SUDDEN DEATH

Yoni Syukriani
Department of Forensic and Legal Medicine
REFERENCE

Knights, Simpson’s Forensic Medicine, 13th ed.,

Arnolds, 2008.
OBJECTIVES

 To learn the concept of sudden death from

forensic and clinical point of views.
 To learn how to estimate unnatural causes of
death
 To learn the natural causes of death
 To learn when a death certificate can be issued
 To learn how to diagnose death
 To learn how to estimate time of death
DEFINITION OF DEATH ?

= Brainstem death

Indonesian Medical Association (SK PB IDI No. 336/PB/A.4/1988)

Do we need EEG to
diagnose death??
TYPES OF DEATH

Death is a process not an event, at the time of death

there is a progression from clinical death to brain
death, to somatic death, to cellular death.

1. Cardiac death
2. Clinical death
3. Somatic death
4. Brain death
5. Cellular death

So, what is sudden death?

SUDDEN DEATH

 WHO : someone who dies within 24 hours

of symptoms appearing.

 Forensics: different meaning

 Manner of death

 Mechanism of death
 MANNER OF DEATH

Natural Unnatural

Suicidal Accidental
Homicidal
WHY MANNER OF DEATH?

 Death certificate
Once the fact of death is established,
a death certificate is issued unless a
post-mortem examination is requested.
NATURAL CAUSES ???
 Heart attacks • Typically a person who
 Strokes dies of natural causes
 Fatal diseases has been under a
 Pneumonia doctors care.
 SIDS • However, some times
 Old age a death is made to
 Cancer look like it is from
 etc natural causes.
NATURAL CAUSES

 Cardiovascular causes

 Extra-cardiac causes
CARDIOVASCULAR CAUSES
 Coronary artery disease
 50% of cardiovascular deaths
 Above 30 y.o.
 Coronary insufficiency 
 Narrowing of the lumen  chronic ischaemia
 Hypoxic myocardium is electrically unstable
 No need for severe ischaemia for ventricle fibrillation.
 Complication of atheroma  stenosis
 Myocardial infarction
 Cardiac tamponade
 Old women
 2 or 3 days after the onset of infarction

 Hypertensive Heart Disease & Aortic stenosis

 Left ventricular hypertrophy  size
CAD: MECHANISM OF DEATH
Within seconds of coronary occlusion  PO4 hydrolyzed
 pH i [K+] h for 10’
 Resting membrane potential i
 Voltage difference btw resting membrane potential
and the threshold potential  speeding of
conduction
 Inhomogeneous conduction, slowing, block at the
lateral margin of the ischemic zone; endocardial
surface between the subendocardium,
midendocardium, and subepicardium;
 Conduction block
 Initial shortening of refractory period  lengthening
of the period
DISEASE OF THE ARTERIES
(EXTRA-CRANIAL OR INTRA-CRANIAL)

 Aneurysm

 Congenital or family history

 Young woman  dd/
 Complication of
pregnancy
 Pulmonary embolism
 History of internal pressure
(during delivery, high
pressure cough, fall)
 Mechanism: cathecolamine
release.
 Cerebral haemorrhage
 Cerebral thrombosis and infarction
MECHANISM OF DEATH
Infarct  injury
 [K+] extracell h
 nerotransmitter out, glutamic acid, aspartic acid
 Ca++ entering neuron
 [K+] extracell hh protease activation
 membrane & cytosceleton destruction
 Phospholipase C, aracidonic acid &
prostaglandin  radicals
 vascular & BBB destruction
 edema
 Cause of death
- Transtentorial herniation 48%
RESPIRATORY SYSTEM

 Vascular causes  thromboemboli

 Deep vein thrombosis following skeletal trauma
(fracture), operation, immobility or bed rest)

 Massive hemoptysis

 Fulminating chest infections

RESPIRATORY SYSTEM
THROMBOEMBOLI
GASTROINTESTINAL SYSTEM
 Perforation of peptic ulcer
 Acute pancreatitis
 Severe bleeding
GYNAECOLOGICAL CONDITIONS

Caution for cases involving woman in

childbearing age !

 Ruptured ectopic gestation

 Abortion
 Vagal shock, haemorrhage, infection
RUPTURED ECTOPIC GESTATION
ASTHMA AND EPILEPSY

Often for ‘no obvious’ reasons.

Epileptic patient :
 Accident
 Asphyxia

Asthmatic patient:
 Even no status asthmaticus nor severe periode
 Over-use of adrenergic drugs, especially by inhaler
HOW TO DIAGNOSE DEATH ?

Clinical examination, to confirm one or more of the following findings:

 Prolonged auscultation of the precordial  negative

 Feeling the radial, or the carotid pulse  negative
 Other signs of stoppage of circulation include an un-
recordable arterial blood pressure, and a flat ECG

1. Complete absence of light reflexes in the pupils

2. Cessation of respiration
3. Insensibility and absent sensory responses to stimuli
4. Loss of nerve reflexes and flat EEG.
5. Ophthalmoscopic examination of retinal vessels, shows
segmentation of the blood within them
HOW TO DIAGNOSE THE CAUSE OF DEATH ?

The cause of death can only be established

by a physician in:

1. Patient admitted to ER, or

2. Hospitalized patient, or
3. Autopsy (forensic or clinical autopsy)
 Time of Death

Can estimate time of death from:

• early changes after death (thanatology)
• insect action (forensic entomology)
• stomach contents (stage of digestion)
• last known activity (last sighting, newspaper/mail)
• normal postmortem changes
 Early Changes After Death

Can estimate time of death from:

• Rigor mortis

• Post mortem hypostasis

• Body temperature (algor mortis)

estimate: [98.6 oF – rectal temp]/1.5
TIME OF DEATH
Time since death: Change observed

1-2 hours: ......... Early signs of lividity.

2-5 hours: ........ Clear signs of lividity throughout body.
5-7 hours: ......... Rigor mortis begins in face.
8-12 hours: ....... Rigor mortis established throughout the body,
extending to arms and legs
12 hours: .......... Body has cooled to about 25oC internally.
20-24 hours: ..... Body has cooled to surrounding temperature.
24 hours: .......... Rigor mortis begins to disappear from the body
in roughly the same order as it appeared.
36 hours: .......... Rigor mortis has completely disappeared.
48 hours: .......... Body discolouration shows that decomposition is
beginning.
The End