WELCOME TO THE WORLD OF FORENSIC MEDICINE

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WELCOME TO THE WORLD OF FORENSIC MEDICINE

• Marie Cassidy
• Professor of Forensic Medicine and
• State pathologist

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FORENSIC MEDICINE

• THE BRANCH OF MEDICINE THAT APPLIES THE
  PRINCIPLES AND KNOWLEDGE OF THE MEDICAL SCIENCES
  TO PROBLEMS IN THE FIELD OF LAW

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FORENSIC MEDICINE/PATHOLOGY

• Scientific investigation of the cause of injury
  and death in unexplained circumstances
  particularly when criminal activity is suspected

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FORENSIC SPECIALISTS

• Forensic pathologist
• forensic pathologist/neuropathologist
• G.P.
• Police surgeon
• Accident and emergency doctor
• Forensic physician
• Paediatricians
• Forensic Psychiatrist

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FORENSIC SPECIALISTS

• Forensic pathologist - suspicious deaths
• forensic pathologist- nonsuspicious deaths
• Neuropathologist head injuries, brain damage
• G.P.- injured or deceased patients
• Police surgeon-prisoner, drink driver, victim
• Accident and emergency doctor - injured
• Forensic physician - a/a, sexual crimes
• Paediatricians- any abnormality in children
• Forensic Psychiatrist- prisoners

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FORENSIC EXAMINATIONS

• WOUNDS AND INJURIES
• SEXUAL ASSAULTS
• CHILDREN
• SCENE OF DEATH
• DETERMINATION OF DEATH
• CAUSE OF DEATH
• POSTMORTEM EXAMINATIONS
• COURT TESTIMONY AND REPORTS

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INVESTIGATION OF DEATHS

• To determine the cause and the manner of death
• To identify the deceased if unknown
• To determine the time of death and injury
• To collect evidence from the body that can be
  used to prove or disprove an individuals guilt
  or innocence and to confirm or deny the account
  of how the death occurred

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INVESTIGATION OF DEATHS

• To document injuries or lack of them
• To deduce how the injuries occurred
• To document any natural disease present
• To determine or exclude other contributory or
  causative factors to the death
• To provide expert testimony if the case goes to
  trial
  Forensic pathology, DiMaio

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DEALING WITH DEATH

• The doctor and death

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The dead patient

• History
• Examination
• Diagnosis of death

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Definition of DEATH

• CESSATION OF LIFE IN A PREVIOUSLY VIABLE ORGANISM

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DEATH

• A DOCTOR MUST DECLARE DEATH
• ?duty of care to determine death

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DEATH

• Somatic death
• Molecular death
• Brain death
• Brain stem death
• NO law defines death

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SOMATIC DEATH

• 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

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Somatic death

• 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

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Somatic death

• Auscultate for 4 to 5 minutes
• D.D. shock, hypothermia, electrocution,
  depressant drugs

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MOLECULAR DEATH

• 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

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BRAIN DEATH

• CORTEX
• BRAIN STEM
• WHOLE BRAIN

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BRAIN DEATH

• CORTICAL brain death
• deep coma
• brain stem functioning

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BRAIN DEATH

• 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

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BRAIN DEATH

• 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

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BRAIN DEATH

• Severe irreversible cortical damage
• Brain stem damage
• WHOLE BRAIN DEATH
• Beating heart donor

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Brain stem death tests

• 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. Dolls eye phenomenon
• 6. No vestibulo-ocular reflexes
• 7. Persistent apnoea when ventilator disconnected

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Cause of Death
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Cause of death

• 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

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THANATOLOGY

• SUDDEN NATURAL DEATH

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Sudden Death

• Deaths at home
• Deaths in hospital
• Death outside
• Death in unusual circumstances place, position,
  appearance of body

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Sudden Death

• G.P. or Hospital doctor
• Medical history
• Treatment for recent illness
• Other information

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Sudden Death

• Natural death
• Accident
• Suicide
• Homicide

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Sudden Death

• Age
• Children
• Teenager/young adult
• Adult
• Elderly

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Sudden Death

• Children
• Stillbirths
• Congenital abnormalities
• Sudden infant death syndrome
• Tumours

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Sudden Death

• Young adults
• Suicide
• Accidents - RTAs
• Homicides
• Natural

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Sudden Death

• Adults
• Natural
• Accidents - RTAs
• Homicides
• Suicides

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Sudden Natural DeathIn the developing world
sudden cardiac death remains the major cause of
death

• Adults and elderly
• Cardiovascular disease
• Cancer

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SUDDEN NATURAL DEATH- cardiac causes

