Its cause, mode, mechanism

& manner
What is death ?
 It is the brain stem death promoting the
removal of vital organs and essentially
consists of :
 Deep unconsciousness ( no response
to external stimuli / internal need )
 No movements / spontaneous breathing
 Cessation of spontaneous cardiac rhythm
 No reflexes
 Bilateral dilation and fixation of pupils
 Flat isoelectric EEG
PROVIDED THAT...
The following features are present
 For a 24 hour period
 Patients body temperature is not below
32o Celsius
 Other metabolic & endocrine causes for
coma have been excluded
……. by two doctors
 The study of death is called thanatology
Its important to differentiate death from :

A ) stupor
patient appears asleep, responds only to vigorous
stimulation & then lapsing back to somnolence.

B ) vegetative state
patient is unaware of self & environment but has
stable circulation, respiration & cycles of eye
opening & closing. Its due to bilateral cerebral
damage with intact brainstem.
Confusing terminology
Examples...
 A person dies of coronary. A thrombosis

Significant
Coronary
MI resulting syncope death
thrombosis
in LVF
Example 2
 A person was stabbed & left to bleed to death

CNS
bleeding Brain stem
ischemia & death
from injury hypovolemia
coma
Modes of death
 Coma
It’s the state of insensibility of the central portion of the brain
stem and thus can lead to death
 Coma…..

 Injuries or disease of the brain , if

responsible

 Congestion of the lungs, brain, & the

meninges
Syncope (fainting)
It’s the sudden stoppage of the action of heart, that can be
fatal & lead to death
Causes of syncope
 Sudden & excessive hemorrhage

Reflex Cerebral
Massive
sympathetic ischemia,
blood loss &
vaso syncope &
hypovolemia
constriction death

 Carotid sinus syndrome

 Myocardial weakness : fatty degeneration , pompes
disease , MI & post MI fibrosis , cardiomyopathies ,
myocarditis , exhausting diseases
At the autopsy...
 Heart
 Shrunken & the chambers empty in case of
hypovolemia
 Chambers dilated & filled with blood in case of
asthenia

 Lungs, abdominal organs, brain: pale

Asphyxia
 It is the mode of death caused by interference in normal
respiration
 Nervous tissues are affected first as they are the least
susceptible to hypoxia

Hypoxia Unconsciousness
interference or / and and
hypercapnoea death
Types of anoxia (Gordon's classification)
Anoxic Anaemic Stagnant Histotoxic
O2 is Reduced o2 Impaired Block of
unable to carrying circulation oxidative
reach the capacity of reducing o2 phosphoryl
circulating blood delivery to ation
blood tissues (inhibition
• Anaemia
• Airway heart of
• Massive cytochrome
blockade bleeding failure
oxidase)
• Lack of o2 • NO3, CO Thrombus
in air poisoning • Cyanide
poisoning
Types of asphyxia
1)Mechanical obstruction
Closure of ext.
respiratory
orifices
(smothering)

Airways & Closure of

alveoli filled airway by ext.
pressure on neck
with fluid
(Hanging,
(drowning) strangulation)

External Closure of airway

compression of by impacted
chest/ abdominal foreign bodies
wall disabling
respiration (choking)
 Resp. centre
depression
(opium,
Blockade of barbiturates)
breathing
Resp. muscle
paralysis
Reduced
capacity of Hb to (gelselmium)
toxic bind O2
(CO poisoning)

Cyt. Oxidase
inhibition
(cyanides)
ENVIRONMENTAL TRAUMATIC

Pulmonary
embolism from
Lack of o2 in air DVT of leg
following trauma
(enclosed spaces,
deep wells, high
altitude)
Pulmonary fat
embolism from
fracture of long
bones

