Sudden death

1. Sudden death Yoni Syukriani Department of Forensic and Legal Medicine

2. Reference Knights, Simpson’s Forensic Medicine, 13thed., Arnolds, 2008.

3. 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

4. = Brainstem death Indonesian Medical Association (SK PB IDI No. 336/PB/A.4/1988) definition of death ? Do we need EEG to diagnose death??

5. 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. • Cardiac death • Clinical death • Somatic death • Brain death • Cellular death So, what is sudden death? Types of death

6. WHO : someone who dies within 24 hours of symptoms appearing. • Forensics: different meaning • Manner of death • Mechanism of death Sudden Death

7. Manner of death Natural Unnatural Accidental Suicidal Homicidal

8. Death certificate Once the fact of death is established, a death certificate is issued unless a post-mortem examination is requested. WHY manner of death?

9. Natural Causes ??? • Typically a person who dies of natural causes has been under a doctors care. • However, some times a death is made to look like it is from natural causes. • Heart attacks • Strokes • Fatal diseases • Pneumonia • SIDS • Old age • Cancer • etc

10. Cardiovascular causes • Extra-cardiac causes Natural causes

11. 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 Cardiovascular causes

12. Within seconds of coronary occlusion  PO4hydrolyzed • pHi[K+] hfor 10’ • Restingmembrane potential i • Voltage difference btw restingmembrane potential and the threshold potential speedingof conduction • Inhomogeneousconduction, slowing, block atthe lateral marginof the ischemic zone; endocardial surfacebetweenthe subendocardium, midendocardium, and subepicardium; • Conduction block • Initialshortening of refractoryperiod  lengthening of the period • Reentrantventricular arrhythmias CAD: Mechanism of Death

14. 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.

15. Cerebral haemorrhage • Cerebral thrombosis and infarction

16. 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 - Transtentorialherniation 48% Mechanism of death

17. Vascular causes  thromboemboli • Deep vein thrombosis following skeletal trauma (fracture), operation, immobility or bed rest) • Massive hemoptysis • Fulminating chest infections Respiratory system

18. Respiratory system

19. thromboemboli

20. Perforation of peptic ulcer • Acute pancreatitis • Severe bleeding Gastrointestinal system

22. Caution for cases involving woman in childbearing age ! • Ruptured ectopic gestation • Abortion • Vagal shock, haemorrhage, infection Gynaecological conditions

23. Ruptured ectopic gestation

24. 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 Asthma and epilepsy

25. Clinical examination, to confirm one or more of the following findings: • 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 death ?

26. The cause of death can only be established by a physician in: Patient admitted to ER, or Hospitalized patient, or Autopsy (forensic or clinical autopsy) How to diagnose the cause of death ?

27. 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

28. 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

29. 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 throughoutthe body, extending to arms and legs12 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. Time of death

30. The End