Noaimi Doa Khalid Outline Definition Medicolegal importance Causes of sudden natural death Sudden infant death syndrome Investigation and examination Definition SD is defined as a natural ID: 908826
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Sudden natural death
Hossam Al-
Noaimi
Doa
Khalid
Slide2OutlineDefinitionMedicolegal importanceCauses of sudden natural deathSudden infant death syndromeInvestigation and examination
Slide3DefinitionSD is defined as a natural, unexpected fatal event, in an apparently healthy subject or one whose disease was not so severe enough as to predict such an abrupt outcome.WHO definition: Death occur within 24 hrs of the onset of symptoms.Forensic science: Most of such deaths die in minutes or even seconds of the onset of symptoms. Natural: Death that is primarily attributed to natural agents : usually an illness or an internal malfunction of the body . (not suicide, external accident, homicide)
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Slide4~When the physician can’t certify that the death was caused by the disease, then medicolegal investigations must be done. Sometimes even after autopsy, the cause of death may still be unknown. ~The description “sudden” or “unexpected” means that the clinician was unable to offer a cause for the death~It is crucial to remember that a sudden death is not necessarily unexpected, and an unexpected death is not necessarily sudden, but these are oftencombined.
~there is a small percentage of cases that could be due to unnatural factors. It is to identify and exclude these un-natural causes, that a medico legal investigation is mandatory in all cases of sudden deaths.
Slide5Medicolegal importance:2- to excludes violent or traumatic deaths (un-natural)3-profound effects on the health and welfare of the family of the deceased6-for benefits of hospital authorities (malpractice /suspecting certain illnesses)1-To know the cause of death5-Reconstructing
the event of death when a proper eyewitness account or a history is not available;
4-Screening certain people for certain illnesses (for society screening-athletes/Pilots))
Slide6Causes of SND:Cardiovascular system diseases. a. Heart diseases b. Vascular diseases Central nervous system diseases.Respiratory system diseases.Gastrointestinal system diseases.Gynecological system diseases.
Slide7A. Cardiovascular SystemCardiovascular disease is the most common cause of sudden unexpected deaths in adults.Most of cardiovascular diseases related deaths are mainly due to coronary atherosclerosis.
Slide8a. Heart Diseases:Coronary artery disease.Hypertensive heart disease.CardiomyopathiesValvular heart diseases.Myocarditis.Infective endocarditis.
Slide9I. Anatomy of the coronary arteries
Slide10Coronary artery diseasesCauses of coronary artery disease:Coronary stenosis or complete occlusion due to atheroma.Coronary artery spasm.Dissecting coronary aneurysm.Myocardial bridging.
Slide11AtheromaA fatty deposit in the intima (inner lining) of an artery, resulting from atherosclerosis.The most common cause of death from cardiovascular diseases is coronary atherosclerosis. Approximately half of the individuals with coronary artery disease die suddenly.Atheroma causes stenosis or occlusion to one or more of the major branches of the coronary arteries. It may be focal or diffused . Results in reduced blood flow, either by atheromatous lesion itself or by its complications (
ulceration, rupture, haemorrhage or thrombosis).
Slide12Slide13Slide14Sites of coronary artery occlusion:First 2 cm of the left anterior descending coronary artery. Right coronary artery.Circumflex coronary artery.Effects of coronary artery disease:
Fatal cardiac arrhythmia.Myocardial infarction.
Myocardial fibrosis.Postmortem findings:coronary atheroma.areas of myocardial fibrosis.rarely, areas of recent infarcts.
Slide15CORONARY ARTERY SPASM 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 without anatomical narrowing of the coronary arteries, in association with angina)
Slide16CORONARY ARTERY ANEURYSMIt’s an intramural hematoma of the media of the vessel wall, which flattens and occludes the lumen, reducing the blood flow.A dissecting aneurysm of the coronary artery maybe, either secondary to extension of an aortic root dissection, or primary and limited to the coronary artery.
Slide17Slide18Primary 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.
Cont:
Slide19MYOCARDIAL BRIDGINGoccurs when the one of the coronary arteries (left anterior descending coronary artery rarely the right) tunnels through the myocardium rather than resting on top of it.Typically, the arteries rest on top of the heart muscle and feed blood down into smaller vessels that populate throughout the myocardium. But if the muscle grows around one of the larger arteries, then a myocardial bridge is formed.
Slide20Cont:As the heart squeezes to pump blood, the muscle exerts pressure across the bridge and constricts the artery.This defect is present from birth.This condition can cause complications such as vasospasm, angina pectoris, arrhythmia, Which results in sudden death
Slide21Slide22Slide23HYPERTENSIVE HEART DISEASESudden death in individual with hypertension is usually associated with and in most instances due to, accompanying atherosclerosis.HTN 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.
Slide24CARDIOMYOPATHIESThe hallmark here is myocardial dysfunction. The diseases are 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.
Slide25Slide26VALVULAR HEART DISEASESudden death associated with valvular disease usually involves a floppy mitral valve or aortic stenosis. Rarely, sudden death will be due to an acute bacterial valvulitis.Postmortem findings - the valve is thickened, rigid, with
fusion of the commissures 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).
