WELCOME TO THE WORLD OF FORENSIC MEDICINE

1. WELCOME TO THE WORLD OF FORENSIC MEDICINE Marie Cassidy Professor of Forensic Medicine and State pathologist

2. THE BRANCH OF MEDICINE THAT APPLIES THE PRINCIPLES AND KNOWLEDGE OF THE MEDICAL SCIENCES TO PROBLEMS IN THE FIELD OF LAW FORENSIC MEDICINE

3. ‘Scientific’ investigation of the cause of injury and death in unexplained circumstances particularly when criminal activity is suspected FORENSIC MEDICINE/PATHOLOGY

4. FORENSIC SPECIALISTS • Forensic pathologist • ‘forensic’ pathologist/neuropathologist • G.P. • Police surgeon • Accident and emergency doctor • Forensic physician • Paediatricians • Forensic Psychiatrist

5. FORENSIC SPECIALISTS • Forensic pathologist - suspicious deaths • ‘forensic’ pathologist- nonsuspicious deaths • Neuropathologist – head injuries, brain damage • G.P.- injured or deceased patients • Police surgeon-prisoner, drink driver, victim • Accident and emergency doctor - injured • Forensic physician - a/a, sexual crimes • Paediatricians- any abnormality in children • Forensic Psychiatrist- prisoners

6. FORENSIC EXAMINATIONS • WOUNDS AND INJURIES • SEXUAL ASSAULTS • CHILDREN • SCENE OF DEATH • DETERMINATION OF DEATH • CAUSE OF DEATH • POSTMORTEM EXAMINATIONS • COURT TESTIMONY AND REPORTS

7. INVESTIGATION OF DEATHS • To determine the cause and the manner of death • To identify the deceased if unknown • To determine the time of death and injury • To collect evidence from the body that can be used to prove or disprove an individual’s guilt or innocence and to confirm or deny the account of how the death occurred

8. INVESTIGATION OF DEATHS • To document injuries or lack of them • To deduce how the injuries occurred • To document any natural disease present • To determine or exclude other contributory or causative factors to the death • To provide expert testimony if the case goes to trial ‘Forensic pathology, DiMaio’

10. DEALING WITH DEATH The doctor and death

11. The dead patient • History • Examination • Diagnosis of death

12. Definition of DEATH CESSATION OF LIFE IN A PREVIOUSLY VIABLE ORGANISM

13. DEATH A DOCTOR MUST DECLARE DEATH ?duty of care to determine death

14. DEATH • Somatic death • Molecular death • Brain death • Brain stem death • NO law defines death

15. SOMATIC DEATH • Failure of the body as an integrated system • loss of circulation, respiration and innervation • for such a time impossible for life to return • irreversible unconsciousness

16. Somatic death • Heart stops no pulse, no heart sounds, flat ECG, segmentation of blood in retinal vessels • Lungs stop no breathing, no chest movement • Brain activity stops • muscles floppy • metabolism stops, body cools down

17. Somatic death • Auscultate for 4 to 5 minutes • D.D. shock, hypothermia, electrocution, depressant drugs

18. MOLECULAR DEATH • Depends on susceptibility to oxygen deprivation • varies - important in organ harvesting • brain most susceptible, 3 to 7 minutes • wbcs may remain motile for up to 12hours • muscles respond to stimuli for few hours • skin viable for several days • importance - transplants

19. BRAIN DEATH • CORTEX • BRAIN STEM • WHOLE BRAIN

20. BRAIN DEATH CORTICAL brain death • deep coma • brain stem functioning

21. BRAIN DEATH PERSISTANT VEGETATIVE STATE • functioning brain stem but non functioning higher centres • respiratory centres functioning do not require permanent assisted ventilation • require parenteral feeding • if heart protected from hypoxic damage and nutrition sustained, may survive for years

22. BRAIN DEATH BRAINSTEM INJURY • COMA due to damage to the ascending reticular activating system • require assisted ventilation due to failure of the respiratory motor system • beating heart

23. BRAIN DEATH Severe irreversible cortical damage + Brain stem damage WHOLE BRAIN DEATH Beating heart donor

24. Brain stem death tests 1. Absent pupillary response to light 2. Absent corneal reflex 3. No motor response within the cranial nerve distribution and the limbs 4. Absent gag reflex 5. Doll’s eye phenomenon 6. No vestibulo-ocular reflexes 7. Persistent apnoea when ventilator disconnected

26. Cause of Death

27. Cause of death “The pathologist is bound to rely in part on what he/she is told of the events leading up to death for functional lapses like fall in blood pressure, cardiac arrythmia, spasm of the glottis or vagal inhibition which leave no trace at autopsy.” Simpson

