LEGAL MEDICINE Notes: BRAIN DEATH DEATH CERTIFICATE

BRAIN DEATH
- is the complete and irreversible loss of brain function (including involuntary activity necessary
to sustain life).
- follows Clinical Death
- prevented by resuscitative procedures

*Human brain CANNOT (under normal circumstances) survive without oxygen loss for less than 8 10 minutes.

STAGES OF BRAIN DEATH:

1. CEREBRAL CORTEX
- Highest center
- Most sensitive to changes in supply of oxygen and blood
- When C.E. dies: Cortical Death

2. CEREBELLUM
- the older part developmentality
- function: equilibrium
- follows Cortical Death

3. BRAIN STEM and VITAL CENTERS

- Controls: (1) respiration, (2) heart rate, (3) blood pressure
- When it dies: Brain Stem Death; equivalent to Legal Death
- Medulla (destroyed): failure of respiratory center
- Ascending Reticular Activating System (damaged): permanent loss of consciousness

CRITERIA FOR DIAGNOSING BRAIN DEATH

1. Patient must be in deep coma (not caused by drugs, etc.)
2. Patient must be on artificial respirator
3. A defensable diagnosis must be available due to irremediable brain damage.
4. Diagnostic test for brain stem damage must be unequivocally POSITIVE as determined by two (2) doctors.

PREVENTIVE VEGETATIVE STATE (PVS)

- (1) Irreversible destruction of the Cortex occurs without damage to the vital centers, and (2)
permanent eyes-open state of unconsciousness
- Cardio-respiratory functions continue (w/ or w/out respiratory support)
- Irreversible loss of all neocortical function
- Have (1) elicitable reflexes, (2) spontaneous respiratons and (3) reactions to external stimuli.

HARVARD CRITERIA OF WHOLE BRAIN DEATH

1. Unreceptivity and Unresponivity
- Total unawareness and complete unresponsiveness
2. No spontaneous movements or breathing
- Absence of all spontaneous muscular movement
3. No reflexes
- Lack of eye movement; Lack of response to noxious stimuli
4. Flat Electroencephalogram (EEG) of Confirmatory Value
- NEUROLOGISTS:
two (2) clinical examinations of six (6) hours apart with absent pupillary light reflex and also
absent corneal reflex, CONFIRMS DEATH.
- HARVARD STANDARD:
Above findings be confirmed by tow EEGs taken at least 24 hours apart.

WHOLE BRAIN DAMAGE = CORTICAL DEATH + BRAIN STEM DEATH

WHOLE BRAIN DEAD:
- Brain ceased all functions, even though the heart continues to beat.
- Doctors can legally declare whole brain dead:
(a) 12 hours after they have corrected all treatable medical problems
(b) Brain doesnt respond to pain
(c) Eyes do not react to the light
(d) Person does not breathe without respirator
 LEGAL MEDICINE Notes: BRAIN DEATH DEATH CERTIFICATE
BIOLOGICAL DEATH
- All components of the brain are dead.
- Permanent extinction of bodily life
- Cardio respiratory death + Brain death
- It is so clear and manifest to the naked eye of an ordinary layman, he can testify with
certainty that death has in fact occurred.
CELLULAR DEATH
- Permanent cessation of cellular function
- Sever swelling of the cell mitochondria, extensive damage to plasma membranes, and selling
of the cell iysosomes.
- Cessation of respiration and metabolism of the tissues; followed by autolysis and decay.

In the sequence of dying, there comes a point of irreversibility, which physicians diagnose as death. When the
point is reached, nothing more can be done to bring the person back to life.

SIGNS OF DEATH:
1. Cessation of heart and circulation
2. Cessation of respiration
3. Cooling of the body (Algor Mortis)
Post mortem caforicity is the rise of temperature of the body after death to rapid and early putrefactive changes or
some internal changes.
4. Loss of motor power
5. Loss of sensory power
6. Changes in the skin
- Pale and waxy
- Loss of elasticity, opacity, and no inflammatory reaction of the skin on the application of heat.
7. Changes in and about the eye
- Loss of corneal reflex, clouding of the cornea, ftaccidity of the eyeball, the optic disc shows
atrophy and a black spot may be found in the cornea.
Tache noir de la sclerotique is an oval or triangular spot with the base towards the cornea appearing in the sclera
a few hours after death.

