ELECTRICAL INJURIES

Electric shock occurs when an electrical current touches or travels through the body. It can happen anywhere there is electricity. Exact effects vary depending on the electrical source. For instance, shocks from household outlets are often mild, while shocks from power lines can be severe or fatal. When an electric shock is fatal, providers call it electrocution.

Voltage pushes electricity through lines, wires, and devices. High voltage means there is more electricity, while low voltage means there is less. But low-voltage electric shocks can still be dangerous or, in some cases, fatal. Seemingly minor injuries can cause complications inside your body that might not be noticeable right away. For this reason, anyone with an electric shock injury, even a minor one, should see a healthcare provider as soon as possible.

If you are with someone who experiences electric shock, call 911 immediately. Do NOT touch the person if they are still in contact with an electrical current. Unless they are in danger of additional injuries, do NOT move them. Doing so can cause further injury. If possible, turn off the source of power.

Possible symptoms of electric shock are:

• Unconsciousness

• Numbness or tingling

• Muscle spasms

• Weak or irregular pulse, or no pulse

• Burns (usually where the electricity enters and exits your body)

• Shortness of breath (dyspnea)

• Abdominal pain

• Chest pain

• Seizures

• Headaches

• Vision or hearing issues

• Cataracts (if the electricity passes through your eyes)

• Burned, charred lips (if a child gets shocked from chewing on an electrical cord)

Several things can cause electrical injuries:

• Old, damaged, or exposed electrical wiring

• Getting water on household outlets or appliances

• Cutting through a live electrical cable

• Faulty household appliances

• Fallen power lines

• Lightning strikes (less common)

Around 30,000 non-fatal electric shock injuries occur in the United States every year. About 20% of these occur in children (often from chewing on electric cords or sticking metal objects into outlets). The rest occur in adults and typically in those who work in construction or similar industries.

About 1,000 people in the United States are electrocuted (fatally shocked) every year. Around 400 of these deaths occur from high-voltage electric sources. Between 50 and 300 cases occur from lightning.

Electric shock can cause a range of health complications including:

• Infection (most common cause of death in people hospitalized after an electric shock injury)

• Irregular heartbeat (arrhythmia)

• Cardiac arrest

• Coma

• Amnesia

• Respiratory arrest (when you can’t breathe on your own)

• Burns

• Psychiatric disorders, including anxiety, depression or personality changes

• Blunt force trauma or broken bones (if thrown from the electric source)

Electrical injuries can cause significant damage to the body through several mechanisms:

1. Direct Electrical Injury: When an electric current passes through body tissues, it can cause direct damage. This is often seen in the form of burns at the entry and exit points of the current.

2. Thermal Injury: Electrical energy is converted into thermal energy, which can cause burns. The amount of heat generated depends on the current, resistance of the tissues and the duration of exposure. Tissues with higher resistance, such as skin, bone, and fat, tend to suffer more damage.

3. Mechanical Injury: High-voltage electrical injuries can cause intense muscle contractions, leading to fractures, dislocations, and falls. These mechanical effects can result in additional trauma.

4. Cardiac and Respiratory Effects: Electrical currents can disrupt the normal electrical activity of the heart and respiratory system, potentially leading to arrhythmias, cardiac arrest, or respiratory failure.

Electrical injuries can be categorized into several types based on the nature and severity of the injury:

1. Electrocution: This is the most severe type of electrical injury, resulting in death or serious injury when an electrical current passes through the body.

2. Electric Shock: This occurs when a person comes into contact with an electrical source, causing an electrical current to pass through part of the body. Unlike electrocution, it does not result in death but can cause serious injuries.

3. Burns: Electrical burns can occur at the entry and exit points of the current or internally. These burns can be both disabling and disfiguring, affecting not only the skin but also deeper tissues, muscles, and organs.

4. Arc Flash/Blast Injuries: These injuries result from high-voltage electrical systems where an arc flash or blast can cause burns, blunt trauma, and even blast injuries due to the intense release of energy.

5. Trauma to the Brain: Electrical injuries can cause neurological damage, leading to memory loss, depression, and difficulty performing normal tasks.

The long-term effects of electrical injuries can be quite varied and may affect multiple systems in the body. Here are some of the most common long-term effects:

1. Neurological Problems: Persistent issues such as memory loss, chronic pain, numbness, and tingling can occur due to nerve damage.

