GROUP – A (LAQ-15 MARKS) 1. One 22 years old female married for 3 years caught fire over her body in her in-law's house. She was admitted in the burn ward of a nearby hospital with 60% of total body surface area burn (10% 1st degree, 45% 2nd degree & 5% 3rd degree burn as per Wilson's classification) and succumbed to her injury after 6 days. Her pre-burn body weight was 55kg. i. What could be the possible causes of death in this case? ii. How hypovolemic shock could be treated in this patient? iii. Under what section, is the inquest conducted in this case & by whom & why? iv. Describe external and internal post mortem findings to establish the cause of death as antemortem burn injury. v. What should be the surest sign of antemortem burn injury if soot is not found inside the trachea? (1.5+3+1.5+3+1 = 10) [JNM] 2. A 25 years old women was admitted in MJN Medical College & Hospital, Cooch Behar with extensive burn injuries on her body. Investigation revealed that she tried to commit suicide on the day of her 3rd wedding anniversary night owing to her marriage disharmony. She died after 7 days of treatment in the hospital following which the body was send for autopsy. What type of inquest is conducted in such situation? How do you classify burn injury? What could be the various causes of death following burn injury. Describe the salient Post mortem findings in such a case. (2+3+5+5=15) [MJNMCH] 3. One recently married lady was brought to the casualty with the H/O of burn injuries few hours back and declared brought dead by the attending doctor. Deceased was subsequently forwarded to mortuary for autopsy examination. i. Who will do the inquest in this case? ii. Enumerate the five causes of death? iii. Write down Wallace Rule of Nine and its importance. iv. How will you differentiate antemortem burn injuries from postmortem burn injuries? (2+5+3+5=15) [JALPAIGURI] 4. One 22 years old female married for 3 years caught fire over her body in her in law's house. She was admitted in the burn ward of a nearby hospital with 60% of total body surface area burn and succumbed to her injury after 6 days. (i) What could be the possible causes of death in this case? (ii) How hypovolemic shock could be treated in this patient? (iii) Who will conduct the inquest in this case and why? (iv) Describe external and internal post mortem findings to establish the cause of death a antemortem burn injury. (v) What should be the surest sign of antemortem burn injury if soot is not found inside the trachea? (2+3+2+6+2) [JHARGRAM] GROUP – B (SAQ-10 MARKS) 1. Define burns. Classify burns based on the depth of tissue involvement (degrees of burns). Describe the internal and external PM findings in a case of death due to ante-mortem burns. (2 + 3 + 5 = 10) [MSDMCH] GROUP – C (S/N-5 MARKS) 1. Joule Burn [SMCH] [DHGMCH] 2. Define and classify burns. Differentiate comprehensively between antemortem and postmortem burns based on autopsy findings. (1+1+3) [SSKM] 3. Describe post mortem finding in a case of death due to ante-mortem burn injuries. [RPHGMCH]

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BURNS - Comprehensive Forensic Medicine Exam Answer Bank

Sources: The Essentials of Forensic Medicine and Toxicology (36th ed., 2026); Parikh's Textbook of Medical Jurisprudence; P C Dikshit's Textbook of Forensic Medicine and Toxicology

GROUP A (LAQ - 15 Marks)

QUESTION 1 / 4 (Combined) — 22-year-old married female, 60% TBSA burn, died after 6 days

(i) Possible Causes of Death (2 marks)

In a patient with 60% TBSA burns, death on the 6th day is most likely due to a combination of the following:

Early causes (within 48 hours):

Hypovolemic/burn shock - massive plasma loss from the burned surface causing circulatory failure
Respiratory failure - laryngeal oedema from inhalation of superheated air/steam, causing acute airway obstruction
Carbon monoxide (CO) poisoning - cherry-red carboxyhaemoglobin (HbCO 30-50%) causing tissue hypoxia

