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Death in Forensic Medicine

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Death in Forensic Medicine

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Death in Forensic Medicine

  1. 1. DEATH AND CHANGES AFTER DEATH Dr SM Arman Hossain
  2. 2. • Concept of death & definition of death • Types of death • Different aspects of death • Diagnosis of death • D/D of death • Death trance • Lazarus syndrome • Unconsciousness • Presumption of death & survivorship • Sudden death • Euthanasia • Post mortem changes
  3. 3. Concept of death & life. Philosophical , legal & medical/scientific concept of death. Oxford dictionary gives the meaning of death as –„ The end of life‟. Chamber‟s twentieth century dictionary defines death as - „Extinction of life.‟ Black‟s law dictionary defines death as –„ The cessation of life; the ceasing the exist‟.
  4. 4. Death • Law does not define death clearly. • Definition of death (Medico legal definition): • Death may be defined as permanent & irreversible cessation of three interlinked vital systems of body , called tripod of life, namely –the nervous , circulatory & respiratory systems. • In the United States, a person is dead by law if a Statement of Death or Death certificateis approved by a licensed medical practitioner. Various legal consequences follow death, including the removal from the person of what in legal terminology is called personhood.
  5. 5. Types of death : • The advent of human organ transplantation, in the 1960s specially the heart transplantation lead to the necessity of scrutinizing the phenomena of death. The problem increased many folds because of the increasing use of the modern medical technology i.e. connection to the artificial means to support a dying man. This generated the newer concepts of moments of death. • For the purpose of understanding about death and its mechanism death is divided into two types (1) somatic death, and (2) molecular death.
  6. 6. Types of death : 1. Somatic death/systemic death /Clinical death: It means complete & irreversible stoppage of vital functions . 2. Cellular death/molecular death : It means death of tissues & cells of body individually
  7. 7. Somatic death/Systemic death/Clinical death It is defined as irreversible cessation of functioning brain, heart, and lungs resulting in complete loss of sensibility and ability to move the body. It is the extinction of personality or the death of the body as a whole (soma means body), also known as clinical or systemic death. The cells of different tissues of the body are still alive and dies after sometime at different rate. Cessation of heart beating:-Clinical criteria: 1.Absence of pulse (central i.e. carotid ) 2.Absence of heart sound on repeated prolonged auscultation. 3.A flat electrocardiogram (ECG).
  8. 8. Somatic death/Systemic death/Clinical death Cessation of breathing:-Clinical criteria 1.Absence of respiratory movement 2.Absence of breath sound on thorough auscultation of chest. (Central) Cessation of brain activity:-Clinical criteria 1.Generalized flaccidity with generalized anesthesia. 2.Dilated fixed pupils, not responding to light 3.Absence of motor responses within the cranial nerve distribution on painful stimuli. 4.Absence of corneal reflexes.
  9. 9. Cellular or molecular death and the concept of brain death • Somatic death is followed by progressive disintegration of body tissues and is called as cellular or molecular death. • In absence of circulation and respiration different cells die at different times. Death of some cells are mentioned below in sequential order from the earliest:-
  10. 10. Brain death or brain stem death Brain death means irreversible loss of cerebral function. Or Brain death means that the patient is dead whether or not the function of some other organ such as heart beat is maintained by artificial means and all the function of the brain must have permanently and irreversibly ceased.
  11. 11. Brain Death Brain death : Permanent & irreversible cessation of function of brain irrespective of function of other organs like heart , lungs. Types of brain death: 1.Cortical death /cerebral death/ vegetative stage :Loss of function of cerebral cortex. , heart & lungs may work. . 2.Brain stem death: Damage & failure of function of brain stem , heart & lungs can not work independently. 3.Combined brain death: both cortical & brain stem death. Brain death is now considered as legal death . It has great importance from legal , ethical point of view & in relation to organ trans plantation .
  12. 12. Brain Death Cortical death Death of the cortex with an intact brain stem. Permanent & irreversible cessation of function of cerebral cortex is called cortical death. Brain stem death Cerebrum is intact but loss of all vital center causes the victim to be irreversible comatose and incapable of spontaneous breathing. Combined brain death: both cortical & brain stem death
  13. 13. Criteria for diagnosing brain death (1)The patient must be in a deep coma, which is not due to depressant drugs, metabolic or endocrine disorder. (2) The patient must not be in hypothermia. (3)The patient must be on a mechanical ventilator/heart-lung machine. (4)Diagnostic test for brain death:- (a) Absence of corneal reflex. (b) Dilated and fixed pupil not reacting to light. (c) Absence of vestibulo-ocular reflex. (d) Absence of cranial nerve response to painful stimuli. (e) Absence of cough reflex.