2. Psychological Changes: Survivors may experience anxiety, depression, and post-traumatic stress disorder (PTSD) following an electrical injury.

3. Cardiac Issues: Arrhythmias or other heart problems can persist long after the initial injury.

4. Musculoskeletal Problems: Muscle damage and severe contractions during the injury can lead to long-term pain, weakness, and mobility issues.

5. Eye Damage: Cataracts and other vision problems can develop, especially if the injury involves high voltage.

6. Chronic Pain: Many survivors report ongoing pain that can be difficult to manage.

CHEMICAL INJURIES

Chemical injuries are produced by contact with caustic materials (acids and bases) that damage cells by directly reacting with cellular components to alter or destroy their structure.  The severity of the injury is dependent on the concentration and amount of chemical agent and the duration with which it is in contact with tissue.

Chemical burns range from mild to severe. Mild chemical burns usually heal quickly, but severe chemical burns can cause permanent tissue damage, scarring, or death. Chemical burns require immediate medical treatment.

Who’s at risk for chemical burns?

Anyone who works with chemicals is at risk for chemical burns, including:

• Construction workers

• Factory workers

• Farmers

• Laboratory technicians

• Mechanics

• Military personnel

• Plumbers

It is important to note that children (especially toddlers) are at a high risk for burns caused by household chemical products. They may accidentally touch or swallow detergents, bleach, or cleaning products.

Common examples of chemical injuries include:

1. Chemical Burns: These occur when corrosive substances like bleach, battery acid, or disinfectants come into contact with the skin, eyes, or internal tissues.

2. Inhalation Injuries: Breathing in harmful chemicals such as chlorine, ammonia, or carbon monoxide can cause respiratory issues and damage to the lungs.

3. Eye Injuries: Exposure to chemicals like acids or alkalis can lead to severe eye damage, including burns and vision loss.

4. Poisoning: Ingesting toxic substances such as pesticides, detergents, or certain household cleaners can result in systemic poisoning.

5. Skin Irritations and Blisters: Contact with irritants like detergents or solvents can cause skin rashes, blisters, and other dermatological issues.

While there are a multitude of substances that can cause chemical burns, some of the most common include:

• Battery acid

• Bleach

• Detergents

• Drain cleaners

• Fertilizers

• Hair relaxers

• Metal cleaners and rust removers

• Paint removers

• Pesticides

• Sanitizers and disinfectants

• Swimming pool chemicals

• Toilet bowl cleaners

• Wet cement

What are the symptoms of chemical burns?

Chemical burns on your skin may cause:

• Blisters or scabs

• Cracked, dry skin

• Pain

• Peeling skin

• Redness

• Skin discoloration

• Swelling

Chemical burns in your eyes may cause:

• Blurry vision

• Eyelid swelling

• Pain.

• Redness

• Stinging or burning

• Watery eyes

• Blindness (in severe cases)

Chemical burns from ingestion (swallowing) may cause:

• Chest pain

• Cough

• Difficulty speaking (dysphonia)

• Drooling

• Hoarseness

• Low blood pressure (hypotension)

• Nausea and vomiting, or vomiting blood

• Pain in your mouth or throat (especially when swallowing)

• Perforations (holes) in your stomach, esophagus (the tube connecting your stomach and throat), or cornea (the outermost lens of your eye)

• Shortness of breath (dyspnea)

• Upper airway swelling (edema)

Chemical burn assault crimes, also known as acid attacks or vitriolage, are violent acts that involve throwing corrosive substances, often household chemicals such as bleach or ammonia, on a victim’s body.  The common targets of the attacks are the face, head, and neck and the main objective is often not to kill, but to maim and/or punish.  Potential consequences for the victims of these crimes range from permanent blindness and disfigurement to long-term feeding difficulties and psychological trauma.  Some of the most common motives center on relationship issues, such as marital issues, volatile relationships, revenge for extramarital affairs, divorce, etc.  Other motives may involve larceny and assault.  Acid attacks take place worldwide but are more prevalent in developing countries.

THERMAL INJURIES

Thermal injuries, commonly known as burns, occur when the skin or other tissues are damaged by heat.  When excessive heat is transferred to the skin, it radiates outward from the point of contact and initiates local and, if severe enough, systemic responses from the body.  The mechanism of injury depends on the heat source which can include flames, hot liquids, hot solid objects, and steam. The severity of the burn depends on the heat source temperature and duration of contact.

