Death and changes after death This document discusses various topics related to death including: 1. Types of death such as somatic/clinical death and cellular/molecular death. 2. Diagnosis of death including criteria for brain death. 3. Differences between somatic and molecular death. 4. Modes, causes and manners of death. It also discusses topics like suspended animation and sudden death.

1. DEATH AND CHANGES AFTER
DEATH
Dr SM Arman Hossain

2. • Concept of death & definition of death
• Types of death
• Different aspects of death
• Diagnosis of death
• D/D of death
• Death trance
• Lazarus syndrome
• Unconsciousness
• Presumption of death & survivorship
• Sudden death
• Euthanasia
• Post mortem changes

3. Concept of death & life.
Philosophical , legal & medical/scientific concept of
death.
Oxford dictionary gives the meaning of death as –„ The
end of life‟.
Chamber‟s twentieth century dictionary defines death as -
„Extinction of life.‟
Black‟s law dictionary defines death as –„ The cessation
of life; the ceasing the exist‟.

4. Death
• Law does not define death clearly.
• Definition of death (Medico legal definition):
• Death may be defined as permanent & irreversible
cessation of three interlinked vital systems of body ,
called tripod of life, namely –the nervous ,
circulatory & respiratory systems.
• In the United States, a person is dead by law if a
Statement of Death or Death certificateis approved by a
licensed medical practitioner. Various legal
consequences follow death, including the removal from
the person of what in legal terminology is called
personhood.

5. Types of death :
• The advent of human organ transplantation, in the
1960s specially the heart transplantation lead to the
necessity of scrutinizing the phenomena of death. The
problem increased many folds because of the increasing
use of the modern medical technology i.e. connection to
the artificial means to support a dying man. This
generated the newer concepts of moments of death.
• For the purpose of understanding about death and its
mechanism death is divided into two types (1) somatic
death, and (2) molecular death.

6. Types of death :
1. Somatic death/systemic death /Clinical death:
It means complete & irreversible stoppage
of vital functions .
2. Cellular death/molecular death :
It means death of tissues & cells of body individually

7. Somatic death/Systemic death/Clinical death
It is defined as irreversible cessation of functioning brain,
heart, and lungs resulting in complete loss of sensibility and
ability to move the body. It is the extinction of personality or
the death of the body as a whole (soma means body), also
known as clinical or systemic death. The cells of different
tissues of the body are still alive and dies after sometime at
different rate.
Cessation of heart beating:-Clinical criteria:
1.Absence of pulse (central i.e. carotid )
2.Absence of heart sound on repeated prolonged auscultation.
3.A flat electrocardiogram (ECG).

8. Somatic death/Systemic death/Clinical death
Cessation of breathing:-Clinical criteria
1.Absence of respiratory movement
2.Absence of breath sound on thorough auscultation of
chest. (Central)
Cessation of brain activity:-Clinical criteria
1.Generalized flaccidity with generalized anesthesia.
2.Dilated fixed pupils, not responding to light
3.Absence of motor responses within the cranial nerve
distribution on painful stimuli.
4.Absence of corneal reflexes.

9. Cellular or molecular death and the concept of
brain death
• Somatic death is followed by progressive disintegration
of body tissues and is called as cellular or molecular
death.
• In absence of circulation and respiration different cells
die at different times. Death of some cells are
mentioned below in sequential order from the earliest:-

10. Brain death or brain stem death
Brain death means irreversible loss of cerebral function.
Or
Brain death means that the patient is dead whether or not
the function of some other organ such as heart beat is
maintained by artificial means and all the function of the
brain must have permanently and irreversibly ceased.

11. Brain Death
Brain death : Permanent & irreversible cessation of function
of brain irrespective of function of other organs like heart ,
lungs.
Types of brain death:
1.Cortical death /cerebral death/ vegetative stage :Loss of
function of cerebral cortex. , heart & lungs may work. .
2.Brain stem death: Damage & failure of function of brain
stem , heart & lungs can not work independently.
3.Combined brain death: both cortical & brain stem death.
Brain death is now considered as legal death . It has great
importance from legal , ethical point of view & in relation to
organ trans plantation .