Exposure to Pulmonary air

irrespirable gases embolism from
incised wounds in
(volcanic areas, veins like IJV
heavily industrial
areas
Bilateral
pneumothorax
from stab injuries
etc..
6)Postural asphyxia
 Seen in people made unconscious by heavy
alcohol intake or drugs
 Lie in inverted posture pressure by
abdominal viscera on diaphragm
disables chest expansion death

7)iatrogenic
 Associated with deep anesthesia
Stages of asphyxia
 There are 3 stages lasting for 3- 5 minutes
before death occurs

• Resp. movements increase in rate & amplitude, slight

1)Stage of cyanosis present
dyspnoea • Tachycardia; pulse rate & b.p. rises

• Predominating expiratory efforts, face deeply congested,

2)Stage of neck veins swollen, b.p. & pulse rate further increases
convulsions • Frequent convulsions occur followed by loss of
consciousness and reflexes lost with pupils widely dilated

• Resp. centre starts to get paralysed ,breathing is gasping,

3)Stage of predominantly inspiratory with long intervals between
exhaustion • b.p. falls, muscles relax, resp. stop & death occurs
Pathology of post asphyxial changes
asphyxia

anoxia

Decreased
Anaerobic
cardiac
glycolysis
output

Accumulation of
Peripheral venous
adenosine, lactic
stasis , decreased
acid &
venous return
vasodilatation
Asphyxial stigmata
 Tardieu spots
 Petechial hemorrhages seen on the skin, mucosa, serous
membranes
 Caused by capillary congestion giving rise to rupture of micro
vessels ( esp. thin walled venules )
 Seen above the level of strangulation
 more commonly in areas where vessels are weekly supported (
subconjunctival, serous membranes , circum oral skin )
 Occur as isolated hemorrhages or in large no. Sometimes
combing to form red patches ( esp. at back of heart)
 Usually round, dark & well defined ranging in size from pin’s
head to 2 mm
 Can also be seen in natural diseases (bleeding disorders, Addison's
disease, inf. Endocarditis , some hematological malignancies ,
meningococcal septicemia, a/c heart failure) . These are general in
their distribution.
 Post mortem appearances
Skin & subcutaneous Blood vessels Blood
Oedema, cyanosis , Tardieu Congested , many ruptured Fluid & dark (rise in blood
spots & bleeding CO2 & fibrinolysin)

Larynx & trachea

Lungs
Oedematous & contain Abdominal viscera
Congested, dark,
bloody , frothy mucous. Oedematous, congested,
oedematous , contain
May also contain the mucosa show petechial
transudated blood stained
vomitus caused by hemorrhages
fluid
medullary anoxia

Brain
heart Serous membranes
Congested & oedematous.
Congested, edematous, may Oedematous & show
Cranial sinuses filled with
or may not be dilated petechial hemorrhages
blood
Causes of death as per autopsy findings
Natural causes with definite evidence
Cardiovascular causes
Coronary thrombus,
Aneurysms & their CCF following c/c
atherosclerosis,
rupture, rupture of pressure & volume cardiomyopathies
embolism resulting
fresh MI hypertrophy
in MI

a/c Endocarditis a/c pericarditis,

Cardiac & vascular cardiac tamponade, Congenital heart
Inf. Endocarditis
malignancies constrictive diseases
a/c myocarditis pericarditis

Conducting system Valvular lesions

Shock Fatty degeneration
lesions causing (stenosis,
(hypovolemic, of heart ( anoxic,
arrhythmias, heart regurgitation,
cardiogenic, septic) toxic ,hereditary)
blocks prolapse )

c/c hypertension & Heart failure

associated Pulmonary secondary to Systemic
cardiovascular embolism pulmonary diseases embolisation
diseases (cor pulmonale)
Respiratory causes
Massive hemoptysis in Advanced lobar & broncho Advanced lung abscess
cavitory T.B pneumonia bronchiectasis

Laryngospasm & oedema Severe a/c asthma &

Malignancies of bronchus
Diphtheria advanced exacerbated COPD

Pulmonary embolism & Pneumothorax, massive

Myasthenia gravis, impacted
infarction , pulmonary pleural effusion with
food particles
oedema pulmonary collapse
CNS causes