CHANGING IN THE BODY FOLLOWING DEATH:

1. Changes in the Muscle
a. Stage of primary flaccidity
- Pupils are dilated, sphincters relaxed, with incontinence in urination and defecation.
b. Cadaveric rigidity or Rigor mortis
- The whole body becomes rigid due to muscular contraction which develops 3-6 hours after
death and may last for 24 hours.
- Rigor Mortis may also be utitlized to approximate the length of time the body has been dead
from three to thirty six hours.
c. Stage of Secondary flaccidity or commencement of putrefaction
- The muscles are no longer capable of responding to mechanical or electrical stimulus.

Cadaveric Spasm
- The immediate or instantaneous spasm or rigidity of the skeletal muscles occurring the
moment of death due to exhaustion, nervous tension or stress, fear, anger, or injury to the
motor nerves or injury to the chest.
- It may not always happen
- IMPORTANCE:
a. In suicide, or accidental death to the deceased himself, the gun or weapon used to kill
himself, may still be held in the hand of the deceased and can only be removed with
difficulty.
b. The presence of wood or any floating material in the hands of the dead in the water, may
show that the victim was still alive before he ultimately died in the water.

2. Changes in the Blood:

a. Coagulation of the Blood
 LEGAL MEDICINE Notes: BRAIN DEATH DEATH CERTIFICATE
- There may be Disseminated Intravascular Coagulatory in cases of death due to infectious
diseases or septicemia.
- Blood may remain fluid inside the blood vessels for 6 to 8 hours.

b. Postmortem lividity (Livor Mortis or post mortem Suggillation)

- Occurs in the most dependent areas (also in internal organs like lungs, intestines and brain)
and for 3 to 6 hours after death
- After clotting has occurred or the blood has substantially diffused into the body tissues, a
change in the position of the dead body will not alter the positon of post mortem lividity.
3. Autolytic or Auto digestive changes after death:
- After death, auto digestion of the glands and organs of the body happens.
4. Putrefaction of the body
- Breaking down of complex proteins
- Evolution of foul smelling gases
- Change of body color
- Liquefaction of eyeballs, brain, stomach, intestines, liver and spleen
- Distention of the abdomen with bloating of the body
- Eyes and tongue protrude
- Face blackens with thick lips
- Small bubbles are found in the visceral organs
- A very offensive, nauseating odor to the environment is produced
Marbolization
- Happens on the later part of putrefaction
- The prominence of the superficial veins among the dead with fair complexion

*Conditions in putrefaction are not constant. They might change depending upon the weather, the climate or temperature
in the area.

1. Within 12 hours
- Rigor Mortis is present all over the body. Hypostasis is well developed and fixed
2. Within 24 hours
- Abdomen is distended with gases. There is a greenish discoloration over the whole abdomen
spreading to the chest
3. Within 48
- Moving maggots are seen and ova of flies are present. The trunk is bloated, face discolored
and swollen with blisters.
4. Within 72 hours
- Whole body is grossly swollen and disfigured. The hair, nails and tissues are loose and
discolored
5. Within one week
- The soft viscera is putrefied
6. Within two weeks
- The soft tissues of the body are gone
7. Within one month
- The body becomes a skeleton. All bones
After burial, the following factors influence the changes occurring in the body:
1. When buried in a mass grave there is rapid composition of the body due to the multiplicity of different kinds of
bacteria.
2. Depth of the grave the deeper the grave, the slower the decomposition. Insects and animals may alter the
temperature frequently in shallow graves.
3. Time element the longer the time of exposure conducive to bacterial growth before burial, the faster the
decomposition.
4. Condition of the soil wet, muddy, dump soil accelerates decomposition
5. The presence of food and drinks accelerates decomposition
6. Intrusion of air access of air hastens mummification. Bacteria laden air, hastens decomposition
7. State of body an emaciated body at the time of burial, will decompose slower, compared with well-nourished
persons.
8. Traumatic death persons with violent deaths, decompose slowly, while septic death accelerates decomposition.
9. Coffin effect - If the coffin is airtight, there is delay of decomposition. If water leaks into the coffin, there is faster
decomposition. Burial in coffins have slower decomposition in general.
 LEGAL MEDICINE Notes: BRAIN DEATH DEATH CERTIFICATE
10. Presence of clothing there is delay in decomposition because clothing affords protection from insects and
bacteria