12. Brain Death
Cortical death
Death of the cortex with an intact brain stem.
Permanent & irreversible cessation of function of cerebral
cortex is called cortical death.
Brain stem death
Cerebrum is intact but loss of all vital center causes the
victim to be irreversible comatose and incapable of
spontaneous breathing.
Combined brain death:
both cortical & brain stem death

13. Criteria for diagnosing brain death
(1)The patient must be in a deep coma, which is not due to
depressant drugs, metabolic or endocrine disorder.
(2) The patient must not be in hypothermia.
(3)The patient must be on a mechanical ventilator/heart-lung
machine.
(4)Diagnostic test for brain death:-
(a) Absence of corneal reflex.
(b) Dilated and fixed pupil not reacting to light.
(c) Absence of vestibulo-ocular reflex.
(d) Absence of cranial nerve response to painful stimuli.
(e) Absence of cough reflex.

14. Difference of somatic & molecular death
1. Complete & irreversible stoppage of
functions three vital organs –brain,heart
& lungs .
2. It may be confused with suspended
animation.
3. In this stage muscles response to
electric stimuli .
4. At this stage of death organs
can be removed for transplantation .
5. It precedes molecular death.
1. Death of tissue & individual cells
takes place .
2. No chance of confusion.
3. In this stage muscles do not
response to electric stimuli .
4. At this stage of death organs cannot
be removed for transplantation .
5.It follows somatic death .

15. Different aspects of death-
3 main aspects to be considered:
1. Mood of death
2. Cause of death
3. Manner of death

16. Mode of death
The term „mode of death‟ usually refers to the system that
initiates the process of death.
Stoppage of which system initiated the process of death.
These modes are:
1. Coma. (failure of nervous system).
2. Syncope (failure of circulatory system).
3. Asphyxia (failure of respiratory system).

17. Cause of death
• Natural causes-
Natural disease & geriatric causes
• Unnatural causes –
Injury, poisoning, drowning etc.
• *Obscure causes.

18. Manner of death :
It is the way by which cause of death was produced.
1.Natural
2.Unnatural–
Suicidal, homicidal, accidental
*Undetermined/unexplained

19. Coma
Coma means insensibility or loss of consciousness,which may
be partial or complete depending on the degree of involvement
of the C.N.S.
Causes of coma:
1.Cerebral compression.
2.Cerebral injuries.
3.Infective states like, encephalitis, meningitis, abscess.
4.Any growth.
5.Metabolic disorder.
6.Cerebral embolism.
7.The effect of certain drugs.
8.Miscellaneous causes like epilepsy, heat stroke.

20. ASPHYXIA
Asphyxia is a condition caused by interference with
respiration, or due to lack of oxygen in respired air due to
which the organ and tissues are deprived of oxygen
causing unconsciousness or death.

21. Hypoxia & Anoxia
HYPOXIA
Lack of supply of oxygen to the tissues below normal is
known as hypoxia.
ANOXIA
Anoxia means total lack of oxygen in the tissues.

22. SYNCOPE
Syncope is the sudden cessation of the action of
the heart and failure of circulation leading to
death.

23. Cause of death
1. Immediate cause
2. Basic cause
3. Contributory cause

24. WHO Syntax regarding writing cause of death
I. Cause of death
a) Direct cause ...Myocardial infarction
(due to or as a consequence of)
b) Antecedent cause ...Coronary thrombosis
(due to or as a consequence of)
c) Underlying cause ...Coronary atherosclerosis
II. Contributory causes…
(Usually applicable for geriatric death)
DM
Hypercholesterolemia.

25. Death certification.
A doctor is the person who is legally authorized to declare
a death & issue a death certificate.
To issue a death certificate/Condition of certifying death:
1.Inspection of the dead body by the doctor himself.
2.Full satisfaction about the death
3.The doctor must sure of the cause of death
4.The doctor should free from least suspicion of foul play
5. The doctor has seen/examined the person within 14
days before death as alive.
6.The doctor registered as a qualified medical practitioner.

26. DEATH CERTIFICATE (WHO)
I do herby certify that I attended the deceased (Name) ...................................... aged ....................
residing at ...................................................................... during his last illness and that to the best of
my belief the cause of his death (time)............... on (date) was as stated below:
Cause of Death Approximate interval between onset and death
1. Disease of condition or condition
directly leading to death (a) ................................ Years Months
(due to or as consequence of ) Days Hours
Antecedent cause (b) ................................ Years Months
(due to or as consequence of ) days hours
Morbid conditions, if any, (c) ................................ Years Months
giving rise to the above cause, days hours
stating the underlying condition last
2. Other significant conditions …………………………………… Years Months
contributing to the death but not .....……………………………….. days hours
related to the disease or condition
causing it.
Address or rubber stamp of the institution Signature, designation, degree and
registration number.

