Sudden Natural Deaths
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Transcript of Sudden Natural Deaths
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DEFINITION:- SUDDEN DEATH
The World Health Organization (WHO) defines
sudden death as a death occurring within 24hours of the onset of symptoms.
Death is said to be sudden or unexpected
when a person not known to have beensuffering from any dangerous disease, injury or
poisoning is found dead or dies within 24 hours
after the onset of terminal illness (reddy)
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Sudden Death is defined as a natural,unexpected fatal event, in an apparentlyhealthy subject or one whose disease wasnot so severe enough as to predict such anabrupt outcome.
Sudden deaths are mostly natural deathsthat occur immediately or within 24 hours
of the onset of terminal symptoms whichmay be different from the symptoms thatthe patient was having so long.(Krishnan vij)
4
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Forensic sense:
Most of such deaths occur in minutes oreven seconds of the onset of symptoms.
Its difficult to find the exact classification of
sudden unexpected deaths , the problemcomes from the definitions of both sudden
and unexpected.
Sudden cardiac death (SCD): Unexpected lossof heart function within seconds/minutes of
onset of Symptoms
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Clinical and investigation information:
Death can be certified by an attending physician that
has seen the patient recently, and is convinced that
the death was caused by lethal disease that he knew
the patient was suffering from.
When the physician cant certify that the death was
caused by the disease, then medicolegalinvestigations must be done.
Sometimes even after autopsy, the cause of death
may still be unknown.
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Photographs.
Radiographs.
Collection and preservation of evidence and/orspecimen.
Toxicological examinations.
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Special problems arise in certain cases and situations,because they require more investigation than usual,and because they have the most potential for serious
error: No Identification.
No cause of death.
Environmental exposure.
Decomposed body. Skeletal remains.
Deaths in police custody and police shootings.
Mass disaster.
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There should be careful examination of :
External surface :
For evidence of injury and resuscitation.Internal examination :
Will be extremely important in a death considered
sudden and unexpected.
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Diseases of the CVS (45-50 %)
Diseases of the RS (15 -23%)
Diseases of the CNS (10-18 %) Diseases of the alimentary system (6-8%)
Diseases of genitourinary system (3-5 %)
Miscellaneous(5-10 %)
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SUDDEN DEATH FROM CARDIACDISEASES.
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CORONARY ATHEROSCLEROSIS.
HYPERTENSIVE HEART DISEASE.
CORONARY ARTERY EMBOLISM SYSTEMIC EMBOLISM IN
BACT.ENDOCARDITITS.
ACUTE ENDOCARDITIS, MYOCARDITIS,
PERICARDITIS AORTIC VALVE DISEASE
ANOMALIES OF THE CORONARY
CIRCULATION. OTHER CORONARY ARTERY DISEASES
SUCH AS POLY ARTERITIS
CARDIOMYOPATHIC ENLARGEMENT
CONGENITAL HEART DISEASE.
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Coronary atherosclerosis is the largest contributor tothe ischemic heart disease which itself is the mostcommon cause of sudden death in many countries.
CAPTAIN OF THE MEN OF THE DEATH. Basic mechanism is the stenosis or occlusion of one or
more branches of the coronary arteries byatheromatous lesions.
As coronary atheroma may be focal, every part ofthe vessel must be examined at autopsy , withtransverse cuts at no more than 3 mm intervals.
Atheromatous plaques often are eccentric, leaving a
crescentic residual lumen, however, concentricplaques may also be found which is more common inthe younger individuals.
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Cause of death due to coronary atherosclerosis
are mainly due to its complicationswhich are:
1. Ulcerated plaques: The endothelialthickening involving the media gets infiltrated
with the lipids which leads to luminal
reduction due to the enlarging plaque and
subsequently leads to formation offibroendothelial cap which comes under
pressure of the blood flow causing its rupture
in the lumen leading to ulcerated plaques
2. Hemorrhage.
3. Coronary Thrombosis.
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1. Hemorrhage:- occurs within an atheromatous
plaque usually into the softened, necrotic
centre. This subintimal hemorrhage causessudden reduction in the blood carrying
capacity of a coronary artery and cause
sudden death.
2. Coronary Thrombosis:- The atheromatousplaque undergoes progressive internal
necrosis which erodes the luminal surface
and expose the fibrofatty contents wich
forms a nidus for thrombus formation, which
accrete in layers reducing the lumen or even
occluding it reducing the blood flow to the
distal myocardium.
