Death and its medico legal aspect. brain death, somatic death, sudden death

1. Dr Kaleem Khan
Assistant Professor
GFIMSR

2. History
Examination
Diagnosis of death

3. CESSATION OF LIFE IN A PREVIOUSLY VIABLE
ORGANISM

4. Somatic death
Molecular death
Brain death
Brain stem death
 NO law defines death

5.  Failure of the body as an integrated system
 loss of circulation, respiration and
innervation
 for such a time impossible for life to return
 irreversible unconsciousness

6.  Heart stops
no pulse, no heart sounds, flat ECG,
segmentation of blood in retinal vessels
 Lungs stop
no breathing, no chest movement
 Brain activity stops
 muscles floppy
 metabolism stops, body cools down

7. Auscultation for 4 to 5 minutes
D.D. shock, hypothermia,
electrocution, depressant drugs

8.  Depends on susceptibility to oxygen deprivation
 Varies - important in organ harvesting
 Brain most susceptible, 3 to 7 minutes
 Wbcs may remain motile for up to 12hours
 Muscles respond to stimuli for few hours
 Skin viable for several days
 Importance - transplants

9.  CORTEX
 BRAIN STEM
 WHOLE BRAIN

10. CORTICAL (Brain Death)
 Deep coma
 Brain stem functioning

11. PERSISTANT VEGETATIVE STATE
 Functioning Brain Stem But Non Functioning
Higher Centres
 Respiratory Centres Functioning Do Not Require
Permanent Assisted Ventilation
 Require Parenteral Feeding
 If Heart Protected From Hypoxic Damage And
Nutrition Sustained, May Survive For Years

12. BRAINSTEM INJURY
 COMA due to damage to the ascending reticular
activating system
 Require assisted ventilation due to failure of
the respiratory motor system
 Beating heart

13. Severe irreversible cortical damage
+
Brain stem damage
WHOLE BRAIN DEATH
Beating heart donor

14. Three criteria to be fulfilled:
 Absent Cerebral Function
 Absent Brainstem Function
 Apnea
 Unreceptivity & unresponsivity
 No movements and breathing
 No reflexes
 An added confirmatory test was a flat or
isoelectric EEG

15. 1. Absent Pupillary response to light
2. Absent corneal reflex
3. No motor response within the cranial nerve
distribution and the limbs
4. Absent gag reflex
5. Doll’s eye phenomenon
6. No vestibulo-ocular reflexes
7. Persistent apnoea when ventilator disconnected

16.  Causes of irreversible Brainstem damage (eg.
hypoxia, trauma, illness, toxic insult etc.)
 Reversible causes to be excluded: intoxication,
depressant drug, ms relaxant, hypothermia,
hypovolemic shock, metabolic disturbances.
 Pt. must be examined twice with a gap of 6 hrs.

17. Disposal of body
Resuscitation
Transplantation:
Viability of different organs
 Liver -15min
 Kidney-45min
 Heart-1hr
 Cornea-6 hrs
 Skin-24hr
 Bone-48hrs
 blood vesseles-72hrs

18. COMA
SYNCOPE
ASPHYXIA

19.  Defn: Cessation of brain fn due to
irreversible damage to vital centers
Causes
 Raised intracranial pressure
 Poisons
 Metabolic disorders
 Autopsy findings:
 Edema and congestion of brain and its covering
membranes, signs of head injury

20.  Defn: Failure of heart fn leading to hypo-
perfusion and hypoxia
 Causes
 Heart disease
 Hemorrhages
 Pathological state of blood
 Exhaustive disease
 Poisons

21.  Reflex cardiac arrest due to (no
characteristic autopsy findings)
 vasovagal attack (e.g. throttling, blow to
epigastrium, abortion, sudden immersion body in
cold water, insertion of instruments into uterus,
bladder or rectum)
 Ventricular fibrillation (due spontaneous
sympathetic nervous discharge).
 Autopsy findings:
 Contracted heart with empty chambers, pale
viscera, and congested capillaries. Splanchnic
pooling of blood

22.  Defn: Interference with respiratory fn or
due to lack of O2 in respired air d/t which
organs and ts are deprived of O2 causing
death.
 Causes
 Pathological or diseased condition
 Decreased oxygen carrying capacity of blood
e.g. massive hemorrhage
 Decreased oxygen supply as in case of
poisonous gases
 Decreased inhalation capacity e.g. mechanical
interference in respiratory passage

23.  Autopsy findings:
 Cyanosis
 Pronounced lividity
 Petechial hemorrhage
 Visceral congestion
 Special signs or changes

24. “The pathologist is bound to rely in part on
what he/she is told of the events leading up
to death for functional lapses like fall in
blood pressure, cardiac arrythmia, spasm of
the glottis or vagal inhibition which leave no
trace at autopsy.”
Simpson

25. Natural death
Accident
Suicide
Homicide

26. (Cot Death)
The sudden death of any infant or young
child, which, from the case history, is
unexpected, and in which a thorough
postmortem examination fails to
demonstrate an adequate cause for the
death.
It is a diagnosis of exclusion

27. Features
Age - 2 weeks to 2 years
few after 9 months
male>female
Time - during sleep
80% found dead by 6am
weekends>weekdays
COLDER months

28. Features
Prematurity
low birth weight
twins
urban>country
Lower social classes
Poor social classes
Young mothers/single parent/smoker

29. Sleeping position
Over heating
pvc mattresses
sleep apnoea
viruses-cause or incidental
small size of larynx
trace metal deficiency
allergy to cow’s milk
abnormal nervous conducting system to heart
excess Na in feeds
overhead electric cables
nuclear power stations

30. Autopsy Findings
1. Nothing
2. Non- specific findings
froth at mouth
petechial haemorrhages
congestion of lungs
3. Manifest illness- NOT SIDS