, face, and neck are predominantly affected but the fluid may spread to
the chest and trunk as well.

• Patients develop findings consistent with burns from acids or alkalis because
cellular damage results from coagulative or liquefactive necrosis, respectively.
• Primary management consists of prompt removal of contaminated clothing or
other materials as soon as possible and irrigation of the affected area with copious
amounts of water.

• Patients may also require rapid resuscitation with intravenous fluids and pain
control, with or without airway management.

• These patients may also develop a significant electrolyte abnormality, such as

metabolic acidosis or hypocalcemia, which require close monitoring and treatment.
 FORENSIC ASPECTS OF
MOTOR VEHICLE TRAUMA
 PERSPECTIVE
• Globally, road traffic injuries are estimated to
be the eighth leading cause of death.

• Infrequent helmet use, riding against traffic,

and use of electronic devices while driving are
important factors.

• Young adults between 15 and 44 years

account for 59% of global road traffic deaths,
with 77% of those deaths occurring in men.
 Evaluation of MVCs

• Determination of a vehicle occupant’s role may be simple (eg, if the driver is

pinned behind the steering wheel) or complex (eg, if the vehicle’s occupants
are ejected).

• Many impaired drivers claim to be passengers.

• Short-lived evidence or pattern injuries that might be destroyed or altered in

the delivery of patient care should optimally be preserved and photographed.
 Pattern injuries
• Common pattern contusions, abrasions, and lacerations are seen from steering wheels, air bags, air bag module
covers, window cranks, radio knobs, door latches, dashboard components, and front and side window glass.

• A deployed air bag may induce a pattern abrasion to the face, cornea, forearms, or other exposed tissue.
Pattern lacerations, specific fracture patterns, and amputations are seen when the deployed air bag module
cover impacts the hand or forearm.

• Laminated glass (windshields) and tempered glass (side and rear windows) produce pattern injuries.

• Laminated glass breaks into shards on impact and causes linear incised wounds.

• Tempered or safety glass is a single layer of glass that breaks into small cubes when fractured, imparting a
dicing pattern to the skin.
 Trace evidence
• Clothing, shoes, and biologic standards (eg, hair, tissue, blood) may determine an occupant’s role.

• The soles of leather shoes may reveal the imprint of the gas or brake pedal.

• Preservation of clothing permits the comparison of clothing fibers with those fibers transferred to
vehicle components during the collision.

• Imprints of fabric may also be transferred to components within the vehicle, including the steering
wheel.

• Contact with the windshield often transfers hair and tissue to the glass.

• Glass collected from within a patient’s wound can be matched with a particular window within the
vehicle.

• Air bags can be an excellent source of trace evidence.

 Pattern injuries
• When struck by the front of a vehicle, a standing adult will sustain bumper injuries,
which include open and closed fractures of the tibia and fibula, soft tissue damage, and
pattern injuries from vehicle components and hardware.

• The presence of bumper injuries at one height on one leg and at another height on the
other may indicate that the pedestrian was walking or running at the moment of
impact, with one leg elevated.

• Examination may show lateral striations or abrasions when a patient has been dragged.
• A victim who is struck from behind may have pattern contusions on the calf or thigh,
whereas pattern contusions from a grill on the anterior aspect of the thigh indicate
that the pedestrian was standing and facing the vehicle.

• Pedestrians struck by a glancing portion of a vehicle may also display a pattern injury.

• Victims who are run over may display a tire tread pattern.

• Tire marks and the absence of bumper injuries suggest that the patient was supine
or prone in the roadway before he or she was run over.