27. Tests for death:
1.For stoppage of function of NS
Look for movement -No movement
Look for response-No response to stimulus
Look for jerk-No jerks
Look for reflex-No reflex
Confirmation by EEG.
2.For Stoppage of respiration
Inspection , palpation & auscultation for respiration–repeated for at least 5 min.
Feather test –Feather/cotton –Nose -Movement
Mirror test –Mirror –Nose/Mouth -Hazy
Winslow‟s test –Water bowl –Chest –Light reflection
3.For stoppage of circulation
Inspection, palpation & auscultation for HS–repeated for at least 5 minutes.
Detection of pulse & BP : absent
Icard‟stest -1 ml of 20% alkaline fluorescein S/C –Colourchange spread
Ligature test(Magnusstest) –Ligature –Finger –Swollen & Bluish
Finger web inspection (Diaphanous test) –Hand –Light –Pinkish & translucent / Yellowish & opaque.
By applying heat –Skin –Hot Object –Blister & redness.
Confirmation by ECG.
Earliest & surest sign of death : Segmentation/trucking of blood
column in the retinal blood vesceles–by opthalmoscope.

28. Suspended Animation/Apparent Death/Death
Trance/Catalepsy:
Death trance is a condition in which all the signs of life
or vitality are seemed to be absent although the individual
still remains alive.
It is a condition , wherein the vital functions of body
(heart beat and respiration) are maintained at a low pitch
reduced to a minimum for sometime, that they could not
be detected by routine methods of clinical examination.

29. Suspended Animation/Apparent Death/Death
Trance/Catalepsy:
(1) It is the condition in which all signs of life or vitality are
seemed to be absent although the individual still remains alive.
(2) The person appears to be dead because of very feeble or
minimum function of his body systems.
(3) The function of circulatory , respiratory or nervous system
may not be perceived by conventional method though the
person is still alive.
(4) The function of these system may return after sometime by
proper resuscitaion.
(5) Such a death like state is known as suspended animation.
Actually the circulation do not completely stop but is
maintained in minimum.

30. Causes of Suspended Animation/Apparent Death/Death
Trance
Voluntary-Yoga practicing.
Involuntary-
1. Newborn infants
2. Drowning
3. Electrocution
4. Thunder injury
5. Sever diarrhea/Cholera
6. Poisoning
7. Anesthesia
8. Shock
9. Sun-stroke
10. Snake bite
11. Epilepsy
12. Head injury
13. Sever narcosis

31. Test to avoid death trance
1. Repeated auscultation over a period longer then 5
minutes.
2. E.C.G.
3. E.E.G.
4. Demonstration of rectal temp. <75 F
5. Ophthalmoscopy should be done routinely and is
confirmed by detecting segmentation of blood column in
retinal vessel.

32. Medico legal importance of Suspended Animation
1.It can lead error if precautions are not taken.
2.Confusion may lead to issue of a dead certificate for a
live person
3.An alive person may be sent to mortuary.
4.Premature burial / funeral.
5.May create professional problems for doctor.
6.May create social/public agitation/problems.

33. Natural death
Natural death means death occurring due to natural
disease or pathological condition or old age , debility in
which death is not intended or attempted and also does
not occur accidentally.

34. Unexpected and Sudden Death
Definition:
Death is biologically, legally, and literally an absolute and
irreversible event.
WHO Definition:
Who dies within 24 hours of symptoms appearing.
Forensic Definition:
Who dies in minutes or even seconds of the onset of the
symptoms.

35. Sudden death
Sudden death may be defined as a death which occur
suddenly or unexpectedly when a person not known to
have been suffering from any dangerous disease, injury or
poisoning is found dead or dies within 24hours after the
onset of terminal illness.
The incidence is approximately 10 percent of all deaths.
Death may be delayed in a survivor of cardiac arrest, but
"survival after cardiac sudden death” is an irrational term.
Currently the accepted definition (SCD) is natural death due to
cardiac causes, heralded by abrupt loss of consciousness
within 1 hour of the onset of acute symptoms.

36. Causes Of Sudden Death:
Where a natural death is very rapid, perhaps virtually
instantaneous,thecauses are as follows---
(I) Diseases of Cardiovascular system(40-50%):
Sudden Cardiac Death (SCD)
SCD must be carefully defined. In the context of time,
“Sudden” is defined, for most clinical and epidemiologic
Purposes ,as one hour or less between the onset of the
terminal clinical event , or an abrupt change in clinical
status, and death. A exception is unwitnessed deaths in
which pathologists may expand the definition of time to 24
hour after the victim was last seen to be alive an
stable.