28. THANATOLOGY SUDDEN NATURAL DEATH

29. Sudden Death • Deaths at home • Deaths in hospital • Death outside • Death in unusual circumstances: place, position, appearance of body

30. Sudden Death • G.P. or Hospital doctor • Medical history • Treatment for recent illness • Other information

31. Sudden Death • Natural death • Accident • Suicide • Homicide

32. Sudden Death Age • Children • Teenager/young adult • Adult • Elderly

33. Sudden Death Children • Stillbirths • Congenital abnormalities • Sudden infant death syndrome • Tumours

34. Sudden Death Young adults • Suicide • Accidents - RTAs • Homicides • Natural

35. Sudden Death Adults • Natural • Accidents - RTAs • Homicides • Suicides

36. Sudden Natural DeathIn the developing world sudden cardiac death remains the major cause of death Adults and elderly • Cardiovascular disease • Cancer

37. SUDDEN NATURAL DEATH- cardiac causes • CORONARY ARTERY DISEASE, ischaemic heart disease, atheroma, thrombosis, dissection, ‘bridging’, acute MI, cardiac tamponade, stress associated • HYPERTENSIVE HEART DISEASE, acute LVF, arrythmia • CARDIOMYOPATHY, dilated/congestive, hypertrophic (commonest genetic cause of sudden death), genetic • VALVULAR HEART DISEASE, ‘floppy’ mitral valve, aortic valve stenosis

38. SUDDEN NATURAL DEATH • MYOCARDITIS • AORTIC DISSECTION - hypertension/heredity/inflammation, Marfan’s • Arrhythmogenic Right Ventricular Dysplasia –genetic – MRI – 20% sudden cardiac deaths – cardioverter/defibrillator • RUPTURE OF AORTIC ANEURYSM

39. SUDDEN NATURAL DEATH PHYSIOLOGICAL – • Wolff-Parkinson-White, • long QT syndrome, ion channelopathy– congenital (inherited as a dominant gene) or acquired (antipsychotic/antiarrhythmic/allergy drugs, electrolytes, toxins, hypothermia, anorexia nervosa, dieting with liquid protein diets)

40. SUDDEN NATURAL DEATH-CNS causes • EPILEPSY - SUDEp • SUBARACHNOID HAEMORRHAGE - berry aneurysms • INTRACEREBRAL HAEMORRHAGE- hypertension • INTRACRANIAL PATHOLOGY ASSOCIATED WITH ACUTE HYDROCEPHALUS OR EPILEPSY - tumours,meningitis

41. SUDDEN NATURAL DEATH PSYCHIATRIC PATIENTS, Schizophrenics +/- phenothiazine, Neuroleptic malignant syndrome

42. SUDDEN NATURAL DEATH • EPIGLOTTITIS • PULMONARY THROMBOEMBOLISM • ASTHMA • HAEMOPTYSIS, T.B., tumour • SPONTANEOUS PNEUMOTHORAX OF THE NEWBORN

43. SUDDEN NATURAL DEATH • HAEMATEMESIS, rupture of oesophageal varices, duodenal ulcer • CHRONIC ALCOHOLICS, acute fatty degeneration of the liver • ADRENAL HAEMORRHAGE, septicaemia

44. SUDDEN NATURAL DEATH – other causes • AIR EMBOLISM • FAT EMBOLISM • AMNIOTIC FLUID EMBOLISM • Ruptured ectopic pregnancy • Toxic shock syndrome • Sudden death in Diabetes – IHD, CM, hypo or hyperglycaemia • Sudden death in alcohol • Commotio cordis

45. Sudden death Sudden adult death syndrome ‘SADS’ Sudden Arrhythmic Disease Syndrome

46. Sudden Death The negative autopsy

47. SADS • Sudden unexpected death in an adult • no signs or symptoms prior to death • postmortem shows no anatomical cause of death • specialised pathology examinations negative e.g. neuropathology • toxicology negative • bacteriology etc. negative • presumed cardiac dysrrhythmia

48. SADS Now agreed to be due to acute onset of a chaotic rhythm in the heart

49. SADS Risk factors include • A family history of unexplained sudden death in a relative under 40years • Unexplained fainting in young people • Approx 1000 cases/year in UK

50. SADS Differential Diagnosis • ARVD – abnormal ECG, anatomical changes may not be obvious at postmortem; 30-50% have a family history • Disorders of the Ion Channel – Long QT syndromes, Brugada Syndrome (south east Asia), Catecholaminergic Polymorphic Ventricular Tachycardia (AD; Finland and Italy)