  14. 14. Difference of somatic & molecular death 1. Complete & irreversible stoppage of functions three vital organs –brain,heart & lungs . 2. It may be confused with suspended animation. 3. In this stage muscles response to electric stimuli . 4. At this stage of death organs can be removed for transplantation . 5. It precedes molecular death. 1. Death of tissue & individual cells takes place . 2. No chance of confusion. 3. In this stage muscles do not response to electric stimuli . 4. At this stage of death organs cannot be removed for transplantation . 5.It follows somatic death .
  15. 15. Different aspects of death- 3 main aspects to be considered: 1. Mood of death 2. Cause of death 3. Manner of death
  16. 16. Mode of death The term „mode of death‟ usually refers to the system that initiates the process of death. Stoppage of which system initiated the process of death. These modes are: 1. Coma. (failure of nervous system). 2. Syncope (failure of circulatory system). 3. Asphyxia (failure of respiratory system).
  17. 17. Cause of death • Natural causes- Natural disease & geriatric causes • Unnatural causes – Injury, poisoning, drowning etc. • *Obscure causes.
  18. 18. Manner of death : It is the way by which cause of death was produced. 1.Natural 2.Unnatural– Suicidal, homicidal, accidental *Undetermined/unexplained
  19. 19. Coma Coma means insensibility or loss of consciousness,which may be partial or complete depending on the degree of involvement of the C.N.S. Causes of coma: 1.Cerebral compression. 2.Cerebral injuries. 3.Infective states like, encephalitis, meningitis, abscess. 4.Any growth. 5.Metabolic disorder. 6.Cerebral embolism. 7.The effect of certain drugs. 8.Miscellaneous causes like epilepsy, heat stroke.
  20. 20. ASPHYXIA Asphyxia is a condition caused by interference with respiration, or due to lack of oxygen in respired air due to which the organ and tissues are deprived of oxygen causing unconsciousness or death.
  21. 21. Hypoxia & Anoxia HYPOXIA Lack of supply of oxygen to the tissues below normal is known as hypoxia. ANOXIA Anoxia means total lack of oxygen in the tissues.
  22. 22. SYNCOPE Syncope is the sudden cessation of the action of the heart and failure of circulation leading to death.
  23. 23. Cause of death 1. Immediate cause 2. Basic cause 3. Contributory cause
  24. 24. WHO Syntax regarding writing cause of death I. Cause of death a) Direct cause ...Myocardial infarction (due to or as a consequence of) b) Antecedent cause ...Coronary thrombosis (due to or as a consequence of) c) Underlying cause ...Coronary atherosclerosis II. Contributory causes… (Usually applicable for geriatric death) DM Hypercholesterolemia.
  25. 25. Death certification. A doctor is the person who is legally authorized to declare a death & issue a death certificate. To issue a death certificate/Condition of certifying death: 1.Inspection of the dead body by the doctor himself. 2.Full satisfaction about the death 3.The doctor must sure of the cause of death 4.The doctor should free from least suspicion of foul play 5. The doctor has seen/examined the person within 14 days before death as alive. 6.The doctor registered as a qualified medical practitioner.
  26. 26. DEATH CERTIFICATE (WHO) I do herby certify that I attended the deceased (Name) ...................................... aged .................... residing at ...................................................................... during his last illness and that to the best of my belief the cause of his death (time)............... on (date) was as stated below: Cause of Death Approximate interval between onset and death 1. Disease of condition or condition directly leading to death (a) ................................ Years Months (due to or as consequence of ) Days Hours Antecedent cause (b) ................................ Years Months (due to or as consequence of ) days hours Morbid conditions, if any, (c) ................................ Years Months giving rise to the above cause, days hours stating the underlying condition last 2. Other significant conditions …………………………………… Years Months contributing to the death but not .....……………………………….. days hours related to the disease or condition causing it. Address or rubber stamp of the institution Signature, designation, degree and registration number.
