RINI Resuscitation Advances in resuscitation techniques, in ventilation and in the support of the unconscious patient have resulted in the

survival of patients who would otherwise have died as a result of direct cerebral trauma or of cerebral hypoxia from whatever cause. There is a spectrum of survival some will recover both spontaneous respiration and consciousness, others will never regain consciousness but will regain the ability tobreathe and will require permanent artificial ventilation to remain alive. The Departement of Health in the UK, acting on advice from a Conference of the Royal Colleges, published a definitive Code of Practise in the 1970s concerning the diagnosis of brain death and this code is now accepted both legally and medically as being reliable. The main points are: The patient must be in deep coma and treatable causes such as depressant drugs, metabolic or endocrine disorders (diabetic or myxoedema coma) or hypothermia must be excluded. The patient must be on mechanical ventilation because of absent or inadequate spontaneous respiration. Neuromuscular blocking agents and any curare-like drugs must be excluded as a posible cause the respiratory failure. A firm diagnosis of the basic pathology must be available and must be known to be due to irremediable brain damage. The most common cause are head injury and intracerebral haemorrhage from a ruptured cerebral aneurysm. Diagnostic tests for brainstem death must be unequivocally positive. These tests should be determined by two doctors, preferably one of whom should be the physician in charge of the patient. This physician should have been registered for at least 5 years and should have had experience of such cases. The second, independent doctor should have similiar experience. If there has been a request for organ donation, none of the doctors involved in the care of the patient or in the final diagnosis of brainstem death may be part of the transplant team. A checklist of the diagnostic tests and their result should be kept in the patients notes and the tests should be repeated at least once, the interval between the tests depending on the opinion of the doctors.

In order to establish the points of the Code of practise in the UK, a series of clinical tests must be performed and these are set out below. In other jurisdictions, additional tests, including electroencephalography and even cerebral angiography or cerebral blood flow measurements, are required. All brainstem reflexes are absent, with fixed dilated and unreactive pupils. Corneal reflexes are absent. It should be noted that persistence of spinal reflexes are irrelevant in the diagnosis of brainstem death. Vestibulo-ocular reflexes are negative when iced water is introduced into the ears. There are no motor responses to painful stimuli in any of the cranial nerves. There is no gag reflex to a catheter placed in the larynx and trachea. There are no respiratory movements when the patients is disconnected from the ventilator with an arterial PCO2 level in excess of 50 mmHg as a stimulus to breathing. Testing must be performed with a body temperature not less than 35C to avoid hypothermia simulating brainstem damage.

Advances in resuscitation and ventilation techniques now prevent the immediate death of many individuals. Previously, brainstem death would lead inexorably to respiratory arrest and this would cause myocardial hypoxia and cardiac arrest. Artificial ventilation breaks that chain and while ventilation is continued, myocardial hypoxia and cardiac arrest are prevented.

ADEK

jaringan dan transplantasi organ

hukum yang berkaitan donasi jaringan dan organ dan transplantasi tergantung pada pandangan agama dan etika dari besarbesaran negara yang mereka terapkan. hukum bervariasi di kedua luas dan detail di seluruh dunia, tetapi ada beberapa negara di mana transplanation secara tegas dilarang religiions beberapa aand yang melarangnya Saksi-Saksi Yehuwa adalah salah satu kelompok tersebut, yang juga menolak. tranfusi darah yang

disumbangkan organ dan jaringan yang akan dicangkokkan dapat berasal dari salah satu dari beberapa sumber. homolog transplantasi. jaringan yang dipindahkan antara situs pada tubuh yang sama misalnya, kulit diambil dari paha untuk graft ke situs bakar atau chip tulang dari panggul dapat diambil untuk membantu dalam penyembuhan dari situs fraktur terfragmentasi dari tulang panjang. homolog tranfusi darah dapat digunakan di mana ada agama penggunaan darah anonim disumbangkan hidup sumbangan dalam proses ini jaringan diambil dari donor hidup yang jaringan telah dicocokkan dengan yang kompatibel, dengan orang-orang atau penerima. contoh yang paling umum adalah transfusi darah, tetapi tranplantation sumsum sekarang juga sangat umum. sumbangan hidup lainnya ususally melibatkan ginjal sehat, maitain elektrolit dan keseimbangan air dengan hanya satu ginjal ginjal yang paling untuk transplantasi berasal dari sumbangan kadaver, namun sumbangan hidup juga mungkin dan ini terkait.

Most kidneys for transplant are derived from cadaveric donation(see below), but live donation is also possible and this, associated with a high demand for kidney, especially in western countries, has resulted in a few surgeons seeking donors ( in particular poor people from developing countries) who would be willing to sell one of their kidney. This practice is illegal inmany countries and, if not specifically illegal, it is certainly unethical. With increasing surgical skill, the transplantation of part of singleton organ with large physiological reverse (such as the iver) has bee attemped. These transplants and the risks to the donor are considerably higher.