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The major trunks are the most effectedas they lie subepicardially often in the
fatty surface tissue. The most common site of occlusion is in
the first 2 cm of the anterior descendingbranck of the left coronary artery.
Next most common is in the rightcoronary artery but the thrombosisoccurs more distally .
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Atheromatous plaques on the aortic orifice
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Infarction will occur in the myocardiumdistal to the complete occlusion of anycoronary artery, in the absence of
adequate collateral circulation.Types :
1. Subendocardial
2. Intra-mural
3. Transmural or full thicknessinfarct
4. Papillary muscle infarction.
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Arrythmias : 50 % of the deaths inischemic heart disease following
arrythmias. LVF and cardiogenic shock: 7% of
deaths occur following cardiogenicshock , more in the cases involving more
than 40 % of left ventricular infarcts andaccounts for more than 90% mortality.
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Other complications include
Rupture of the myocardiumAneuryms , left ventricular aneurysmMyocardial fibrosis
Mural thrombosis and embolismPericarditisPostmyocardial infarction syndrome
(dresslors syndrome)
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Approaching the cause of death :
Historical data:History of chronic cardiovascular disease
Common causes , i.e. pain , fear, apprehension,emotional stress , anger leading to dysfunction or
inability of the heart to respond to a demandingsituation.
In cases of concurrent heart disease and trauma,
witnesses may have a key role on the basis ofobservation of symptoms and signs observed bythem. Further the history of the blow or blunt forceagainst the region of the heart needs to confirmed byautopsy findings.
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Autopsy documentation:documentations of findings is essential for
determination of the role of heart disease in fataltrauma or role of trauma in relation to chronicdisease.
It is also mandatory to include the laboratory studiesduring the detailed and meticulous autopsy.
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Macroscopic appearance in MI
First 12-24 hours: It is not possible to detect with nakedeye within 12 hours. By 24 hours characteristic pallorarea with swelling of surrounding area . The bundlesof muscle appear separated on cutting the ventricleduring autopsy.
End of the 1stday to 2nd-3rdday: The color changesfrom brownish-purple then to reddish bluish until themuscle becomes necrotic and appears yellowish.
Tigroid appearance depicts alternate bands of redand pale areas. Fully developed infarct is yellowish
3-10 days: progressive lysis and removal of the deadmuscle leads to softening and thinning of the infarct.
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Beyond 10 days: Fibrous repair dominates and theinfarct is slowly converted to fibrous scar which is
apparent to naked eye after about 2 weeksprogressing to dense white fibrous scar.
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At autopsy, there is no infarct and the coronary
arteries are found to be patent, without significant
atherosclerosis or congenital anomalies.
Death is believed to be due to transitory coronary
artery spasm. (coronary arteries spasm withoutanatomical narrowing of the coronary arteries, in
association with angina)
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Primary dissecting aneurysms
maybe either spontaneous, or
due to trauma(eg. Chest trauma,
coronary angiography).
Spontaneous coronary artery
dissections is a rare condition,
mostly occurring in females
particularly in the peripartum
period. Usually presenting as
sudden death.
Cross photograph of rupturedaneurysm of right coronary artery and
surrounding hemorrhage.
CORONARY ARTERY ANEURYSM
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Sudden death in individual with hypertension is usually
associated with and in most instances due to,
accompanying atherosclerosis.
H.T may kill in a number of ways, such as by renal
failure, ruptured aneurysm or cerebral hemorrhage, but
here we concerned with primary heart failure, a quite
common cause of death.
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The cardiomyopathies constitute a diverse group ofdiseases of both known and unknown etiology,characterized by myocardial dysfunction. The diseasesare not the result of arteriosclerotic, hypertensive,congenital, or valvular disease.
Can be grouped into 3 general categories :
1. Dilated.
2. Restrictive.
3. Hypertrophic. Cardiomyopathy may result in sudden death(during
exercise) as a result of arrhythmia.
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Sudden death associated with valvular disease usuallyinvolves a floppy mitral valve or aortic stenosis.Rarely, sudden death will be due to an acute bacterialvalvulitis.
Postmortem findings- the valve is thickened, rigid, with fusion of thecommissures in most cases.
- the whole valve maybe unrecognizable, chalky mass,
with a stenosed lumen.- left ventricular hypertrophy.
- increase heart weight, up to (800-1000 gms).
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When the aorta ruptures
spontaneously, rather than as the
result of trauma, it is usually in
an aortic aneurysm.
The aorta is such a large blood
vessel that, if it ruptures, death is
very rapid although the process
might be slow enough to permit
emergency surgery.
