SUDDEN DEATH Yoni Syukriani Department of Forensic and Legal Medicine REFERENCE Knights, Simpsons Forensic Medicine, 13th ed., Arnolds, 2008. OBJECTIVES To learn the concept of sudden death
from forensic and clinical point of views. To learn how to estimate unnatural causes of death To learn the natural causes of death To learn when a death certificate can be issued To learn how to diagnose death To learn how to estimate time of death DEFINITION OF DEATH ? = Brainstem death
Indonesian Medical Association (SK PB IDI No. 336/PB/A.4/1988) Do we need EEG to diagnose death?? TYPES OF DEATH Death is a process not an event, at the time of death there is a progression from clinical death to brain death, to somatic death, to cellular death. 1. 2.
3. 4. 5. Cardiac death Clinical death Somatic death Brain death Cellular death So, what is sudden death?
SUDDEN DEATH WHO : someone who dies within 24 hours of symptoms appearing. Forensics: different meaning
Manner of death Mechanism of death MANNER OF DEATH Natural Suicidal Unnatural
Accidental Homicidal WHY MANNER OF DEATH? Death certificate Once the fact of death is established, a death certificate is issued unless a post-mortem
examination is requested. NATURAL CAUSES ???
Heart attacks Typically a person who dies of natural Strokes causes has been Fatal diseases under a doctors Pneumonia care. SIDS However, some Old age times a death is
Cancer made to look like it etc is from natural causes. NATURAL CAUSES Cardiovascular causes
Extra-cardiac causes CARDIOVASCULAR CAUSES Coronary artery disease 50% of cardiovascular deaths Above 30 y.o. Coronary insufficiency Narrowing of the lumen chronic ischaemia Hypoxic myocardium is electrically unstable No need for severe ischaemia for ventricle fibrillation.
Complication of atheroma stenosis Myocardial infarction Cardiac tamponade Old women 2 or 3 days after the onset of infarction Hypertensive Heart Disease & Aortic stenosis Left ventricular hypertrophy size CAD: MECHANISM OF DEATH Within seconds of coronary occlusion PO4 hydrolyzed
pH i [K+] h for 10 Resting membrane potential i
Voltage difference btw resting membrane potential and the threshold potential speeding of conduction Inhomogeneous conduction, slowing, block at the lateral margin of the ischemic zone; endocardial surface between the subendocardium, midendocardium, and subepicardium; Conduction block Initial shortening of refractory period lengthening of the period Reentrant ventricular arrhythmias DISEASE OF THE ARTERIES
(EXTRA-CRANIAL OR INTRA-CRANIAL) Aneurysm
Congenital or family history Young woman dd/ Complication of pregnancy Pulmonary embolism History of internal pressure (during delivery, high pressure cough, fall) Mechanism: cathecolamine release.
Cerebral haemorrhage Cerebral thrombosis and infarction MECHANISM OF DEATH Infarct injury [K+] extracell h nerotransmitter out, glutamic acid, aspartic acid Ca++ entering neuron
[K+] extracell hh protease activation membrane & cytosceleton destruction Phospholipase C, aracidonic acid & prostaglandin radicals vascular & BBB destruction edema Cause of death - Transtentorial herniation 48% RESPIRATORY SYSTEM
Vascular causes thromboemboli Deep vein thrombosis following skeletal trauma (fracture), operation, immobility or bed rest) Massive hemoptysis
Fulminating chest infections RESPIRATORY SYSTEM THROMBOEMBOLI GASTROINTESTINAL SYSTEM Perforation of peptic ulcer
Acute pancreatitis Severe bleeding GYNAECOLOGICAL CONDITIONS Caution for cases involving woman in childbearing age !
Ruptured ectopic gestation Abortion Vagal shock, haemorrhage, infection RUPTURED ECTOPIC GESTATION ASTHMA AND EPILEPSY Often for no obvious reasons.
Epileptic patient : Accident Asphyxia Asthmatic patient: Even no status asthmaticus nor severe periode Over-use of adrenergic drugs, especially by inhaler HOW TO DIAGNOSE DEATH ? Clinical examination, to confirm one or more of the following findings:
1. 2. 3. 4. 5. Prolonged auscultation of the precordial negative Feeling the radial, or the carotid pulse negative Other signs of stoppage of circulation include an un-recordable arterial blood pressure, and a flat
ECG Complete absence of light reflexes in the pupils Cessation of respiration Insensibility and absent sensory responses to stimuli Loss of nerve reflexes and flat EEG. Ophthalmoscopic examination of retinal vessels, shows segmentation of the blood within them HOW TO DIAGNOSE THE CAUSE OF DEATH ? The cause of death can only be
established by a physician in: 1. 2. 3. Patient admitted to ER, or Hospitalized patient, or Autopsy (forensic or clinical autopsy) Time of Death Can estimate time of death from:
early changes after death (thanatology) insect action (forensic entomology) stomach contents (stage of digestion) last known activity (last sighting, newspaper/mail) normal postmortem changes Early Changes After Death Can estimate time of death from: Rigor mortis Post mortem hypostasis
Body temperature (algor mortis) estimate: [98.6 oF rectal temp]/1.5 TIME OF DEATH Time since death: Change observed 1-2 hours: ......... Early signs of lividity. 2-5 hours: ........ Clear signs of lividity throughout body. 5-7 hours: ......... Rigor mortis begins in face. 8-12 hours: ....... Rigor mortis established throughout the body,
extending to arms and legs 12 hours: .......... Body has cooled to about 25oC internally. 20-24 hours: ..... Body has cooled to surrounding temperature. 24 hours: .......... Rigor mortis begins to disappear from the body in roughly the same order as it appeared. 36 hours: .......... Rigor mortis has completely disappeared. 48 hours: .......... Body discolouration shows that decomposition is beginning. The End
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