There are various types of thermal injuries:

• Flash and flame burns: These can occur when someone is directly or indirectly exposed to a flame.

• Scald burns: These occur when someone is exposed to a high-temperature liquid or steam.  The exposure is generally from either a spill or immersion such as into a hot bathtub.

• Grease burns: These occur when someone is exposed to high-temperature grease. Since grease has a higher viscosity than water and other thinner substances, it travels down the skin more slowly.  Grease also does not evaporate resulting in a longer contact time with the skin.  Therefore, these burns can be deeper than they initially appear.

• Contact burns: These occur when someone comes into direct contact with a high-temperature object such as burners on a stove.

• Inhalation injuries: Open flames in an enclosed space can cause facial and supraglottic burns.  The products of combustion travel into the respiratory tract and cause mucosal irritation, bronchospasm, local or systemic inflammation, and capillary leak. This type of injury can be seen in house fires.

Resulting Injuries related to thermal injuries

• Depth of Injury: The depth of thermal injury is directly related to the contact temperature, duration of exposure, and the thickness of the skin. Burns are typically classified into three degrees:

• Local Response: The body’s response to a burn includes three zones similar to the rings of a bullseye.

1. Zone of Coagulation: This is the center of the bullseye and is the area of maximum damage where tissue is irreversibly destroyed.

2. Zone of Stasis: This is the next ring of the bullseye as you move out and surround the zone of coagulation.  This area has decreased tissue perfusion but is potentially salvageable with proper treatment.

3. Zone of Hyperemia: The outermost ring of the bullseye and the one furthest from the point of contact. This area has more blood flow than the others and can usually recover unless there is a severe infection or prolonged hypoperfusion.

• Systemic Response: Severe burns can trigger a systemic response, especially if they cover a large body surface area. This response can include:

  • Cardiovascular Changes: Increased capillary permeability leads to fluid loss and systemic hypotension.

  • Respiratory Changes: Inflammatory mediators can cause bronchoconstriction and, in severe cases, adult respiratory distress syndrome (ARDS).

  • Metabolic Changes: The basal metabolic rate can increase significantly, necessitating early and aggressive nutritional support.

Other Factors: Burns can also result from electrical discharge, friction, chemicals, and radiation. Each of these causes has its own unique mechanism of injury and effects on the body.

ACCELERATION/DECELERATION TRAUMA

Forensically, acceleration/deceleration injuries are often referred to as whiplash injuries.  They frequently occur as a result of high-speed vehicle accidents, abusive head trauma/physical abuse, or falls.  These injuries result from rapid changes in velocity involving the forward and backward movement of the head and neck and can lead to potential damage to the soft tissues, ligaments, and muscles in the cervical region as well as severe head injuries.

Here’s a breakdown of the mechanism:

1. Sudden Change in Velocity: When the body experiences a sudden stop or start, different parts of the body may move at different speeds. For example, in a car crash, the torso might be restrained by a seatbelt and stop with the vehicle, but the head continues to move forward at the speed the vehicle was moving, leading to injury.

2. Shearing Forces: The differential movement between the fixed and mobile parts of the body creates shearing forces. These forces can cause significant damage to tissues, particularly in the brain, where the brain tissue moves at a different rate than the skull.

Resulting Injuries:

1. Diffuse Axonal Injury (DAI): A type of traumatic brain injury (TBI) and one of the most severe outcomes of shearing forces.  The axons (nerve fibers) in the brain are stretched and torn as the brain moves rapidly within the skull. This can lead to widespread brain damage and is a common result of high-speed impacts from coup-contrecoup forces.

2. Whiplash: A specific type of acceleration/deceleration injury, often seen in rear-end car collisions, is whiplash or cervical hyperextension injuries. This involves a rapid back-and-forth movement of the neck, leading to soft tissue damage.

3. Internal Organ Damage: The rapid deceleration can also cause internal organs to collide with the body’s skeletal structure, leading to bruising, bleeding, or even rupture.

