بسم الله الرحمن الرحيم

الرحمن الله بسمالرحيم

Medicolegal importance of the death diagnosis

1- A death should not be certified as a natural death if suspicion of a accident ,homicidal or suicidal arise as I the following cases:-A- a young ,middle age adults known to be healthy.B- sudden death occurring outdoors(eg:- traffic accident ,…).

2- Death certification should be supported by the cause , mechanism and manner of death.

3-Physicians in ICU should rely on the clinical death criteria for diagnosis of death ,they should not switch off life support equipment and medicines as long as brain stem death is not legalized.

4- Diagnosis of death must be accurate to avoid premature burial.5- Death must be differentiated from suspended animation state .

Medicolegal importance of diagnosis of brain stem death:-1- To permit withdrawal of mechanical ventilatorIn countries allowing this.2- To prove the relation between the primary injury that placed the victim on mechanical ventillation and death ,as the assilant defense may claim that doctors caused victim death by switching of ventilator.3- To allow harvesting organs for transplantation in countries allowing this.

Clinical death (somatic death)

DDefinition: A total permanent cessation of circulation and

respiration as well as other vital functions.

Diagnosis of clinical death

(A) Examination of circulation:• Absence of radial and carotid pulse. heart beats by palpation. heart sounds by auscultation.• Contact the skin with hot object does not lead

to congestion, reddening or flushing.

• On cutting a small artery, no spurting of blood.• Webs between fingers become opaque on

transillumination in a dark room).• Injection of fluorescein does not lead to

yellow coloration of distant skin and conjunctiva.

• Flat ECG

(B) Examination of Respiration:• Absence of breath sounds and thoracic and

abdominal respiratory movements.• No condensation of water vapor.• No movement of a feather put in front of the

nose or lips.• No respiratory movement.

(C) Examination of nervous system:• Absent reflexes.• Flat EEG.D) Ocular signs:• No blinking, mucus is present over the cornea.• Corneal dimness.• Loss of corneal reflex.• Loss of light and accommodation reflex.

• Unequal dilated pupils.• Loss of intraocular pressure (softening of the

eye) triangular pupil.• Fundus pale empty arteries and segmented

retinal veins (trucking sign).

E) Primary flaccidity:• Loss of tone of both voluntary and

involuntary muscles all over the body ( drop of jaw).

• loss of facial wrinkles • complete body flaccidity and loss of power of

excitability to electric stimuli.

(F) Loss of skin and muscle elasticity (contact flattening): In bodies kept in supine position flattening of buttocks, calves and shoulders due to evacuation of blood by compression of veins and loss of muscle elasticity.

Brain death

Definition: It is a special form of clinical death created to overcome the problem which occurred after the discovery of organ transplantation.

OR: Irreversible end of brain cortical activity, brain stem activity or whole brain activity.

I-Cortical death

Definition:- When? the higher levels of cerebral activity are selectively lost the victim will exist in a “vegetative state”.

Then the victim may be in deep coma.A functioning brain stem so, spontaneous respiration and cardiac functions. The victim can remain in deep coma for years.

NB :-Debilitating complications as postural skin necrosis, muscle contractures and secondary chest infections may shorten life. Such vegetative patient is not considered dead.

II- Brain stem death (legal death)

Definition: It is the irreversible cessation of brain stem functions. At this stage arrangements may be made for organ and tissue donation.Causes:-Primary lesions in CNS.-Increased intracranial pressure due to:

-Head injuries.-Subarachnoid hemorrhage.-Cerebral edema.-Hypoxic damage affect the brain as in:• Heart attack.• Respiratory distress.

Mechanism:When the brain stem is damaged :- loss of vital centers (respiration ) ., incapable of spontaneous breathing (respiratory - motor system failure) and irreversible coma .

The majority of brain stem dead patients suffer cardiac arrest within 2-3 days, while adequately oxygenated.

Without medical intervention, cardiac arrest inevitably follows within minutes and then the usual progression of cellular death ensues.

Criteria for certification of brain stem death

• Patient must be in deep coma (not due to depressant drugs, metabolic, endocrine disorders or hypothermia).

• The patient must be on mechanical ventilation due to absence or inadequate spontaneous respiration.

• A firm diagnosis of the basic pathology must be available

• Rectal temperature must be above 35 degree.• Two licensed physicians who are not

members of the transplant team must write in the progress notes that the patient has irreversible and total cessation of brain stem function.

• Careful records should be kept.

• All the brain stem reflexes must be absent: 1-No light reflex, dilated Pupils fixed 2-No corneal reflex. 3-No gag reflex. 4-No vestibulo-ocular reflex. 6-No oculocephalic reflex 5-No motor response within the cranial nerve distribution after adequate stimulation of any somatic area. 6- Apnea test:-no respiratory movements when the patient is disconnected from the ventilator up to 10 minutes.

Molecular life:It is the time lapse between brain stem

death and cellular death (molecular death). This allows organ donation from recently dead bodies.Cellular (molecular) death:

In a particular cell, death is defined as the point beyond which irreversible cessation of cell functions occur = point of no return.

Determination of cellular death: Tissues vary in their tolerance to hypoxia: (brain cell, skin and bone) Cellular death can be diagnosed:Microscopically: by light or electron microscopy.Microchemically: by detection of the concentration of different chemical constituents inside the cell.Physically: by determination of changes in intracellular viscosity.

ExamplesThe ganglionic cells of CNS are highly sensitive to anoxia so it has short molecular life in comparison to renal cells which has less sensitivity to anoxia.Evidence of molecular life:-• Muscle contraction on electric stimulation

after somatic death.• Pupillary (ciliary)respons to atropine and

physiostigmine after somatic death.• Living sperms in the epididymis after somatic

death.

Medicolegal importance :-Proper timing for harvesting an organ for transplantation after certification of somatic death.

Suspended animationIt is a condition in which the vital functions of the

body are at such a low level that they cannot be appreciated by clinical examination

Apparent death

This may last few seconds to minutes. Voluntary- by yogis

Involuntary – drowning, electrocution, heat stroke, typhoid fever etc.

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