Sudden Natural Deaths

8/12/2019 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)

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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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Sudden Natural Deaths

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