Intermediate causes (2-7 days): 4. Septicaemia/Toxaemia - the burned surface becomes an ideal culture medium; gram-negative organisms (Pseudomonas, E. coli) and gram-positive organisms invade causing bacteraemia 5. Acute renal failure (ARF) - haemoglobinuria, myoglobinuria, and reduced renal perfusion lead to acute tubular necrosis 6. Acute respiratory distress syndrome (ARDS) - inhalation injury + systemic inflammatory response 7. Cyanide poisoning - from burning of synthetic materials (plastic, nylon, silk, wool) 8. Curling's ulcer - stress gastric ulcer with haemorrhage (described in delayed burn deaths)

Rule of thumb: Burns >50% in a young adult can be fatal. In a 22-year-old with 60% TBSA burns, septicaemia with multi-organ dysfunction (renal, pulmonary, hepatic) is the most likely cause of death on day 6. - The Essentials of Forensic Medicine and Toxicology, 36th ed.

(ii) Treatment of Hypovolemic Shock (3 marks)

Immediate fluid resuscitation is the cornerstone of management.

Fluid Calculation - Parkland Formula:

4 mL × body weight (kg) × % TBSA burned (2nd + 3rd degree only)

For this patient: 4 × 55 × (45 + 5) = 4 × 55 × 50 = 11,000 mL (11 litres) in 24 hours

First 8 hours: Give 5,500 mL (half the total) - Ringer's Lactate preferred
Next 16 hours: Give remaining 5,500 mL

Note: 1st degree burns are excluded from Parkland formula calculation.

Other measures:

Two large-bore IV access; insert urinary catheter to monitor urine output (target 0.5-1 mL/kg/hr)
Oxygen therapy (100% O2 via face mask) - also treats CO poisoning
Analgesics (morphine IV - NOT IM, as absorption is erratic in shock)
NGT insertion - prevents Curling's ulcer, reduces gastric dilatation
Blood/plasma colloids after 24 hours
Escharotomy if circumferential full-thickness burns restrict circulation
Prophylactic antibiotics (systemic and topical - silver sulfadiazine)
Tetanus prophylaxis

(iii) Inquest - Section, Conducted by Whom, and Why (1.5-2 marks)

Type of inquest: Police Inquest under Section 176 CrPC (now Section 194 BNSS, 2023)

Conducted by: The Executive Magistrate (in cases of dowry death/unnatural death of a married woman within 7 years of marriage). Specifically under Section 176(1A) CrPC, the magistrate must conduct the inquest (not merely may).

Why Magistrate's inquest (not Police inquest alone)?

This is a case of a married woman dying within 7 years of marriage under suspicious circumstances (fire in the in-law's house)
This raises a presumption of dowry death / cruelty under Section 304B IPC (now Section 80 BNS) and Section 498A IPC (now Section 85 BNS)
Therefore, it falls under the specific provision that mandates a Magistrate's inquest to ensure a more thorough, independent inquiry
The inquest establishes the apparent cause of death, identity, and circumstances, and the body is sent for medicolegal autopsy

Note: If the death occurred at a hospital, the treating doctor issues the Intimation to Police under MLC protocols. The Police registers an FIR and the Magistrate's inquest follows.

(iv) External and Internal Post-Mortem Findings to Establish Antemortem Burn Injury (3-6 marks)

A. EXTERNAL POST-MORTEM FINDINGS

1. Pugilistic Attitude (Boxing Pose)

Body assumes a characteristic pugilistic (boxer's) stance due to heat stiffening of muscles
Arms are flexed at elbows, legs at knees, fists clenched - resembles a boxer
This is a heat artefact, NOT a vital reaction, and does NOT indicate antemortem injury

2. Charring, Singeing, and Burns

Varying depths: redness (1st degree), blistering (2nd degree), charring/leathery skin (3rd degree)
Splitting of skin by heat - must be distinguished from lacerations (no bridging of tissue strands in heat splits)

3. Line of Redness (Zone of Hyperaemia) - KEY ANTEMORTEM SIGN

A zone of hyperaemia 5-20 mm wide at the margins of the burned area
Due to oedema and capillary dilatation - a vital reaction
Persists after death; absent in postmortem burns
If whole body is burnt, the line of redness will not be seen