Slide27Slide28Slide29Slide30MYOCARDITISMany infective diseases produce an acute myocarditis which may be an acute cause of death.The criteria for the diagnosis is to find inflammatory and infiltrative degenerative or necrotic myocytes.Viruses (eg. Influenza) infections are the most common cause of myocarditis.
Slide31Slide32INFECTIVE ENDOCARDITISThe 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.
Slide33VASCULAR DISEASES Dissecting aortic aneurysm. Ruptured atheromatous aortic aneurysm. Cerebrovascular disease.
Slide34DISSECTING AORTIC ANEURYSMA tear in the tunica intima results in blood splitting the tunica media. This produces a false lumen that can progress in an antegrade or retrograde direction. Rupture may occur back into the lumen or externally. Result of an intimal tear causing a false lumen between the media and the adventitia. Over
90% occur in the ascending aorta
either just distal to the aortic valve or the left subclavian artery.
Slide35Slide36Slide37It can rupture but more commonly dissection propagates distally, involving vessels branching off the aorta producing ischemia in the kidneys, lower extremities, viscera or spinal cord (in descending order of probability). Can also undergo antegrade extension to produce acute aortic regurgitation, myocardial infarction and cardiac tamponade.
Slide38RUPTURED ATHEROMATOUS AORTIC ANEURYSMThe 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.
Slide39B. Central nervous systemThe most common causes of death are:
Slide40I. EPILEPSY Sudden Unexpected Death in Epilepsy is used when a person with epilepsy suddenly dies, in whom a postmortem examination fails to uncover a gross anatomical, toxicological or environmental cause of death. Death in an epileptic patient could be by asphyxia during a fit in bed when the face is pressed into the pillow.Or due to traumatic deaths because of fits occurring when patient in some vulnerable position.Or Antiepileptic drug overdose
Slide41AutopsyShould always include a search for bites on the tip and distal tongue which suggest fit.Examination of Brain is essential : to search for any cause of post-traumatic epilepsyOn Heart Ex : patchy myocardial fibrosis caused by episodic hypoxia from apnea from fits .
Slide42II. SUBARACHNOID HEMORRHAGESAH is a very serious neurological emergency and it is the 4th most common intracranial cause of death.This may occur spontaneously, or may result from head injury.85% of spontaneous SAH is caused by rupture of “saccular” berry aneurysms.Aneurysms are usually found at bifurcation of the cerebral arteries, particularly in the region of circle of Willis.
Slide43Slide44SAH typically presents with a sudden sever 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 also occurs after: Emotions, exercise, alcohol, sexual intercourse, and direct trauma to the neck…Most cases of death are due to vasospasm following the rupture .
Slide45Point 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.Autopsy
Slide46Slide47III. INTRACRANIAL HEMORRHAGEICH is bleeding directly into the brain parenchyma itselfThe most common cause is hypertention by damaging the small intracerebral arterioles, or acute rise in BP which cause rupture of penetrating arteriesOther causes include trauma, use of anticoagulants, use of drugs like cocaine or amphetamines, vascular malformation, or hemorrhage in an underlying brain tumor.
Slide48AutopsyDeep hemorrhage anywhere within the hemisphere.Rupture inside the ventricular system.Sever contrecoup lesions : large hematomas in one or both hemisphere.
Slide49IV. MENINGITIS Mortality rate 5% in children,25% in neonatesThe severity depends on the causative organism.Eg: untreated TB meningitis is fatal in a few weeks. The patient may have chills, high fever, dizziness, nausea, vomiting,headaches or weakness. 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. The individual may
die in less than 10 hrs from the onset of symptoms.Sometimes, a person who is walking around will collapse and die. At autopsy pt. will be found to have meningococcemia.
Slide50AutopsyA diffuse inflammation of the pia-arachnoid area. Neutrophil, leucocytes tend to have migrated to the cerebrospinal fluid and the base of the brain + cranial nerves + spinal cord, may be surrounded with pus as may the meningeal vessels.There may be cyanosis, petichiae, and purpura of the skin, acute bilateral hemorrhagic adrenal necrosis
Slide51Slide52Slide53V. TUMORSHigh mortality rate associated with grade 4 glioma (glioblastoma multiform)20% of glioma survive for 1 year.
Slide54C. Respiratory system
Slide55I. PULMONARY THROMBOEMBOLISM It is a Major cause of sudden death in RS.It is a common cause of death in patients with cancer and stroke and remains the most common cause of death in pregnancy75% of PE arise from the propagation of lower limb DVTPredisposing factors include immobility, pregnancy, trauma, surgery…As result a small emboli break off and impact in the peripheral branches of pulmonary arteries infarction.Massive emboli occlude major pulmonary vessels.