KINDS OF PUTREFACTION
1. MUMMIFICATION
- There is preservation of the body due to evaporation of body or tissue fluids.
- The natural physical appearance undergoes little changes
- The internal organs become also preserved

2. SAPONIFICATION (Adipocere Formation)

Adipocere is a waxy, rancid or moldy material that floats in water.
- Saponification delays body decomposition and makes the body greasy or oily to touch.

3. MACERATION
- Occurs when the body is found in liquid medium
- The body is either reddish or greenish depending on the liquid
- The body is with blisters and skin peelings
- Usually develops after 24 hours

FACTORS TO CONSIDER IN APPROXIMATING THE DURATION OF DEATH IN A CADAVER

1. ENTEMOLOGY of the fly
- The presence of maggots in the cadaver indicates a duration of death for more than 24 hours
2. Presence of live FLEAS in the clothing
- In death by drowning, a flea can survive 24 hours submerged in the water.
3. Blood vessel clots
- Occurs 8 6 hours after death
4. Post mortem lividity
- Develops 3 6 hours after death
5. Rigor Mortis
- Begins to develop in 3 6 hours; lasts for 24 48 hours
6. Onset of Decomposition
- Takes place within 24 48 hours
7. Food in the stomach
- Peristalsis starts within 10 minutes from entering the mouth
- Medium-sized Meal takes 3-4 hours to be completely moved out of the duodenum
- Liquids move faster
- Vegetables require more time
8. Skeletal soft tissues
- May disappear 1.5 to 2 years after burial.
- When exposed, faster

POSITION OF THE BODY AT THE TIME OF DEATH

1. Post mortem lividity
- Occurs in areas of the body in contact with a hard surface (e.g.floor).
- Change in the position of the body will not alter the location of the lividity when blood
coagulation has already developed or blood has already diffused into the body tissues
- IMPORTANCE: utilized to approximate the time of death; Muscular contractions occur from 3
until 36 hours.
2. Cadaveric spasm
- Death due to violence or inflicted physical injuries
- Drowning: due to holding unto objects
- Gunshot, suicide: grip on the gun
- These positions of the body can be of great significance in determining the relative positions
of the accused and the victim, immediately before a violent crash.
- IMPORTANCE: occurs after death; useful to ascertain the circumstances of death.

MEDICO LEGAL INVESTIGATION OF DEATH:

- Involves cases that are criminal, suspicious, accidental, suicidal, murderous, homicidal,
sudden and unexpected, or unexplained.
 LEGAL MEDICINE Notes: BRAIN DEATH DEATH CERTIFICATE
DEATH CERTIFICATE
- Legal document necessary for the burial of the dead
- Certifies the occurrence of death
- From the Office of the Civil Registrar General
- Indicates whether or not an autopsy was performed, embalmed and how the corpse was
disposed
Immediate/ Primary cause of death last series of events or chain of causes tending to a given result and which,
of itself, and without the intervention of any further cause, directly produces the result or event.
Antecedent Cause / causes of death events or conditions that substantially contribute the Immediate Cause of
death.
Under cause of death basic cause or bottom line cause of death. It is the diagnosis of the patients or victims
illness or sickness that resulted to his death.
Proximate cause of death legal cause of death. Is that cause that which in the natural and continuous
sequence, unbroken by without which the result would not have occurred.
Death Warrant warrant from the proper executive authority appointing the time and place for the execution of
the sentence of death upon a convict judicially condemned to suffer death.