4. Antemortem Blisters (Vesicles)

Surrounded by a thin bright red area of inflammation
Contain highly albuminous fluid with chlorides and RBCs
When ruptured, the base is injected (red) with underlying viable tissue
If blister contains pus - the person survived at least 36 hours after injury
Contrast with postmortem blisters: contain air or non-albuminous fluid, no red rim, base not injected

5. Eyes

Corneal haziness, scleral injection

6. Genitalia/Protected areas

Areas protected by tight clothing may show intact skin - helps in identification and demonstrating extent of burns

B. INTERNAL POST-MORTEM FINDINGS

1. Respiratory Tract

Soot (carbon particles) in the mouth, pharynx, larynx, trachea, and bronchi - definitive antemortem sign
Burns/singeing of nasal hairs and mucosa
Laryngeal and tracheal oedema; sloughing of mucosa
Inhalation of superheated air causes burns of vocal cords, epiglottis
Pulmonary oedema, desquamated epithelial cells in smaller bronchi

2. Blood

Cherry-red colour due to carboxyhaemoglobin (HbCO) - antemortem inhalation of CO
HbCO >10% in a non-smoker is evidence of antemortem smoke inhalation
Carboxyhaemoglobin in peripheral blood and in any extradural haematoma confirms fire was started ante-mortem

3. Stomach Contents

Soot particles in oesophagus and stomach - strong antemortem evidence (swallowed while alive)

4. Gastrointestinal Tract - Curling's Ulcer

Acute stress ulcers in stomach/duodenum - appear within 24 hours; petechiae and erosions
Acute gastric/duodenal ulcers with haemorrhage in those who survive several days

5. Brain and Skull

Heat haematoma (epidural/extradural) - chocolate-coloured, bilateral, diffuse; in parieto-temporal region; due to heat boiling blood from diploic veins. Differs from traumatic extradural haematoma (see table below)
Cerebral oedema or shrinkage
Thermal fractures of skull (flaked fractures of outer table)

Feature	Heat Haematoma	Traumatic Extradural
Location	Bilateral, diffuse	Unilateral, near Sylvian fissure
Shape	Diffuse	Localized, lens-shaped
Overlying scalp	Burnt/charred	Bruised/lacerated
HbCO in clot	Present (same level as blood)	Absent
Dura	Shrunken	Intact or torn by blow

6. Kidneys

Cloudy swelling, capillary thrombosis
Haem casts in medullary tubules (haemoglobinuria)
Acute tubular necrosis

7. Liver

Cloudy swelling, centrilobular necrosis

8. Spleen

Enlarged, softened; necrosis of germinal centres

9. Adrenals

Enlarged and congested (stress response)

10. Histopathology (Microscopy)

PMN leucocyte infiltration within 6 hours
Epidermal and dermal vacuolization
Vascular dilatation in dermis
Epithelial cell streaming (perpendicular to skin surface) - similar to electric mark
Necrosis of epidermal cells in 12-24 hours
Epidermal migration/proliferation in 48-72 hours

(v) Surest Sign of Antemortem Burn if Soot is NOT Found in Trachea (1-1.5 marks)

If soot is absent in the trachea (as can occur when kerosene/petrol is the burning agent, where rapid flame burns occur with little smoke generation), the surest sign of antemortem burn injury is:

Carboxyhaemoglobin (HbCO) in blood - HbCO >10% in a non-smoker is definitive evidence that the person was alive and breathing during the fire.

Alternative surest sign (if CO also absent, e.g., petrol/kerosene fire):

Presence of soot in the oesophagus and stomach (swallowed while alive) or the typical vital reaction - line of hyperaemia at the burn margins with albuminous blister fluid containing chlorides and RBCs on histology.

Parikh's Textbook: "The presence of antemortem blisters, finding of particles of soot in air passages, oesophagus, and stomach, and cherry red colour of blood due to CO are certain signs of death from burning."

