Sudden Death and Apparent Death | Presumption of Survivorship and Death | Premature Burial | Anesthetic and Operative death| Custodial death|

            Death            

 Natural death: It may be defined that the death was caused entirely by the disease, pathological condition, old age, debility or devitalization & the trauma or poison did not play any part in bringing it about. 

Sudden death: Death is said to be sudden or unexpected when a person not known to have been suffering from any dangerous disease, injury or poisoning is found dead or dies within 24 hrs after the onset of terminal illness (WHO). 

Note: The incidence of sudden death is approximately 10% of all deaths. 

Causes of sudden death: 

A) Cardiovascular causes (40-50%): -

1. Myocardial infarction
2. Angina pectoris.
3. Arterial hypertension with atherosclerosis.
4. Coronary artery embolism.
5. Pulmonary embolism 
6. Cardiac myopathies.

B) Respiratory causes (15-23%): -

1. Pulmonary embolism and infraction.
2. Lobar pneumonia.
3. Air embolism
4. Massive collapse of the lung
5. Bronchial asthma
6. Pleural effusion

C) CNS causes (10-18%): -

1. Cerebral hemorrhage 
2. Cerebral Infraction 
3. Cerebellar hemorrhage
4. Pontine hemorrhage
5. Brain abscess, brain tumors.
6. Meningitis, encephalitis.

D) Gastrointestinal causes (6-8%): -

1. Perforation of ulcers e.g. peptic, typhoid, amoebic or malignant.
2. Acute Appendicitis, 
3. Acute hemorrhagic pancreatitis.
4. Strangulated hernia, bursting of the liver
5. Abscess, Rupture of enlarged spleen
6. Intestinal obstruction

'E) Genitor-urinary cause (3-5%): -

1. Chronic nephritis
2. Nephrolithiasis
3. Tuberculosis of the kidney
4. Tumors of the kidney or bladder
5. Rupture of an ectopic pregnancy 
6. Toxemia of pregnancy. 

F) Miscellaneous cause (5-10%)

1. Diabetes mellitus
2. Addisons disease
3. Hyperthyroidism 
4. Blood Dyscrasias
5. Cerebral malaria
6. Reflex vagal inhibition

Possible causes of death: 

🔷Poisoning by traveler's poisons or any other homicidal poisons, e.g., datura, cannabis indica. 

🔷Snake bite poisoning. 

🔷Suicidal (OPC) 

🔷Terrorist attack/Crossfire. 

🔷Electrocution /injury by electric shock 

🔷Lightening

Diagnosis of death: 

💥To detect stoppage of circulation: -

1. Absence of pulse- Radial, carotid & popliteal on palpation.
2. Absence of heartbeat on palpation & auscultation.
3. Absence of heart sound after continuous period of 5 minutes, or more by repeated exam.
4. E.C.G. - Flat on maximum sensitivity.
5. B.P. - non-recordable.
6. Tests- 

• Ligature test/Magnus test.
• Icard's test. 
• Fingernail test
• Heat test 
• Cut test.

💥To detect stoppage of respiration: -

1. Inspection- Absence of respiration by careful inspection of the chest & abdominal movement (Observed for >10 minutes). 
2. Palpation: Respiratory movement cannot be appreciated
3. Auscultation- Absence of breath sound mainly in trachea &  larynx for 3-5 minutes.
4. Tests- 

• Mirror test. 
• Winslow's test. 
• Feather test. 

💥To detect stoppage of nervous system: -

1. Superficial & deep reflex will be absent.
2. loss of motor function, loss of sensory function 

💥Surest signs: -

1. Putrefaction.
2. Adipocere formation 
3. Mummification. 

Presumption of death:

 Presumption of death: This is a legal issue which, strictly speaking does not have any medical implication or involvement. It is in connection with inheritance or succession of property of a person, missing for a long period. 

Explanation: A person is presumed to be alive, if there is nothing to suggest the probability of death within 30 yrs. But if proof is produced that the same person has not been heard for seven yrs by his friends & relatives, death is presumed. There is no legal presumption that the person dies at any particular time during the 7 yrs. The burden to prove that the person is alive lies with the person who claims so. 

Legal importance: The question of presumption of death arises in the following cases- 

1. Inheritance of property. 
2. Obtaining of insurance of money. 
3. Person serving in armed forces reported missing.
4. When a particular person has gone abroad & has not been heard for a considerable time or when he is alleged to have been dead & the body is not found. 

Contact pallor: 

Contact pallor: After death, the areas of the body which remain in contact with the ground, become flat & the blood from vessels of these areas are pressed out, as a result post-mortem staining does not develop in these areas. This is called contact pallor. 

Medico-legal importance: Position of the body after death can be known. 

Apparent death: -

Apparent death is also known as: -

Death trance/suspended animation/Apparent death/Catalepsy: 

The vital signs of life or vitality such as heartbeat and respiration on routine clinical method detection, are seemed to be absent but the person remains still alive, which can be detected by repeated auscultation, ECG or EEG, this condition in known as Catalepsy.

Or, 

Apparent death is defined as the condition in which a person seems to be apparently death because of interruption or minimum function of 3 vital systems (nervous, circulatory, nervous). Although the individual is still alive which can be detected by repeated auscultation, ECG, EEG.

Medico-legal importance: 

1. It may be confused with death & the doctor may give a death certificate.
2. If precautions are not taken an alive person may be died. 
3. An actual death may be confused with suspended animation
4. Providing proper treatment/ resuscitation may be delayed.
5. An alive may be sent to the mortuary for autopsy.
6. Living person may be buried. 

