Sudden Unexpected Death

Dr. Mohammed Madadin

Reflective
Why people Die ? (Medically)
Q
From Introduction
lecture
What are the cases that seen by forensic Pathologist and why?
 “
What is S.U Death ?

The World Health Organization (WHO) defines

sudden death as a death occurring within 24
hours of the onset of symptoms.

The definition of sudden cardiac death is most

commonly taken to mean death within 1 hour of
the onset of symptoms
Forensic Medicine Perspective

■ All deaths in which no adequate diagnosis of a lethal

medical disease before death, regardless of the duration
of the illness

■ Unexpected deaths may occur in previously healthy

individuals and in those with known natural disease when
the severity of the person’s condition does not explain
death
What are the causes of S.U death?
 SUD

■Wide variety
■Depends on: age, ethnicity
■Systemic classification (CVS,
Respiratory)
■Organs (heart, lungs)
■By groups (athletes, young,
obese)
What is the commonest system that cause S.U
death?
T or F. The following disease can cause SD?
What are CVS causes of SUD?
CVS causes of SD

■Instantaneous or sudden death may result from dysfunction of the

heart and/or its vessels, noncardiac vessels, pulmonary system, and
central nervous system (CNS).

■CVS is major cause of instantaneous or sudden death.

■Heart and coronary arteries

Ventricular fibrillation the main mechanism of instantaneous/sudden
death:
■Coronary arteries: ■Hypertensive heart disease:
Occlusion (atherosclerosis, Cardiomegaly
thrombosis, embolus) Fibrosis
structural abnormalities of the
epicardial arteries
coronary artery dissection or
aneurysm
■Acute myocardial infarction, cardiac tamponade.
■Congenital heart disease.
■Cardiomyopathies:

Hypertrophic cardiomyopathy.
dilated cardiomyopathy (genetic, myocarditis, toxic, peripartum,
idiopathic).
Restrictive cardiomyopathy (idiopathic, amyloidosis, sarcoidosis, radiation
fibrosis, metastasis, deposition disease/inborn errors of metabolism).
■Other cardiomyopathies: Arrhythmogenic right ventricular dysplasia,
restrictive conditions (endomyocardial fibrosis, Loeffler endomyocarditis,
endocardial fibroelastosis)
■Inflammatory:
Myocarditis
pericarditis (bacterial, viral, Dressler syndrome)
Bacterial endocarditis

■ Valvular:
Congenital abnormalities (bicuspid valve)
rheumatic heart disease

cardiac outflow obstruction :

(aortic stenosis, valvular prosthesis thrombosis, atrial
myxoma),
■Functional abnormalities: ■Drug induced cardiac toxicity:
Iatrogenic and illicit (cocaine)
Long QT syndrome (LQTS)
short QT syndrome (SQTS)
catecholaminergic polymorphic
ventricular tachycardia (CPVT)
Brugada syndrome
■Aorta and noncardiac vessels

Aneurysmal rupture (atherosclerotic, mycotic, traumatic aneurysm)

Aortic dissection

Mesenteric artery thrombosis: Bowel infarction and septic shock

Miscellaneous: Ruptured ectopic pregnancy/CNS infarction or haemorrhage

What are pulmonary causes of SUD?
■Asphyxia:

Mechanical airway obstruction (café coronary); laryngeal edema from

infection (epiglottitis), anaphylaxis, neoplasm, and trauma; sleep apnea
Pneumothorax
Bronchial asthma
Pulmonary embolism
Massive acute haemorrhage: Neoplasms, pulmonary tuberculosis
 Pulmonary causes of unexpected death

■ Infection: bronchopneumonia, lobar pneumonia, aspiration pneumonia;TB

■ Chronic lung disease: Chronic obstructive pulmonary disease (COPD),
pulmonary fibrosis, bronchitis
What are CNS causes of SUD?
 CNS

■Acute haemorrhage: Atherosclerosis, hypertension, spontaneous

rupture of aneurysm (eg, berry aneurysm), rupture of vascular
malformation, thrombosis, sagittal sinus thrombosis, cerebral
amyloid angiopathy