QUESTION 2 (MJNMCH) — 25-year-old woman, suicide attempt on 3rd wedding anniversary, died after 7 days

(a) Type of Inquest (2 marks)

This case involves:

Death within 7 years of marriage under suspicious circumstances
Suicide - an unnatural death

Inquest conducted: Magistrate's Inquest under Section 176(1A) CrPC (Sec. 194 BNSS)

The magistrate must conduct the inquest when a married woman dies within 7 years of marriage in suspicious, suicidal, or violent circumstances. This is to rule out dowry death, abetment to suicide, or homicide disguised as suicide.

The body is then forwarded for medicolegal autopsy (by a forensic medicine specialist).

(b) Classification of Burn Injury (3 marks)

I. Wilson's / Dupuytren's Classification (by depth / degree)

Degree	Layer involved	Features
1st degree	Epidermis only	Erythema, redness, pain; heals without scar
2nd degree	Epidermis + upper dermis (partial thickness)	Blistering, weeping, very painful; heals with minimal scar
3rd degree	Full thickness skin - all dermis	White/leathery/charred; painless (nerve destruction); requires skin grafting
4th degree (Wilson)	Whole skin destroyed	Parchment-like slough, yellowish-brown; separates on day 5-6
5th degree	Subcutaneous tissue, fascia, muscle	Great scarring and deformity
6th degree	Bone and adjacent organs involved	Still compatible with life if initial shock overcome

(P C Dikshit Textbook of Forensic Medicine)

II. ABA (American Burn Association) / Clinical Classification

Grade	Depth	Example
Superficial	Epidermis only	Sunburn
Superficial partial-thickness	Superficial dermis	Scalds
Deep partial-thickness	Deep dermis	Flame burns
Full thickness	Through all skin layers	Prolonged contact
Fourth degree	Into muscle/bone	Electrical, prolonged flame

III. By Extent (Wallace Rule of Nine)

(See below in Q3)

IV. By Cause

Thermal (flame, scald, contact), Chemical, Electrical (Joule burn), Radiation

(c) Various Causes of Death Following Burn Injury (5 marks)

Timing	Cause of Death
Immediate (0-12 hrs)	1. Neurogenic/burn shock - pain, fluid loss 2. CO poisoning - cherry-red HbCO 3. Laryngeal oedema - asphyxia 4. Cyanide poisoning (burning synthetics)
Early (12-72 hrs)	5. Hypovolemic shock - plasma exudation exceeds replacement 6. Renal failure - ATN from haemoglobinuria/myoglobinuria 7. ARDS - pulmonary oedema from inhalation injury 8. CO2 + O2 deficiency asphyxia
Late (>72 hrs)	9. Septicaemia/bacteraemia - wound infection 10. Toxaemia 11. Curling's ulcer with haemorrhage 12. Hepatic failure (cloudy swelling, necrosis) 13. Pulmonary infection (pneumonia) 14. Disseminated intravascular coagulation (DIC)

(d) Salient Post-Mortem Findings (5 marks)

(Refer to comprehensive PM findings under Question 1 (iv) above. Summarised for exam:)

External:

Pugilistic attitude (heat stiffening)
Burns of varying degrees over the body (erythema, blistering, charring)
Line of redness/hyperaemia (5-20 mm) at burn margins - vital reaction
Antemortem blisters - red rim, albuminous content, injected base
Singeing of hair and eyebrows
Heat fractures/splits in skin (not true lacerations)

Internal:

Soot in trachea, bronchi, oesophagus, stomach
Cherry-red blood (HbCO)
Laryngeal/pulmonary oedema
Curling's ulcers in stomach/duodenum
Heat haematoma (bilateral extradural)
Renal: haem casts, ATN
Liver: cloudy swelling/necrosis
Spleen: enlarged, germinal centre necrosis
Adrenals: enlarged/congested
Histology: PMN infiltration, vacuolization, vascular dilatation in dermis

QUESTION 3 (Jalpaiguri) — Recently married lady, brought dead, forwarded to mortuary

(i) Who Conducts the Inquest? (2 marks)

Magistrate's Inquest under Section 176(1A) CrPC / Section 194 BNSS

Conducted by the Executive Magistrate because:

The deceased is a recently married woman (within 7 years)
Death under suspicious/unnatural circumstances in the marital home
Must rule out dowry death (Sec. 304B IPC / Sec. 80 BNS) and abetment (Sec. 306 IPC / Sec. 108 BNS)

The Police may conduct their own inquest simultaneously, but the Magistrate's inquest is mandatory under 176(1A).