First sign may be rupture, rapid
exsanguination and death.
http://www.patient.co.uk/DisplayConcepts.asp?WordId=AORTIC%20ANEURYSM&MaxResults=50http://www.patient.co.uk/DisplayConcepts.asp?WordId=AORTIC%20ANEURYSM&MaxResults=50 -
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MYOCARDITIS
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The commonest cause are various types of bacteria,
though viruses and other microorganism may also be
responsible. the symptoms are often vague, so the
condition may not be diagnosed during life.
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The most common causes of death are:
Subarachnoid hemorrhage
Intracerebral hemorrhage
Cerebellar/ pontine hemorrhage Cerebral thrombosis and embolism
Carotid artery thrombosis
Meningitis
Brain abscess
Epilepsy
Tumours
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SAH is a very serious neurologicalemergency and it is the fourth mostcommon intracranial cause of death.
This may occur spontaneously, or may resultfrom head injury.
85% of spontaneous SAH is caused byrupture of saccular berry aneurysms.
Aneurysms are usually found at bifurcationof the cerebral arteries, particulary in theregion of circle of willis.
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SAH typically presents with a sudden sever
thunderclap headache (often occipital)which lasts for hours or even days,sometimes accompanied by vomiting
There may be loss of consciousness at the
onset. Any rise in the blood pressure will cause
rupture of the apex of the aneurysm alsooccurs after: Emotions, exercise, alcohol,sexual intercourse, and direct trauma to the
neck Most cases of death are due to vasospasm
following the rupture .
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Autopsy Point of bleeding in the circle of Willis
more dense at the base of the brain
especially basal cisterns. Bright red in fresh blood , brown in older
bleeding.
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ICH is bleeding directly into the brain
parenchyma itself
The most common cause is hypertentionby
damaging the small intracerebral arterioles,
or acute rise in BP which cause rupture of
penetrating arteries
Other causes include trauma, use ofanticoagulants, use of drugs like cocaine or
amphetamines, vascular malformation, or
hemorrhage in an underlying brain tumor.
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Deep hemorrhageanywhere withinthe hemisphere.
Rupture inside theventricular system.
Sever contrecouplesions : largehematomas in oneor bothhemisphere.
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Mortality rate 5% in children,25% in neonates
The severity depends on the causative organism.Eg: untreated TB meningitis is fatal in a fewweeks.
The patient may have chills, high fever,
dizziness, nausea, vomiting,headaches orweakness. Petechiae appear on the body in 75%of cases.
In 10% of the cases there is a rapidly progressive
course with toxemia, shock, and collapse. Theindividual may die in less than 10 hrs from theonset of symptoms.
Sometimes, a person who is walking around willcollapse and die. At autopsy pt will be found tohave meningococcemia.
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Autopsy a diffuse (widespread)inflammation of the pia-arachnoid area.
Neutrophil,leucocytes tend to havemigrated to the cerebrospinal fluid and thebase of the brain + cranial nerves + spinalcord, may be surrounded with pus as may
the meningeal vessels. There may be cyanosis,petichiae,and
purpura of the skin,acute bilateralhemorrhagic adrenal necrosis
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Sudden Unexpected Death in Epilepsy isa term used when a person with epilepsysuddenly dies, , in whom a postmortemexamination fails to uncover a grossanatomical, toxicological or
environmental cause of death. Death in an epileptic patient could be
by asphyxiaduring a fit in bed when theface is pressed into the pillow.
Also it may cause due to traumaticdeaths because of fits occurring whenpt in some vulnerable position.
Antiepileptic drug overdose
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Should always include a search for biteson the tip and distal tongue whichsuggest fit.
Examination of Brain is essential : tosearch for any cause of post-traumaticepilepsy
On Heart Ex : patchy myocardial fibrosiscaused by episodic hypoxia from apneafrom fits .
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High mortality rate associated withgrade 4 glioma(glioblastoma multiform)
20% of glioma survive for 1 year.
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Sudden death due to disease of RS comprises 15-25
%. Pneumonia (lobar /bronchopneumonia) Rupture of blood vessel in PTB with cavitation Pulmonary thromboembolisim Air embolism Pleural effusion
Pneumothorax caused by rupture of emphysematousbleb
Hemoptysis
Neoplasm Asthma Impaction of foreign body in the larynx Acute edema of the glottis for eg. anaphylaxis
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It is a Major cause of sudden death in RS.