Slide56Slide57II. BRONCHIAL ASTHMADeath 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
Slide58Slide59III. HEMOPTYSISRare.Pulmonary Tuberculosis Bronchial Tumors rarely cause a fatal hemoptysis, unless major vessel is eroded.The bleeding causes death by sudden filling of the larynx with blood,causing asphxia
Slide60Slide61D. Gastrointestinal System
Slide62I. MASSIVE BLEEDINGLess with the resuscitatory methods.Esophagus varices (most common), they'll be collapsed after death so they are difficult to identify.Gastric and duodenal ulcers eroding the large vessel.Gastric tumor perforating large vesselColonic lesion: carcinoma, UC.Hemorrhage from small intestine(Crohn’s Disease)Bleeding from surgical operations(rare).
Slide63II.PERITONITISUndiagnosed or untreated Acute appendicitis and appendix abscess (rare)Perforation of colon through diverticulum'sPerforation by carcinomaPerforated peptic ulcerAutopsy: turbid fluid found in the peritoneal cavity\early inflammation changes.
Slide64E. Gynecological systemRuptured tubal ectopic pregnancyRuptured uterusAir embolismAmniotic fluid embolism
Slide65I. Ruptured tubal ectopic pregnancyabnormal pregnancy that occurs outside the uterus, within one of the tubes- more than 90% occur in the fallopian tube.Symptoms: Abnormal vaginal bleeding\ Amenorrhea\ breast tenderness
\ lower abdominal pain\others.The most common complication is rupture with internal
bleeding that leads to shock. Death from rupture is rare.
Slide66II. Ruptured Uteruscatastrophic event where a full thickness tear develops, opening the uterus directly into the abdominal cavity. Bradycardia seen on fetal heart rate monitoring are the most common and often the only manifestations of uterine rupture.Sudden gross haematuria Increasing pain and bleeding\ signs of hypovolaemic shock and haemoperitoneum.
Slide67III. Air EmbolismAir embolism can occur whenever a blood vessel is open and a pressure gradient exists favoring entry of gas. An Air Embolus does not always happen when a blood vessel is injured, because the pressure in most arteries and veins is greater than atmospheric pressure. In the veins above the heart, such as in the head and neck, the pressure is less. Most common is criminal abortion by insufflation of uterus by a syringe.Interruption of the circulation by bubble of air that gain access, usually through the venous side.
Mechanism: by muscular rebound of the uterus sucking air into the cervix.
Air veins Rt heart failure of contraction to move the bolus pulmonary air embolism death.
Slide68VI. Amniotic Fluid EmbolismAmniotic fluid embolism in which amniotic fluid , fetal cells, hair or other debris enters the mother's blood stream
via the placental bed of the uterus and triggers an allergic reaction. This reaction then results in
cardiorespiratory collapse and coagulopathySolid elements impacted in the lung capillaries, rarely in the systemic circulation (embolism in kidney,liver,brain)Fluid elements caused allergy response leading to collapse and death.AFE most potent cause of disseminated intravascular coagulopathy.
Slide69Autopsy-negative causes of deathEndocrinopathies: Diabetes mellitus (diabetic ketoacidosis, hypoglycemia); thyroid storm and thyrotoxicosis; adrenocortical insufficiency and hyperaldosteronismElectrolyte abnormalities: Dehydration, diarrhea, vomiting, endocrine dysfunction (Addison disease, Schmidt syndrome), uremia, water intoxication, hypokalemiaCardiac dysrhythmia: Channelopathies, drug induced, electrolyte imbalanceOther: Seizure disorder, anaphylaxis, neuroleptic malignant syndrome, serotonin syndrome
Slide70Crib death, syndrome in which healthy infants die from unknown causes (usually during sleep).Most deaths due to SIDS occur between 2 and 4 months of age, and incidence increases during cold weather. More
boys than girls fall victim to SIDS.
Sudden infant death syndrome(SIDS)
Slide71SIDS risk factors:Smoking, drinking, or drug use during pregnancyPoor prenatal carePoor prenatal nutrition.Prematurity or low birth-weightNo breast feeding.Mothers younger than 20Smoke exposure following birthOverheating from excessive sleepwear and beddingStomach sleeping
Slide72Case history in SIDS: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 oedema
fluid exuding from the mouth, may become blood tinged.The
hands are often found to be grasping fibers from the bedclothes.The face maybe pale or slightly cyanosed or congested.
Slide73Differentiating SIDS from external suffocationThe 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, yet 70% of SIDS
have serosal
petechiae.
Slide74Special problems 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.
Slide75Preliminary steps in the investigationClinical 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 can’t certify that the death was caused by the disease, then medicolegal investigations must be done. Sometimes even after autopsy, the cause of death may still be unknown.
Slide76Scene Investigation Examination at the scene of the death may present potential solutions to the problems of the death’s classification.Any suggestion for “foul play” (crime or violance)Eliminate suggestions of electrocution.Evidence of planning for death( ex. suicide notes)Evidence of medication containers.
Slide77Special proceduresPhotographs.Radiographs.Collection and preservation of evidence and/or specimen.Toxicological examinations.
Slide78Postmortem ExaminationThere 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.
Slide79Thank you