Apparent death is of two types: -

1. Voluntary Suspended animation: Here the persons practiced in voluntary, For example Yogis or Sadhu's or Sanyasi may practice this method.
2. Involuntary Suspended animation: - Here the person lands in apparent death spontaneously.

Example: -

• Newborn
• Shock
• Diarrhea
• Cholera
• Poisoning
• Anesthetic shock 
• Heat stroke / Sun stroke
• Snake bite
• Hypothermia
• Hypoglycemia

Cause of Suspended animation/Apparent death: -

• Yogi
• Trance suspended
• Cataplexy
• Hysteria
• Drowning
• Frozen comma
• Anesthesia

Coma: -

Coma: It may be defined as the loss of consciousness which may be partial or complete depending on the degree of involvement of the central nervous system. 

Causes: 

1. Compression of the brain due to subdural or extradural hemorrhage.
2. Depressed fracture of skull.
3. Brain abscess.
4. Brain tumor.
5. Cerebral embolism 
6. Heat strock

Signs-symptoms: 

1. Patient is not responding to pain, touch or any other external stimuli.
2. Loss of reflexes.
3. Relaxation of the sphincter. 
4. Pulse- Slow. 

Syncope: 

It may be defined as the sudden stoppage of the action of heart leading to death. 

Causes:

1. Severe anemia due to
2. Acute hemorrhage. Rupture of great blood vessels or organs. 
3. Asthenia due to deficient power of heart muscle. 
4. Fatty degeneration of heart.
5. MI. 
6. Aortic regurgitation.
7. Shock due to vagal inhibition.
8. Drinking of large quantity of cold water when overheated.
9. Sudden evacuation of natural or pathological fluid. 
10. Diseases, e.g. malaria, dysentery, enteric fever. 

Signs-symptoms: 

1. Pallor of the face.
2. Dilatation of pupils.
3. Cold, clammy skin.
4. Restlessness.
5. Noise in the ears.
6. Pulse- Slow & weak. 
7. BP falls & ultimately proceeds to death.

Presumption of Survivorship:

The question of presumption of survivorship may arise in connection with inheritance of property, when two or more persons, natural heirs of each other, die in a common disaster, e.g., earthquake, plane-crash accident, etc. the question may arise as to who survived longest, & if no direct evidence on this is available, the question becomes one of presumption. 

Explanation / Example: -

A family of a father & his two sons, the elder of whom is a married man & if in a train accident the father & the elder son die. If the father died earlier, then, even for a few minutes the elder son became the natural successor of his father's property & on the basis of his successive death his wife should get the property. But if the elder son has died earlier than the father, the father had only one living successor of his property i.e., his younger son. He will enjoy the property & not the wife of the elder son.

Brugada syndrome 

Brugada syndrome: - It is a disorder characterized by sudden nocturnal death of an apparently healthy young person with no History of any disease/drug abuse, and the findings at Autopsy are those of asphyxia. In this syndrome, there is mutation in SCN5A gene which makes the person prone to develop a range of arrhythmias and death occurs in deep due to ventricular fibrillation There has been extensive study in Japan and the Philippines on this sudden nocturnal death syndrome. In Northeastern part of India, such cases are frequently found particularly in people of Mongoloid origin.

Custodial Death 

It may be defined as death of a person which in the custody of police or judice or authority.

Type or Example: -

🔷During Arrest: -

1. Traumatic asphyxia
2. Hog tying
3. Chock or Carotid holds

🔷After death: -

1. Suicide in custody/lockup
2. Death due to torture

Anesthetic Deaths: -

Death may be: - 

• During anesthesia 
• Post-anesthetic death 

A) Death occurring during administration of anesthesia but not due to anesthesia 

The causes may be various such as: -

1. Death due to injury or disease for which the operation is being done. The injury or disease may be serious and cause death.
2. Death may be due to disease or disorder other than that for which operation is being done 
3. Death may be due to surgical procedure or surgical complications, for example 

• Accidental cutting of large blood vessel 
• Stock 
• Incompatible blood transfusion. 

B) Deaths as a direct result of administration of anesthesia The causes are 

1. Death due to respiratory failure/respiratory depression 
2. Airway obstruction 
3. Pneumothorax 
4. Aspiration of gastric contents 
5. Hypovolemia 
6. Cardiac arrhythmias 
7. Equipment failure 
8. Overdose of anesthetic agent 
9. Antibiotic misadventure
10. Inexperience 
11. Monitoring and vigilance failure 
12. Malignant hyperthermia.
13. Drug-induced reactions to anesthetics 
14. Adverse drug reaction. 

DEATH DUE TO SURGICAL PROCEDURE / OPERATIVE DEATH: -

Death due to surgical procedures are grouped as: 

A. Death occurring during operation 

1. Death due to anesthetic agents 
2. Death due to injury or disease for which the operation is being done 
3. Death may be due to disease or disorder other than that for which operation is being undertaken 
4. Death due to surgical procedure or occurring complication
5. Technical mishaps, eg explosion from electrocautry.

B. Post-operative deaths: -

1. Delayed hemorrhage 
2. Pulmonary embolism 
3. Nosocomial infections 
4. Surgical complication 
5. Failure of artificial devices kept in body. 

Premature Burial 

In the context of forensic medicine, premature burial, also known as live burial or vivisepulture, refers to the situation where an individual is buried while still alive, often due to a misdiagnosis of death or mistaken circumstances. 

Definition: -

• Premature burial, or live burial, occurs when a living person is unknowingly buried before they have truly died. 

Causes: 

• The reasons for premature burial can vary, including Medical Misdiagnosis: An individual in a coma, vegetative state, or experiencing a similar condition may be erroneously pronounced dead. 
• Misunderstanding or Error: In some cases, individuals have been mistakenly buried due to a lack of accurate death determination or due to accidents. 

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