Cadaveric Doantion

In many countries cadaveric donation is the major source of all tissues for transplantations. The surgical techniques to harvest the organs are improving, as are the storage and

transportation techniques, but the best result are still obantained if the organs are obtained while circulation is present or immediately after cessation of the circulation. The aim being to minimize the warm icshaeic time, kidney are moore resilient to anoxia than some other organs and can survive up to 30 minutes after cardiac stoppage. Cadaveric donation is nowso well established that most developed countries have sophisticated laws to regulated it. However, these laws vary greatly some countries allow the removal of organs nomatter what wishes of the relative , other countries allow for an opting out process in which organs can be taken for transplantations unless there is an objection from relarives. The converse of that system is the one practiced in the UK, whih requires opting . in this system the transplant team must ensure that the donor either gave active permissions durig life or at least did not object an dalsothat no close relative objects after death. The HumanTissues Act ( 1961 and in Northern Ireland 1962) allows the person I lawfull possession of a body to authorize the donations of tissues or organs only if has no reason to belive that he objected to donation and tha the surviving spouse or raltive of the deeased objects. If an autopsy will be required by law any reason, the permissions of the coroner, procurator fiscal or other officer investigating the death must be obtained before harvesting of tissue or organs is undertaken. In general, there is seldom ay reason for legal officer investigating the death to object to organt or tissue donation because it is selt evident that injured diseased or damaged organs are unlikelyto be will be available for examination. In what is almost alwaysa tragic unexpected death. The donation of organs may be the one positive feature ad can often be of great assistance to the relatives.

Xenografts Grafting of animal tissue into humans has always seemed tempting and clinical trials have been performed with limited success. There is condsiderable difficultywith cross matching the tissues and considerable concern about the possibility of transfer of animal viruses to an immunocompromised human host. Strains of donor animals, usually pigs, are being bred in clinically clean conditions to prevent viral contamination, but there is still no guarantee of

close or ideal tissue match. Also, the complexity of their breeding ad rearing means that these animals are expensive. Cloning A Potentially cheaper solutions involves the cloning of animals for use. As transplant donors. This research took a step forward with the successful cloning of dolly the sheep but other advances have been slow to appear anf although cloning remains a theoretical course of actions much research is still to be done.

CUI

MEDICO-LEGAL INVESTIGATION OF DEATH If a death is natural and a doctor can sign a death certificate, this allows the relatives to continue with the process of disposal of the body, whether by burial or cremation. If the death is not natural or if no doctor can complete a death certificate, some other method of investigating and certifying the death must be present. In England and Wales there are approximately 560.000 deaths each year, of which about 435000 are certified by doctors, but some 55000 of these cases are only certified after discussion with the coroners office. The coroners themselves certify some 122000 deaths a year and most usually require an autopsy examination before doing so. The deaths that cannot be certified by a doctor are examined by a variety of legal officers in other countries: coroners, procurators fiscal, medical examiners, magistrates, judges and even police officers. The exact system of referral, responsibility and investigation differ widely, but the general framework is much the same. The systems are arranged to identify and investigate deaths that are, or might be, unnatural and that might be overtly criminal, suspicious, traumatic or due to poisoning or that might simply be deaths that are unexpected or unexplained. There is no common law duty for a doctor to report an unnatural death to the coroner, but it would perhaps be a foolish or foolhardy doctor who did not do so. Conversely, the registrar of deaths does have a duty to inform the coroner about any death that appears to be unnatural or where the rules about completion of the death certificate have not been complied with.

Following the death of a person who has not been receiving medical supervision and where no doctor was in attendance, the fact of death can be confirmed by nurses, paramedics and other healthcare professionals as well as by doctors. The police will usually investigate the scene and the circumstances of the death and report their findings to the coroner or other legal authority. The coroner, through his officers, will attempt to find a family practitioner to obtain medical details. That family practitioner, if found, may be able to complete the death certificate if he is aware of sufficient natural disease and if the scene and circumstances of the death are not suspicious. If not family practitioner can be found, or if the practitioner is unwilling to issue a death certificate, the coroner will usually exercise his right to request an autopsy, but in Scotland the ability to perform only an external examination of the body on cases such as this-the so- called view and grant- is well established. This all-embracing coronial power to order autopsies is not found in other countries, where autopsies are often much more restricted. It is not surprising therefore, that the autopsy rate varies widely from jurisdiction to jurisdiction; in some cases it is nearly 100 per cent but it may fall as low as 5-10 per cent. Some jurisdictions with low autopsy rate insist on the external examination of the body by a doctor with medico-legal training. Autopsy examination are not the complete and final answer to every death, but without an internal examination it can be impossible to be certain about the cause and the mechanism of death. It should be remembered that at least 50 per cent of the causes of death given by doctors have been shown to incorrect by a subsequent autopsy. In England and Wales, the coroner may take an interest in any body lying within, his jurisdiction, whether referred or not. However, most cases are referred to the coroner by doctors, police and members of the public. Deaths if a death certificate issued by a doctor is unacceptable, which it may be for the following reasons: The deceased was not attended in his last illness by the doctor completing the certificate. The deceased had not been seen by a doctor either after death or within 14 days prior to death Where the cause of a death is unknown Where death appears to be due to poisoning or to industrial disease Where death may have been unnatural or where it may have been caused by violence or neglect or abortion or where it is associated with suspicious circumstances

Where death occurred during a surgical operation or before recovery from an anesthetic.