• CORONARY ARTERY DISEASE, ischaemic heart disease,
  atheroma, thrombosis, dissection, bridging,
  acute MI, cardiac tamponade, stress associated
• HYPERTENSIVE HEART DISEASE, acute LVF, arrythmia
• CARDIOMYOPATHY, dilated/congestive, hypertrophic
  (commonest genetic cause of sudden death),
  genetic
• VALVULAR HEART DISEASE, floppy mitral valve,
  aortic valve stenosis

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SUDDEN NATURAL DEATH

• MYOCARDITIS
• AORTIC DISSECTION - hypertension/heredity/inflamma
  tion, Marfans
• Arrhythmogenic Right Ventricular Dysplasia
  genetic MRI 20 sudden cardiac deaths
  cardioverter/defibrillator
• RUPTURE OF AORTIC ANEURYSM

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SUDDEN NATURAL DEATH

• PHYSIOLOGICAL
• Wolff-Parkinson-White,
• long QT syndrome, ion channelopathy congenital
  (inherited as a dominant gene) or acquired
  (antipsychotic/antiarrhythmic/allergy drugs,
  electrolytes, toxins, hypothermia, anorexia
  nervosa, dieting with liquid protein diets)

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SUDDEN NATURAL DEATH-CNS causes

• EPILEPSY - SUDEp
• SUBARACHNOID HAEMORRHAGE - berry aneurysms
• INTRACEREBRAL HAEMORRHAGE- hypertension
• INTRACRANIAL PATHOLOGY ASSOCIATED WITH ACUTE
  HYDROCEPHALUS OR EPILEPSY - tumours,meningitis

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SUDDEN NATURAL DEATH

• PSYCHIATRIC PATIENTS,
• Schizophrenics /- phenothiazine,
• Neuroleptic malignant syndrome

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SUDDEN NATURAL DEATH

• EPIGLOTTITIS
• PULMONARY THROMBOEMBOLISM
• ASTHMA
• HAEMOPTYSIS, T.B., tumour
• SPONTANEOUS PNEUMOTHORAX OF THE NEWBORN

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SUDDEN NATURAL DEATH

• HAEMATEMESIS, rupture of oesophageal varices,
  duodenal ulcer
• CHRONIC ALCOHOLICS, acute fatty degeneration of
  the liver
• ADRENAL HAEMORRHAGE, septicaemia

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SUDDEN NATURAL DEATH other causes

• AIR EMBOLISM
• FAT EMBOLISM
• AMNIOTIC FLUID EMBOLISM
• Ruptured ectopic pregnancy
• Toxic shock syndrome
• Sudden death in Diabetes IHD, CM, hypo or
  hyperglycaemia
• Sudden death in alcohol
• Commotio cordis

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Sudden death

• Sudden adult death syndrome
• SADS
• Sudden Arrhythmic Disease Syndrome

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Sudden Death

• The negative autopsy

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SADS

• Sudden unexpected death in an adult
• no signs or symptoms prior to death
• postmortem shows no anatomical cause of death
• specialised pathology examinations negative e.g.
  neuropathology
• toxicology negative
• bacteriology etc. negative
• presumed cardiac dysrrhythmia

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SADS

• Now agreed to be due to
• acute onset of a chaotic rhythm in the heart

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SADS

• Risk factors include
• A family history of unexplained sudden death in a
  relative under 40years
• Unexplained fainting in young people
• Approx 1000 cases/year in UK

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SADS

• Differential Diagnosis
• ARVD abnormal ECG, anatomical changes may not
  be obvious at postmortem 30-50 have a family
  history
• Disorders of the Ion Channel Long QT syndromes,
  Brugada Syndrome (south east Asia),
  Catecholaminergic Polymorphic Ventricular
  Tachycardia (AD Finland and Italy)

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SADS

• Treatment
• Defibrillation
• Implantable defibrillator

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Sudden adult death

• Sudden death during sporting activities

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Sudden death in sport

• Males gt females
• USA - 1 133,000 males
• USA - 1 800,000 females
• usually underlying, undiagnosed congenital heart
  disease
• cardiomyopathy most common
• anomalous coronary circulation
• viral myocarditis
• gt 40 years - coronary artery disease

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Child Deaths

• 50 due to Natural causes
• Genetic or congenital disorder
• Cot death - SIDS
• Infections
• Neoplasms
• CNS disorders
• U.K - risk of abnormal baby
  140

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Child Deaths

• 50 of Neonatal deaths occur in first
• 2 days
• Prematurity
• Hypoxia
• Congenital Abnormality
• Birth Injury
• Still Birth

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S.I.D.S

• (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

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S.I.D.S

• Features
• Age - 2 weeks to 2 years
• few after 9 months
• malegtfemale
• Time - during sleep
• 80 found dead by 6am
• weekendsgtweekdays
• COLDER months

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S.I.D.S

• Features
• Prematurity
• low birth weight
• twins
• urbangtcountry
• Lower social classes
• Poor social classes
• Young mothers/single parent/smoker

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Theories

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

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Theories

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

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