(ii) Five Causes of Death (5 marks)

Hypovolemic shock - massive plasma and fluid exudation from burn surface (most important early cause)
Respiratory failure / Asphyxia - laryngeal oedema, soot inhalation, ARDS
Carbon monoxide poisoning - HbCO blocks O2 transport; causes rapid death in enclosed spaces
Septicaemia/Toxaemia - wound infection progressing to systemic sepsis; commonest cause of late death
Acute renal failure - haemoglobinuria, myoglobinuria, reduced GFR causing ATN

(Also: cyanide toxicity from burning synthetics; Curling's ulcer)

(iii) Wallace Rule of Nine and Its Importance (3 marks)

Definition: A method to estimate total body surface area (TBSA) burned in adults, dividing the body into regions each representing 9% (or multiples thereof) of TBSA.

Body Region	% TBSA
Head and neck	9%
Each upper limb	9% each (18% total)
Front of trunk (chest + abdomen)	18% (9% + 9%)
Back of trunk	18% (9% + 9%)
Each lower limb (front + back)	18% each (36% total)
Perineum	1%
Total	100%

Importance:

Clinical management - guides fluid resuscitation (Parkland formula uses TBSA%)
Prognosis - >15% in adult and >10% in child requires IV fluid replacement to prevent hypovolemic shock
Mortality prediction - >50% TBSA superficial burns can survive; >60-70% full thickness = very high mortality
Medicolegal documentation - essential in burn injury medicolegal reports and inquest documentation
Not applicable to children - Lund and Browder chart used instead (head is larger, limbs smaller in proportion)

(iv) Differentiation of Antemortem from Postmortem Burns (5 marks)

Feature	Antemortem Burns	Postmortem Burns
1. Line of redness	Present (5-20 mm zone of hyperaemia at margins)	Absent
2. Blisters (vesicles)	Present with bright red inflammatory rim; base injected	Present but no red rim; base not injected
3. Blister contents	Albuminous fluid + chlorides + RBCs	Air, or non-albuminous fluid; no chlorides or RBCs
4. Soot in airways	Present in trachea, bronchi, oesophagus, stomach	Absent (may be found in pharynx only by passive percolation if mouth open)
5. CO in blood	HbCO elevated (>10% in non-smokers) - cherry-red blood	HbCO absent
6. Infection/Pus	Present if survived >36 hrs (pus in blisters)	Absent
7. Healing	Granulation tissue present (if survived days-weeks)	Nil
8. Histology	PMN leucocyte infiltration; vascular dilatation; vacuolisation	No inflammatory reaction (may show only coagulation necrosis)
9. Enzymes	Alkaline phosphatase and other enzymes elevated (vital reaction)	No elevation
10. Brain	Extradural haematoma with HbCO in clot (same level as blood) = heat haematoma due to ante-mortem fire	Traumatic EDH (no HbCO in clot)
11. Vital reaction	Present (redness, oedema, leucocytic infiltration)	Absent
12. Pugilistic attitude	May be present (heat stiffening - not a vital reaction)	Present (heat stiffening - not diagnostic)

"The differentiation depends on presence of a vital reaction as seen by naked eye or by histological examination." - Parikh's Textbook

GROUP B (SAQ - 10 Marks)

Definition, Classification, and PM Findings in Antemortem Burns

Definition of Burns (2 marks): A burn is an injury to the tissues of the body caused by heat, chemical agents, electricity, or radiation. Medically, burns are defined as injuries resulting from the thermal destruction of the skin and underlying tissues due to dry heat (flames, hot solids), moist heat (scalds - steam, hot liquids), chemicals, electricity, or radiation.