  27. 27. Tests for death: 1.For stoppage of function of NS Look for movement -No movement Look for response-No response to stimulus Look for jerk-No jerks Look for reflex-No reflex Confirmation by EEG. 2.For Stoppage of respiration Inspection , palpation & auscultation for respiration–repeated for at least 5 min. Feather test –Feather/cotton –Nose -Movement Mirror test –Mirror –Nose/Mouth -Hazy Winslow‟s test –Water bowl –Chest –Light reflection 3.For stoppage of circulation Inspection, palpation & auscultation for HS–repeated for at least 5 minutes. Detection of pulse & BP : absent Icard‟stest -1 ml of 20% alkaline fluorescein S/C –Colourchange spread Ligature test(Magnusstest) –Ligature –Finger –Swollen & Bluish Finger web inspection (Diaphanous test) –Hand –Light –Pinkish & translucent / Yellowish & opaque. By applying heat –Skin –Hot Object –Blister & redness. Confirmation by ECG. Earliest & surest sign of death : Segmentation/trucking of blood column in the retinal blood vesceles–by opthalmoscope.
  28. 28. Suspended Animation/Apparent Death/Death Trance/Catalepsy: Death trance is a condition in which all the signs of life or vitality are seemed to be absent although the individual still remains alive. It is a condition , wherein the vital functions of body (heart beat and respiration) are maintained at a low pitch reduced to a minimum for sometime, that they could not be detected by routine methods of clinical examination.
  29. 29. Suspended Animation/Apparent Death/Death Trance/Catalepsy: (1) It is the condition in which all signs of life or vitality are seemed to be absent although the individual still remains alive. (2) The person appears to be dead because of very feeble or minimum function of his body systems. (3) The function of circulatory , respiratory or nervous system may not be perceived by conventional method though the person is still alive. (4) The function of these system may return after sometime by proper resuscitaion. (5) Such a death like state is known as suspended animation. Actually the circulation do not completely stop but is maintained in minimum.
  30. 30. Causes of Suspended Animation/Apparent Death/Death Trance Voluntary-Yoga practicing. Involuntary- 1. Newborn infants 2. Drowning 3. Electrocution 4. Thunder injury 5. Sever diarrhea/Cholera 6. Poisoning 7. Anesthesia 8. Shock 9. Sun-stroke 10. Snake bite 11. Epilepsy 12. Head injury 13. Sever narcosis
  31. 31. Test to avoid death trance 1. Repeated auscultation over a period longer then 5 minutes. 2. E.C.G. 3. E.E.G. 4. Demonstration of rectal temp. <75 F 5. Ophthalmoscopy should be done routinely and is confirmed by detecting segmentation of blood column in retinal vessel.
  32. 32. Medico legal importance of Suspended Animation 1.It can lead error if precautions are not taken. 2.Confusion may lead to issue of a dead certificate for a live person 3.An alive person may be sent to mortuary. 4.Premature burial / funeral. 5.May create professional problems for doctor. 6.May create social/public agitation/problems.
  33. 33. Natural death Natural death means death occurring due to natural disease or pathological condition or old age , debility in which death is not intended or attempted and also does not occur accidentally.
  34. 34. Unexpected and Sudden Death Definition: Death is biologically, legally, and literally an absolute and irreversible event. WHO Definition: Who dies within 24 hours of symptoms appearing. Forensic Definition: Who dies in minutes or even seconds of the onset of the symptoms.
  35. 35. Sudden death Sudden death may be defined as a death which occur suddenly or unexpectedly when a person not known to have been suffering from any dangerous disease, injury or poisoning is found dead or dies within 24hours after the onset of terminal illness. The incidence is approximately 10 percent of all deaths. Death may be delayed in a survivor of cardiac arrest, but "survival after cardiac sudden death” is an irrational term. Currently the accepted definition (SCD) is natural death due to cardiac causes, heralded by abrupt loss of consciousness within 1 hour of the onset of acute symptoms.
  36. 36. Causes Of Sudden Death: Where a natural death is very rapid, perhaps virtually instantaneous,thecauses are as follows--- (I) Diseases of Cardiovascular system(40-50%): Sudden Cardiac Death (SCD) SCD must be carefully defined. In the context of time, “Sudden” is defined, for most clinical and epidemiologic Purposes ,as one hour or less between the onset of the terminal clinical event , or an abrupt change in clinical status, and death. A exception is unwitnessed deaths in which pathologists may expand the definition of time to 24 hour after the victim was last seen to be alive an stable.