Signs and Symptoms of acceleration/deceleration injuries can vary depending on the organs affected, but some common signs include:

Signs and Symptoms of DAI:

1. Loss of consciousness

2. Headache

3. Dizziness

4. Nausea and/or vomiting

5. Difficulty with balance and/or coordination

6. Confusion

7. Cognitive impairments, such as memory loss or difficulty concentrating

Signs and symptoms of whiplash and internal organ injury:

1. Abdominal Pain: Persistent or severe pain in the abdomen can indicate damage to organs like the liver, spleen, intestines, or internal hemorrhage.

2. Nausea and Vomiting: These symptoms can be a sign of internal bleeding, traumatic brain injury (TBI), or organ damage.

3. Difficulty Breathing: This can occur if the lungs or diaphragm are injured.

4. Dizziness or Lightheadedness: These symptoms can result from internal bleeding leading to a drop in blood pressure or from whiplash injuries to the neck.

5. Weakness or Feeling Faint: Similar to dizziness, this can be due to significant blood loss.

6. Cervicogenic Headaches: Headaches that generate from the neck and radiate to the temple, top or front of the head, or down the neck

7. Numbness: In the arms and/or hands.

8. Neck pain: Pain that worsens when moving the neck, or stiffness and difficulty moving the neck

9. Headaches: Headaches that often start at the base of the skull

10. Pain: In the shoulders, upper back, arms, or jaw

11. Blurred vision

12. Tiredness, irritability

BALLISTIC TRAUMA

Ballistic trauma is a type of traumatic injury caused by firearm-related wounds or other projectiles. The damage to tissues depends on the kinetic energy of the projectile, which influences the amount of energy that the object has available to transfer to tissue. Ballistic trauma varies widely based on the bullet, velocity, mass, entry point, trajectory, affected anatomy, and exit point; and can have serious long-term health and economic consequences.

It is in ballistic trauma that perforating trauma is more likely to be found, as opposed to a stabbing or other penetrating injury.  Locating and identifying the exit wound is important not only for treatment purposes but also for forensic and crime reconstruction purposes.

Additional injury types include penetrating, the bullet enters the body, but does not exit; re-entry, the bullet enters, exits, then re-enters the body; and graze or tangential, a superficial wound caused by a bullet striking the skin at a shallow angle.

Injuries from ballistic trauma are influenced by many factors to include:

• Velocity of the firearm - high-velocity firearms, such as rifles, cause greater and more extensive tissue damage, whereas lower velocity firearms, such as a handgun, cause more localized tissue damage

• Projectile characteristics - type, composition, shape, the tendency to explode, deform, or fragment

• Density of the affected tissues

• Distance of fire

Ballistic trauma involves two primary mechanisms of injury:

1. Permanent Cavity: This is the direct path taken by the bullet as it crushes and destroys tissue. The extent of this damage depends on the bullet’s type, velocity, and mass, as well as the physical characteristics of the tissues it passes through.

2. Temporary Cavity: As the bullet travels through the body, it creates a temporary cavity by stretching and shocking the surrounding tissues. This cavity is larger than the bullet itself and can cause significant damage to organs and tissues outside of the bullet’s path.

Common complications following ballistic trauma depend on the location and severity of the injury. Here are some of the most frequent complications:

1. Infection: Due to the introduction of foreign materials (like bullet fragments or clothing) into the body, infections are a significant risk.

2. Vascular Injury: Damage to blood vessels can lead to severe bleeding, hematomas, or even loss of limb if not promptly treated.

3. Nerve Damage: Bullets can sever or damage nerves leading to loss of function or sensation in affected areas.

4. Fractures: High-velocity bullets can cause complex fractures, which may require extensive surgical intervention.

5. Compartment Syndrome: Increased pressure within muscle compartments can lead to tissue death and require emergency surgery.

6. Chronic Pain: Long-term pain, including conditions like hyperalgesia (increased sensitivity to pain), can persist long after the initial injury.

7. Lead Poisoning: Retained bullet fragments can lead to lead poisoning over time.

8. Organ Damage: Depending on the trajectory, bullets can cause significant damage to internal organs, leading to long-term complications like bowel obstruction or neurogenic bladder.

PENETRATING TRAUMA

Penetrating trauma occurs when an object pierces the skin and enters the body causing damage. These types of traumas are typically the result of injuries from sharp objects (like knives or broken glass) or high-energy projectiles (such as bullets).

Penetrating trauma can also be “perforating trauma”. Perforating trauma occurs when an object enters AND passes through the body creating entrance AND exit wounds. Perforating trauma is most commonly associated with ballistic wounds, which will be covered in another post; this post will focus on penetrating injuries.