Classification by Depth (Degrees) (3 marks): (See Q2b above for full table)

The simplest clinical classification:

1st degree (Superficial): Epidermis only; erythema; no blistering; heals without scar
2nd degree (Partial thickness): Epidermis + part of dermis; blistering; painful; heals with/without scar
3rd degree (Full thickness): Full skin destruction; painless; requires grafting; always scars
4th degree: Underlying fat, muscle, and bone involved

Internal and External PM Findings (5 marks): (Refer to Question 1(iv) above - full comprehensive answer)

GROUP C (Short Notes - 5 Marks)

1. Joule Burn (Electrical Burns)

A Joule burn (also called electric mark/electrothermal burn) is the skin lesion produced at the entry and exit points of electric current passing through the body.

Mechanism: As electric current meets resistance at the skin surface, electrical energy is converted to heat energy (Joule's law: H = I²Rt), causing a characteristic burn.

Macroscopic features:

Usually circular/oval, well-defined, pale/yellowish-white/grey area
Raised, pearl-like edges (crater-like appearance) with a depressed centre
Central area may be charred or carbonised
Typically small (0.5-2 cm diameter), size depends on contact area
Exit wound usually more extensive than entry wound

Microscopic features (Histopathology):

Characteristic elongation and streaming of epidermal cells - nuclei are elongated, palisaded, oriented perpendicular to skin surface ("streaming/combing effect")
Vacuolisation and separation of epidermal layers
Peripheral haemorrhage in dermis
Homogenised collagen in dermis
Vascular changes (dilatation, thrombosis)

Importance in forensic medicine:

Establishes that the skin was the point of electrical contact
Helps determine entry vs exit site
Distinguishes electrical burns from thermal burns

Note: Lightning strike produces a pathognomonic arborescent (fern-like) burn mark (Lichtenberg figure) on the skin - NOT a Joule burn.

2. Definition, Classification of Burns + Differentiation of Antemortem vs Postmortem Burns on Autopsy (1+1+3)

Definition: (See Group B above)

Classification: (See Wilson's degrees in Q2b above)

Differentiation Antemortem vs Postmortem Burns (Autopsy):

Feature	Antemortem	Postmortem
Line of redness	Present (5-20mm hyperaemia)	Absent
Blister character	Albuminous fluid, red rim, injected base	Air/serous fluid, no rim, pale base
Soot in airways	Present (trachea, bronchi)	Absent (pharynx only by passive percolation)
HbCO in blood	Present (>10%) - cherry-red	Absent - normal blood colour
Vital histological reaction	PMN infiltration, vascular dilatation	Absent
Pus/healing	May be present	Absent

3. PM Findings in Death Due to Antemortem Burns

(Full comprehensive answer with external and internal findings as detailed in Question 1(iv) above)

Summary table for exam:

External:

Pugilistic attitude
Degrees of burns - erythema, blistering, charring
Line of redness (zone of hyperaemia) at margins
Antemortem blisters (red rim + albuminous content)
Singeing of hair/eyebrows

Internal:

Soot in trachea/bronchi/oesophagus/stomach
Cherry-red blood (HbCO)
Laryngeal and pulmonary oedema
Curling's ulcers (stress ulcers)
Heat haematoma (bilateral extradural, HbCO positive)
Renal: haem casts, ATN
Liver: cloudy swelling
Histology: PMN infiltration, vacuolisation, streaming of epithelial cells

Quick Reference Summary Table: Antemortem vs Postmortem Burns

Feature	Antemortem	Postmortem
Line of redness	✅ Present	❌ Absent
Blister fluid	Albuminous + chlorides + RBCs	Air / non-albuminous
Blister rim	Red, inflamed	No rim
Soot in airways	✅ Below vocal cords	❌ Pharynx only (passive)
HbCO in blood	✅ Elevated, cherry-red	❌ Absent
Soot in stomach	✅ (if swallowed)	❌ Absent
Histological reaction	✅ PMN infiltration	❌ None
Healing/Pus	✅ If survived >36 hrs	❌ Never
Heat haematoma	HbCO in clot = same as blood	No HbCO in traumatic EDH

Surest sign of antemortem burn when soot is absent in trachea:

Elevated carboxyhaemoglobin (HbCO) in blood (>10% in non-smoker) -- Parikh's Textbook of Medical Jurisprudence

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