Intracranial
hemorrhage Brain abscess, Brain tumors &
causing infarction, status epilepticus malignancies
compression

Massive
Cerebral Meningitis, severe
hydrocephalus,
thrombosis, a/c polio
massive cysts of
embolism , stroke encephalitis
ventricles
GIT causes
Massive hemoptysis
Perforation of ulcers Volvulus,
(peptic ulcer,
(peptic, typhoid, intussusceptions of
malignancies,
amoebic, malignant) bowel
esophageal varices)

a/c hemorrhagic Intestinal obstruction,

pancreatitis, Gastrointestinal
strangulated hernia,
obstructive malignancies
paralytic ileus
cholecystitis

a/c appendicitis,
Typhoid, hepatitis , Hepatic cirrhosis, c/c
bursting of liver
parasitic & bacterial malabsorption
abscess, rupture of
diarrhoea, dysentery syndromes,
enlarged spleen
Genito urinary causes
c/c nephritis, Obstructive
nephrolithiasis hydronephrosis,
Septic shock post UTI pyonephrosis

Malignancies of kidney,
bladder, Rupture of ectopic
T.B kidney
prostate,testis, ovary, pregnancy
uterus, vulva

Massive Uterine
hemorrhage in fibroids, Twisting of ovary,
Toxaemia of pregnancy
malignancies, difficult ovarian cyst or fibroid
labour
Miscellaneous
Metabolic
disorders
Complicated (ketoacidosis,
Diabetes mellitus uremia, alkalosis,
Na, K, Ca
disturbances )

Endocrine
(hyperthyroidism, Blood dyscrasias
Addison's disease)

Hemochromatosis,
sever anaemia,
Cerebral malaria
hemoglobin
disorders
Sudden death
 Person not suffering from any dangerous disease
injury, poisoning
 Includes only death that is sudden or within 24
hours of onset
 Incident : 10% of all deaths
 No age is exempted
 E.g. : MI in a person who’s not had any
warning signs before
 E.g. : sudden death in athletes due to fatal
arrhythmias
Unnatural (violent) causes
 Homicidal

 Suicidal

 accidental
 Obscure causes
 No lesion is found at autopsy or if found its
too insignificant in explaining the death

Natural diseases
Biochemical Respiratory pigment
(death ppt by emotion, disturbances disorders
stress, vagal inhibition,
(uremia, hypokalemia) (anemia, porphyria)
VF)

Concealed trauma Poisoning

Endocrine disorder (concussion, self (Narcotic poisoning,
(thyrotoxicosis, reduced neck injury, anaesthetic over
Addison's disease) blunt injury to heart, dosage, drug allergy,
vagal inhibition) idiosyncrasy)
 when gross , microscopic, toxicologic & lab
investigations fail to reveal cause of death
Lack of trained
doctor

Inadequate
Inadequate
history
physical
(vagal examination
inhibition,
(drug addict,
status
snake bite)
epilepticus)

Improper Improper
toxicological internal
&lab examination
investigations) (air embolism)
 Vagal inhibition (vaso vagal shock)
 Cause sudden death in susceptible individuals
following minor trauma
 Vagal inhibition causes fatal bradycardia &
hypotension
 leaves no evidence at autopsy
 Proper history needed
Carotid sinus Insertion of Sudden distension of
syndrome Blow on abdomen, instruments into hollow muscular
Severe pressure on testis ,chest, larynx bronchus, uterus, organs
neck (hanging) bladder, rectum (criminal abortion)

Impaction of food in
Extensive injuries to
Sudden evacuation larynx
spine Sudden immersion of
of fluids (pleural & Unexpected
Insertion of objects body into cold water
peritoneal tap) inhalation of fluid
into auditory canal
into upper resp. tract