  37. 37. (I) Diseases of Cardiovascular system(40-50%): 1.Coronary Artery Disease:(Narrowing and obliteration of the lumen by atherosclerosis.) 2.Coronary Atherosclerosis with coronary thrombosis. 3.Coronary Atherosclerosis with hemorrhage in the wall causing occlusion of the lumen. 4.Coronary Artery embolism. 5.Occlusion of the ostium of the coronary artery associated with Atherosclerosis or syphilitic aortitis. 6.Arterial hypertension with atherosclerosis. 7.Rupture of the fresh Myocardial Infarction. 8. Spontaneous Rupture of the aorta. 9.Angina Pectoris. 10.Pulmonary Embolism. 11.Systemic embolism occurring in bacterial endocarditis. 12.Rupture of aortic aneurysm or other aneurysm like circle of Willis. 13.Cardiomyopathies. 14.Lesions of the conducting system: fibrosis, necrosis 15.Valvular lesions: aortic stenosis/regurgitation, mitral stenosis, rupture of chordae, ball-valve thrombosis. 16. Fatty degeneration of heart 17.Acute Endocarditis. 18.Acute Myocarditis. 19.Acute Pericarditis. 20.Congenital Heart disease of new born.
  38. 38. (II) Diseases of Respiratory system(15-23%): 1.Lobar pneumonia. 2.Bronchitis and bronchopneumonia. 3.Rupture of blood vessels in pulmonary tuberculosis with cavitation. 4.Pulmonary embolism and infarction. 5.Air Embolism 6. Influenza 7.Diptheria 8.Acute edema of the glottis. 9. Acute edema of the lung. 10.Lung abscess. 11.Massive collapse of the lung. 12.Pleural effusion. 13.Pneumothorax caused by rupture of emphysematous bleb. 14.Neoplasm of bronchus 15.Bronchial asthma 16.Impaction of foreign in the larynx and regurgitation of stomach contents into air passages and bronchioles.
  39. 39. (III) Diseases of Central Nervous system(10-18%): 1.Cerebral hemorrhage. 2.Cerebellar hemorrhage. 3.Pontine hemorrhage. 4.Subarachnoid hemorrhage. 5.Cerebral thrombosis and embolism. 6.Carotid artery thrombosis and embolism. 7.Brain abscess. 8.Brain tumor. 9.Meningitis. 10.Acute encephalitis. 11.Cysts of third or fourth ventricle 12.Epilepsy.
  40. 40. (IV) Diseases of Alimentary system(6-8%): 1.Haemorrhage into the gastrointestinal tract from peptic ulcer, esophageal varices, cancer esophagus etc. 2.Perforation of ulcers, e.g. peptic, typhoid, amoebic or malignant. 3.Acute hemorrhagic pancreatitis. 4.Strangulated hernia. 5.Twisting and intussusception of the bowel. 6.Paralytic ileus. 7.Appendicitis. 8.Bursting of the liver abscess. 9.Rupturede of enlarged spleen. 10.Intestinal obstruction. 11.Obstructive cholecystitis.
  41. 41. (V) Diseases of Genito-urinary system(3-5% ): 1.Chronitic Nephritis. 2.Nephrolithiasis. 3.Obstructive hydronephrosis and pyonephrosis. 4.TB of kidney. 5.Tumours of kidney and Bladder. 6.Rupture of ectopic pregnancy. 7.Toxaemia of pregnancy. 8.Uterine hemorrhage due to fibroids. 9.Cancer vulva eroding femoral vessel. 10.Twisting of ovary or ovarian cyst or fibroid tumour.
  42. 42. (VI) Miscellaneous(5 -10% ): 1.Addison‟s disease. 2.Diabetes Mellitus. 3.Haemochromatosis 4.Hyperthyroidism 5.Cerebral malaria. 6.Shock due to emotional excitement. 7.Reflex vagal inhibition. 8.Anaphylaxis due to drugs. 9.Mismatched blood transfusion.
  43. 43. Medico-legal Significance In cases of sudden death, it is usually not possible to certify the cause of death from an external examination of the body. In all such cases, an autopsy is necessary to obviate the possibility of unnatural death. A doctor who issues a death certificate in such a case runs the risk of being accused as an accessory to a crime and obstructing the course of justice, should the death be found eventually due to foul play.
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Death in Forensic Medicine

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