The type and severity of resulting injuries depends on several factors, including:

• Location: Wounds to vital areas such as the chest, abdomen, or head can be life-threatening due to potential damage to critical organs or blood vessels.

• Depth: Shallow wounds might only affect the skin and underlying tissues, while deeper wounds can impact muscles, organs, or bones.

• Type of Object: Sharp objects tend to cause cleaner cuts, while blunt or high-energy objects can cause more extensive damage and bleeding.

• Obstacles: If an object has to go through clothing or other objects to reach the skin, the injury may be lesser in depth and severity

• Force: The stabbing force is influenced by the shape of the blade/object and stabbing velocity.  Generally, the greater the stabbing force the greater the depth and potential injury

• Victim: The underlying age and general health of the victim can influence the injury severity and healing

Common types of penetrating injuries include:

1. Knife Wounds: These cause incision (slash marks) or stab (puncture) wounds depending on how the knife is wielded. Damage can range from superficial skin injuries to deep wounds affecting muscles, blood vessels, or organs.  Sharp weapons can also strike bones resulting in a bone fracture, the knife tip could break off in the bone.  There can be a transfer of trace evidence from the knife to the bone or bone fragments onto the knife blade.

2. Puncture Wounds: Caused by sharp objects that penetrate the skin and underlying tissues, creating a small but deep wound.  They can potentially damage deeper structures like muscles, tendons, and organs, and may have a higher risk of infection.

3. Lacerations: These are tear-like wounds caused by sharp objects. Unlike clean incisions, lacerations may have irregular edges and can damage both the skin and underlying tissues. They can be superficial or deep, depending on the force and nature of the object.

4. Stab Wounds: These are a specific type of penetrating injury caused by sharp, pointed objects like knives. Stab wounds can cause severe damage depending on the depth and angle of penetration, potentially affecting internal organs, blood vessels, and other vital structures.

5. Gunshot Wounds: Often referred to as GSWs, these can cause significant damage due to the high energy of the bullet. The injury typically includes a combination of a wound channel where the bullet penetrates, as well as potential tissue damage from the bullet’s impact and fragmentation. Bullet wounds can affect bones, organs, and major blood vessels, leading to severe bleeding and trauma. Bullets or other projectiles cause these injuries. They can lead to a combination of entry and exit wounds, along with tissue damage from the bullet’s path and potential fragmentation

6. Fractures: Penetrating trauma can also result in broken bones, especially if the object causing the injury is large or if it impacts the bone directly.

7. Organs and Vessel Damage: Depending on the location and depth of the penetration, internal organs (such as the lungs, liver, spleen, or intestines) and major blood vessels can be damaged, leading to potentially life-threatening internal bleeding and organ dysfunction.

8. Infection: When the skin is broken, pathogens can be introduced into the body. These wounds can become infected if not properly treated and cleaned, leading to complications like abscesses or systemic infections.

BLUNT FORCE TRAUMA

Blunt force trauma, also known as non-penetrating trauma, occurs when the body is struck by or strikes a blunt object, leading to injury.  Although the weapon or object does not actually penetrate the skin, the skin may be broken due to the type and force of the impact. The mechanism of action involves several forces:

1. Acceleration and Deceleration: Rapid changes in speed that cause internal organs to move at different rates leading to tearing or shearing injuries.speed changes

2. Shearing: The slipping and stretching of organs and tissues in relation to each other causing significant internal damage.

3. Compression:  The body is squeezed between two objects leading to crushing injuries.

4. Torsion: Twisting forces that cause injuries to muscles, ligaments, and other soft tissues.

5. Crushing Pressure: Prolonged pressure on the body resulting in severe damage to muscles, nerves, and blood vessels.

These forces can result in a variety of injuries, including bruises, fractures, and internal bleeding. The severity of the injury often depends on several factors, such as the underlying age and health of the victim, presence of medications or other substances, and the force and location of the impact.  Some common types of injuries include:

1. Contusions (Bruises): The rupture of small blood vessels under the skin causing discoloration and swelling.

2. Abrasions: Superficial injuries where the top layer of skin is scraped off.

3. Lacerations: Deeper cuts or tears in the skin and underlying tissues.

4. Fractures: Breaks or cracks in bone due to the direct impact, shearing, compression, torsion or compression forces.

5. Internal Injuries/Bleeding: These can include damage to internal organs, such as the liver, spleen, or kidneys.

6. Traumatic Brain Injuries (TBI): These occur when the head is struck, leading to concussions or more severe brain damage.  Shockwaves from explosions can also cause TBIs.