Once a death is reported the coroner, if he is satisfied that it is due to natural causes, he can decide not to pursue any further enquiries and to ask the doctor to issue a death certificate. Alternatively, and more commonly, he may order an autopsy and if this reveals that death was due to natural causes, may issues a certificate to allow for disposal of the body. If the autopsy cannot establish that death was due to natural causes or if there is a public interest in a death, the coroner may hold an inquest a public inquiry into the death. The modern inquest is severely restricted in its functions and the verdicts it may return. An inquest seeks to answer four question: who the person is, when and where they died and how they died. The who, when, and where questions seldom pose a problems; it is the answer to the fourth question the how that is often the most difficult. The coroner can sit with or without a jury, except in some specific cases (e.g. deaths on a rail-track or in a prison) when they must sit with a jury. The coroners court cannot form any view about either criminal or civil blame for the death. Indeed, some would say that the coroners system is long overdue for the review that is currently taking place. A coroner or the jury has a prescribed list of possible verdicts and although riders or comments may be attached to these verdicts, they must not indicate or imply blame. The commonly used verdicts include : Unlawful killing (which includes murder, manslaughter, infanticide, death by dangerous driving etc) Lawful killing (legal use of lethal force by a police officer) Accident (misadventure) Killed himself/herself (suicide) Natural causes Industrial disease Abuse of drugs (dependent or non-dependent) Open verdict (where the evidence is insufficient to reach any other verdict)

ABOTH THE AUTOPSY The words autopsy, necropsy and post-mortem examination are synonymous, although post-mortem examination can have a broader meaning encompassing any examination made after death, including a simple external examination made after death, including a simple external examination. In general terms, autopsies can be performed for two reasons: clinical interest and medico-legal purposes. The clinical autopsy is performed in a hospital mortuary after consent for the examination has been sought from and granted by the relatives of the deceased. The doctors treating the patient should know why their patient has died and be able to complete a death certificate even in the absence of an autopsy. These examinations have been used in the past for teaching of medical student etc. and for research. The medico-legal autopsy is performed on behalf of the state. The aims of these examinations are much broader than those of the clinical autopsy and include : To identify of the body To estimate the time of death To identify and document the nature and number of injuries To interpret the significance and effect of the injuries To identify the presence of any natural disease To interpret the significance and effect of the natural disease present To identify the presence of poisons ; and To interpret the effect of any medical or surgical treatment

Taken at its broadest, autopsies can be performed by any doctor, but ideally they should be performed by any doctor, but ideally they should be performed by a properly trained pathologist. Medico-legal autopsies are a specialized version of the standard autopsy and should be performed by pathologists who have had the necessary training and experience in forensic pathology. The autopsy should be performed in a mortuary with adequate facilities. However, where there are no trained staff or no adequate facilities- which can occur not only in some developing countries that do not adequately fund their medico-legal

systems-non-specialist doctors may occasionally have to perform medico-legal autopsies. A poorly performed autopsy may be considerably worse than no autopsy at all; it is certainly worse than an autopsy delayed for a short to await the arrival of a specialist. The first crucial part of any autopsy is observation and documentation and these skills should lie within the competence of almost every doctor. All documentation should be in writing, and diagrams, drawings and annotations must be signed and dated at the end of the examination. Photographs are extremely useful and, if used, should always include a scale and some anatomical reference point.

EXHUMATION It is rare for a body to be removed from its grave for further examination; the most common reasons for exhumation are personal, for example if a family chooses to move the body or if a cemetery is to be closed or aitered. Various legal formalities must be observed before permission to exhume a body can be given, but these lie outside the scope of this book. Once legal permission has been given, the correct site of the grave must be determined from plans and record of the cemetery as well as inscriptions on headstones. In some countries with a low autopsy rate, for example Belgium, exhumations are more common, as legal arguments about an accident or an insurance claim etc. require an examination of the body to establish the medical facts. The mechanics of removal of a coffin require some thought and practice of actually lifting the coffin before dawn owes more to Hollywood than to practical needs. Because the body may need to examined as quickly as possible due to decomposition, the mortuary, the pathologist, the police and everyone else with a legitimate interest must be aware of the time arranged. An examination of a body after exhumation is seldom as good as the examination of a fresh body, but it is surprising how well preserved a body may remain and how useful such an examination often is. It is almost impossible to predict how well preserved a body might be, as there are so many confounding factors. The autopsy that follows an exhumation is basically the same as that performed at any other time, although

decomposition may lead to some modification or the basic technique. Exhumations are the province of the skilled and experienced forensic pathologist.