37. (I) Diseases of Cardiovascular system(40-50%):
1.Coronary Artery Disease:(Narrowing and obliteration of the lumen by atherosclerosis.)
2.Coronary Atherosclerosis with coronary thrombosis.
3.Coronary Atherosclerosis with hemorrhage in the wall causing occlusion of the lumen.
4.Coronary Artery embolism.
5.Occlusion of the ostium of the coronary artery associated with Atherosclerosis or syphilitic aortitis.
6.Arterial hypertension with atherosclerosis.
7.Rupture of the fresh Myocardial Infarction.
8. Spontaneous Rupture of the aorta.
9.Angina Pectoris.
10.Pulmonary Embolism.
11.Systemic embolism occurring in bacterial endocarditis.
12.Rupture of aortic aneurysm or other aneurysm like circle of Willis.
13.Cardiomyopathies.
14.Lesions of the conducting system: fibrosis, necrosis
15.Valvular lesions: aortic stenosis/regurgitation, mitral stenosis, rupture of chordae, ball-valve thrombosis.
16. Fatty degeneration of heart
17.Acute Endocarditis.
18.Acute Myocarditis.
19.Acute Pericarditis.
20.Congenital Heart disease of new born.

38. (II) Diseases of Respiratory system(15-23%):
1.Lobar pneumonia.
2.Bronchitis and bronchopneumonia.
3.Rupture of blood vessels in pulmonary tuberculosis with cavitation.
4.Pulmonary embolism and infarction.
5.Air Embolism
6. Influenza
7.Diptheria
8.Acute edema of the glottis.
9. Acute edema of the lung.
10.Lung abscess.
11.Massive collapse of the lung.
12.Pleural effusion.
13.Pneumothorax caused by rupture of emphysematous bleb.
14.Neoplasm of bronchus
15.Bronchial asthma
16.Impaction of foreign in the larynx and regurgitation of stomach contents into air
passages and bronchioles.

39. (III) Diseases of Central Nervous system(10-18%):
1.Cerebral hemorrhage.
2.Cerebellar hemorrhage.
3.Pontine hemorrhage.
4.Subarachnoid hemorrhage.
5.Cerebral thrombosis and embolism.
6.Carotid artery thrombosis and embolism.
7.Brain abscess.
8.Brain tumor.
9.Meningitis.
10.Acute encephalitis.
11.Cysts of third or fourth ventricle
12.Epilepsy.

40. (IV) Diseases of Alimentary system(6-8%):
1.Haemorrhage into the gastrointestinal tract from peptic
ulcer, esophageal varices, cancer esophagus etc.
2.Perforation of ulcers, e.g. peptic, typhoid, amoebic or
malignant.
3.Acute hemorrhagic pancreatitis.
4.Strangulated hernia.
5.Twisting and intussusception of the bowel.
6.Paralytic ileus.
7.Appendicitis.
8.Bursting of the liver abscess.
9.Rupturede of enlarged spleen.
10.Intestinal obstruction.
11.Obstructive cholecystitis.

41. (V) Diseases of Genito-urinary system(3-5% ):
1.Chronitic Nephritis.
2.Nephrolithiasis.
3.Obstructive hydronephrosis and pyonephrosis.
4.TB of kidney.
5.Tumours of kidney and Bladder.
6.Rupture of ectopic pregnancy.
7.Toxaemia of pregnancy.
8.Uterine hemorrhage due to fibroids.
9.Cancer vulva eroding femoral vessel.
10.Twisting of ovary or ovarian cyst or fibroid tumour.

42. (VI) Miscellaneous(5 -10% ):
1.Addison‟s disease.
2.Diabetes Mellitus.
3.Haemochromatosis
4.Hyperthyroidism
5.Cerebral malaria.
6.Shock due to emotional excitement.
7.Reflex vagal inhibition.
8.Anaphylaxis due to drugs.
9.Mismatched blood transfusion.

43. Medico-legal Significance
In cases of sudden death, it is usually not possible to
certify the cause of death from an external examination of
the body.
In all such cases, an autopsy is necessary to obviate the
possibility of unnatural death. A doctor who issues a
death certificate in such a case runs the risk of being
accused as an accessory to a crime and obstructing the
course of justice, should the death be found eventually
due to foul play.

44. Thanks to all