Common signs of blunt force trauma can vary depending on the type, severity, extent, and location of the injury. Here are some typical symptoms:

1. Pain or Tenderness: This is often the first sign, occurring at the site of impact.

2. Bruising: These are common as blood vessels are damaged under the skin.  The bruising results from the leaking of blood from the damaged vessels (venules and capillaries).

3. Swelling: This occurs as a result of the increased blood/increased fluid movement to the area and the influx of white blood cells to the injured area (the body’s initial healing response injury)

4. Difficulty Breathing: This can occur if the trauma affects the chest or abdomen.

5. Nausea and/or Vomiting: These symptoms can indicate internal injuries.

6. Dizziness and/or Loss of Consciousness: This is particularly concerning and may suggest a head injury.

7. Internal Bleeding: This can be life-threatening and may not be immediately visible.

Blunt force trauma can cause death in a variety of ways which include:

• Intracranial bleeding and/or Cerebral Edema (swelling)

• Severe blood loss/Hemorrhage

• Pneumothorax (air accumulating in the space between the lung and chest wall)

• Hemothorax (blood accumulating in the space between the lung and chest wall)

• Aspiration of blood/stomach contents into the lungs

• Deep Vein Thrombosis (blood clot that forms in a deep vein)

• Pulmonary Embolism (part of a DVT that breaks off and travels to the lungs)

WHAT DO FORENSIC NURSE CONSULTANTS MEAN BY "MECHANISM OF INJURY"?

Mechanism of injury (MOI) refers to the method by which damage or trauma occurs to the body (skin, muscles, organs, and bones).  Now, this is where forensic nurses get to use those high school and freshman college physics lessons!  Understanding MOIs and the resulting bodily insults requires combining a bit of physics with anatomy and physiology to determine the effect of the manner (type), direction, amount, and location of force applied to the body and the resulting injury/injuries.

Isaac Newton’s First Law of Motion states that a moving object will continue to move at the same speed until an opposing or outside force acts upon it.  When this happens, the object’s kinetic energy is transferred to the outside object. For our purposes, the object is a weapon of some type, and the outside object is the body and this transfer of energy causes trauma or injury (typically, blunt/non-penetrating or penetrating). However, the transfer of energy can also be through a thermal agent such as heat, chemical, or cold agents and can also cause trauma to the body. This concept of the transfer of energy helps healthcare providers assess the likelihood and severity of injuries based on the nature of the incident and the Forensic Nurse Consultant to link (or not) the injuries to the indicted charges.

In forensics, determining the mechanism of injury (MOI) is crucial for understanding how an injury occurred, which can help in criminal investigations and legal proceedings. Forensic experts analyze the physical forces and mechanical processes that caused the injury to determine the nature of the incident (i.e. accidental, self-inflicted, self-defense, or an intentional violent act).  For example, in cases of blunt force trauma, the MOI can help differentiate between injuries caused by falls, car accidents, or assaults. Similarly, in cases involving sharp force injuries, understanding the MOI can reveal whether the wounds were caused by knives, glass, or other sharp objects and the directionality and/or angle of entry.

More specifically, when evaluating a case, Forensic Nurse Consultants consider the following:

1. The nature of force applied to the body

2. The estimated amount of force applied to the body

3. The events leading up to the transfer of energy/trauma

4. Positioning, location, and movement of the assailant and victim

5. Physical capabilities of the assailant

6. General medical condition of the victim

7. Post-injury medical care (when and what) provided to the victim

MOI can be crucial in determining court cases for several reasons:

1. Establishing Liability

2. Supporting Evidence

3. Refuting or Confirming Defenses

4. Accurate Diagnosis and Treatment

MOIs are broadly sorted into several categories, based on the type and amount of energy transferred. Each has distinct characteristics and associated injuries.

1. Blunt

2. Penetrating

3. Ballistic

4. Acceleration/Deceleration

5. Thermal

6. Chemical

7. Electrical

8. Blast

9. Crush

10. Asphyxial