It is a common mode of death in patients withcancer and stroke and remains the most commoncause of death in pregnancy
75% of PE arise from the propagation of lower limbDVT
Predisposing factors includeimmobility,pregnancy,trauma,surgery
As result a small emboli break off and impact in theperipheral branches of pulmonary arteriesinfarction.
Massive emboli occlude major pulmonary vessels.
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PULMONARY EMBOLISM
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Death occurs suddenly, with no findings at
autopsy except in chronic asthma state.
some cases are apparent due to status
asthmaticus, others due to drug overdose
Drugs: theophylline and sympathomimetic
agentsventricular fibrillation.
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Rare.
1. pulmonary tuberculosis
2. bronchial tumors rarely cause a fatalhemoptysis, unless major vessel iseroded.
The bleeding causes death by suddenfilling of the larynx with blood,causingasphxia
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GASTROINTESTINAL SYSTEM
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Sudden death usually occurs due to lack of medical attention.
Fatal abdominal problems :
1. Mesenteric thrombosis, infarction and embolism.
2. Strangulated intestine which may lead to gangrene formation.3. Fulminating peritonitis, chemical peritonitis(perforating peptic
ulcer), perforation of colon through a diverticulum.
4. Bleeding from gastric and duodenal ulcers.
5. Acute hemorrhagic pancreatitis.
6. Bursting of the liver abscess.
7. Rupture of the enlarged spleen
8. Intestinal obstruction
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Less with the resuscitatory methods.
Esophagus varices (most common), they'll becollapsed after death so they are difficult toidentify.
Gastric and duodenal ulcers eroding thelarge vessel.
Gastric tumor perforating large v.
Colonic lesion: carcinoma, UC. Hemorrhage from small intestine(CrohnSDIS)
Bleeding from surgical operations(rare).
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Gynaecological system
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abnormal pregnancy thatoccurs outside the uterus,within one of the tubes.
Symptoms: Abnormalvaginal
bleeding\Amenorrhea\breast tenderness\lowerabdominal pain\others.
The most commoncomplication is rupturewith internal bleeding that
leads to shock. Deathfrom rupture is rare.
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catastrophic event where a full thickness teardevelops, opening the uterus directly into theabdominal cavity.
bradycardia seen on fetal heart ratemonitoring are the most common and oftenthe only manifestations of uterine rupture.
Sudden gross haematuria
Increasing pain and bleeding\ signs ofhypovolaemic shock and haemoperitoneum.
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Addisons disease
Diabetes mellitus
Hemochromatosis
Hyperthyroidism Blood dyscrasias
Cerebral malaria
Shock due to emotional excitement
Reflex vagal inhibition Anaphylaxis due to drugs
Mismatched blood transfusion
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Crib death, syndrome in which healthy infants(1month to a year) die from unknown causes (usuallyduring sleep).
Most deaths due to SIDS occur between 2 and 4
months of age, and incidence increases during coldweather.
African-American infants are twice as likely andNative American infants are about three times more
likely to die of SIDS than Caucasian infants. More boys than girls fall victim to SIDS.
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Smoking, drinking, or drug use during pregnancy
Poor prenatal care
Poor prenatal nutrition.
Prematurity or low birth-weight
No breast feeding.
Mothers younger than 20
Smoke exposure following birth
Overheating from excessive sleepwear and bedding
Stomach sleeping
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History of respiratory tract infections or GI upset.
Story records that the infant was put to sleep in the
evening, and was found dead in the morning.
Most infants are found dead in the first half of the day.
The scene of death and findings:
Few infants have edema fluid exuding from the mouth,
may become blood tinged.
The hands are often found to be grasping fibers from thebedclothes.
The face maybe pale or slightly cyanosed or congested.
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The signs of an infant suffocating or with SIDS are
usually nil. So in a completely negative autopsy,
you can never know if the cause of death was
suffocation, or SIDS.
Petechiae in thymic cortex maybe helpful, they are
usually absent in known suffocation(such as those
caused by plastic bags), yet 70% of SIDS have
serosal petechiae.
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3rdedition Knights forensic pathology.
Forensic medicine and toxicology , 5th
edition, By Krishnan Vij. The essentials of Forensic medicine and
toxicology , by Dr. K S Narayan Reddy.
internet
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Dr K.U.Zine Sir, Professor and Head
Dr Sushim Waghmare Sir, Assistt.Professor
Dr. Sandeep Haridas Sir, Assistt.Professor Dr. Mandar Sane Sir, Assistt.Professor
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