■Infection: Leptomeningitis, encephalitis, abscess

■Cerebral edema
CNS unexpected death

■Encephalopathy: Acute ethanol-induced (Wernicke)

encephalopathy, acute hemorrhagic leukoencephalopathy,
transmissible spongiform encephalopathy (TSE)

■Neoplasms: Primary or metastatic

■Other: Multiple sclerosis, Chiari malformation

What are GI causes of SUD?
GI causes of SD

■Massive gastrointestinal haemorrhage: Duodenal or gastric

ulcers, oesophageal varices, acute haemorrhagic gastritis,
Mallory-Weiss tears, vascular malformation, angiodysplasia

■ Acute hemorrhagic pancreatitis

■GI causes of unexpected death include:

Neoplasms
Acute peritonitis
Intestinal obstruction: Neoplasm, incarcerated hernia, volvulus,
adhesions
What are GU causes of SUD?
 GU

■Genitourinary (GU) tract causes of unexpected death include:

Acute pyelonephritis with sepsis

End-stage renal disease (ESRD) with uremia
Chronic pyelonephritis
Glomerulonephritis
Acute renal failure (ARF)
Rupture of ectopic pregnancy
PID
Acute endometritis
Eclampsia
Hematological causes:

■Acute leukemia, aplastic anemia/bone marrow crisis,

hemophagocytic syndrome (following viral illness).

■Acute hemolytic crisis: Sickle cell crisis, malaria,

microangiopathic hemolytic anemia, thrombotic
thrombocytopenic purpura (TTP)
 Miscellaneous causes:

■Infections
■Metabolic
Instructions for use
Common is common
CASE

Two men are found dead in their respective apartments. Both apartments
are locked and secured, and there are no signs of foul play.

One decedent is 20 years old and was previously healthy.

The other decedent is 80 years old and had a history of coronary artery
disease with multiple cardiac bypass grafts.

Do we would have same approach in both cases? Why?

The death of the 20-year-old man is significantly more suspicious and

more likely to receive a complete autopsy than the older man with a
history of heart disease.
 Approach

Hx and Circumstances External Examination Autopsy Investigation

Past Medical Hx. Clothes Full Autopsy Toxicology

Family Hx. Injury All organs Microbiology
Story and circum. Signs of diseases photo Radiology
Medication, Sign of medical ttt Sampling PM-chemistry
symptoms..etc Special dissection Genetecis
Location
Body at scene
Witness
case

■40 year old woman ■Hx (after Hx give DD)

found dead at bed. ■Ex.Ex (Give DD)
■Int. Ex (autopsy finding, special dissection)
Aapproach this case ■Investigation (what expected histo?)
systematically and give
cause of death
Write COD for this case
PE
Interpretation

Finding a disease doesn’t

mean it is the cause of death

Died with disease and not

because of disease
CASE

■59 year old woman located dead inside her locked

accommodation. She had history of alcoholism, arthritis, DMI,
depression, pancreatitis and old head trauma.
■Autopsy revealed liver steatosis, mild cardiac fibrosis, and
diabetic nephropathy.
■Histology: mild cardiac fibrosis, no signs of acute ischaemic
changes, coronary atherosclerosis showed mild intimal
thickening. Kidneys showed tubular vacuolosation and mild
arteriosclerosis.
Acetone: (0)
Glucose: less than 11
Creatinine: less than 100
Urea: 7-10

What is COD?
Negative
Autopsy
❑ Endocrinopathies: Diabetes mellitus (diabetic ketoacidosis, hypoglycemia); thyroid storm and
thyrotoxicosis; adrenocortical insufficiency and hyperaldosteronism

❑ Electrolyte abnormalities: Dehydration, diarrhea, vomiting, endocrine dysfunction (Addison

disease, Schmidt syndrome), uremia, water intoxication, hypokalemia

❑ Cardiac dysrhythmia: Channelopathies, drug induced, electrolyte imbalance

❑ Other: Seizure disorder, anaphylaxis, neuroleptic malignant syndrome, serotonin syndrome

Arrythmia can cause sudden death with underlying pathology found in
autopsy

Long QT
Brugada
short QT syndrome,
catecholaminergic polymorphic ventricular tachycardia
 Thank you

Any question?