Dr.

Sohayla M. Attalla

Assoc. Prof. Forensic

Medicine & Clinical Toxicology

Definition of death
Irreversible loss of properties
of living matter

DEATH
It is the loss of the integrity of
three

principal

interdependent

vital systems:
Circulation
Respiration
Asphyxia
C .N .S.

Syncope

Coma

1- Syncope:
Cardiovascular
by:

failure

is

manifested

1. Fainting & blurring of vision.

2. Marked pallor of the skin & mucous
membranes all-over the body.

3.
4.
5.
6.

Subnormal body temp.

Cold clammy sweating.
Weak rapid pulse.
Low Bl. pr.

2- Asphyxia:
Respiratory failure is manifested
by:

1. Cyanosis of the skin & mucous

membranes.

2. Dyspnea & respiratory distress.

3- Coma:
Failure of CNS is manifested by:

1. Loss of consciousness.
2. Signs

of

respiratory
cyanosis.

both
failure

circulatory
as

pallor

&
&

Stages of Death:
There are two phases of
death:
Somatic (clinical) death
Cellular (Molecular) death

In between there is a
Molecular life

Phases of death
I- Somatic death ( clinical) death
irreversible loss of the vital functions
of the brain, heart and lung.

Somatic death (Clinical death):

It is due to complete and irreversible cessation
of vital functions of the brain, heart and lungs.
After somatic death, the tissues and cells
continue to survive for variable periods of time,
depending on their oxygen requirements.
During this period, cells can respond to chemical
and electrical stimuli, the pupils also dilate with
atropine and constrict with physostigmine.

Phases of death
I- Somatic death ( clinical) death
irreversible loss of the vital functions
of the brain, heart and lung.

II- Cellular ( molecular) death

death of all tissue cells, it follows
somatic death & occurs after variable
time of somatic death (few minutes to
hours) depending on tolerance to
absence of O2

Molecular death (Cellular death):

It occurs when the individual cells
die, it is accompanied with cooling
and changes in the eye.
Molecular
death
is
generally
completed within 3-4 hours of
somatic death.

Diagnosis of somatic death is not always

easy in the following conditions:
1.Suspended
animation
(apparent
death).
2.Coma following acute toxicity by
sedatives or hypnotics especially
barbiturate coma.
3.Hypothermia particularly in old age.

Molecular life:
- It is gap between somatic & molecular
death
- During this period:
*Cells continue to survive for variable
time,
depending
on
their
oxygen
requirements
So organ transplantation can be done
*Cells respond to chemical and electrical
stimuli, e.g. pupils dilate with atropine
and constrict with physostigmine

Molecular life:

*M.L.I of distinction between somatic

and molecular death:
1-To prevent premature
apparent
death.
2-Organ transplantation:
3-Inheritence:

burial

in

Diagnosis of death is based on:

SIGNS OF DEATH
I- Signs due to stoppage of respiration
2- Signs due to stoppage of circulation
3- Signs of brain death
4- Primary flaccidity
5- Contact flattening
6- Ocular signs

Early signs of death

1) Cessation of respiration:
Absent breath sounds for at least 5
minutes
It must be complete and continuous to
constitute a proof for death.
Respiration may cease temporarily for a
very short period without death in some
conditions, such as:
An apparently drowned person.
Newly born infants.

Early signs of death

2) Cessation of circulation:
A.Heart sounds are not heard for a
continuous period of 5 minutes.
B.Absence of radial or carotid arteries
pulsation.
C.Flat ECG.

Early signs of death

3) Signs due to loss of the vital functions of the brain:
A) Signs due to death of cerebral cortex:
1- Flat EEG: "cerebral silence".
Flat EEG alone should never be taken as a conclusive
evidence of death, because temporary silence (temporary flat
EEG) can follow many conditions such as:
* Trauma, including birth injury.
* Circulatory arrest.
* Prolonged fainting attack. * Hypoglycaemia.
* Narcotic and CO Poisonings.
*
Encephalitis.
* Epilepsy.
* Electrocution.
2- Cessation of circulation through the retinal veins
within 10 seconds of clinical death.
3- Lack of responsiveness to internal and external
environment.
4- No muscular movement with generalized flaccidity.

Early signs of death

B) Signs due to brain stem death:

All brain-stem reflexes are absent.
1. Pupils are dilated AND fixed
2. Absent corneal reflexes.
3. The vestibulo-ocular reflexes are
absent.
4. Absent gag and cough reflexes.
5. No spontaneous respiration.
6. Falling of arterial blood pressure
without support by drugs.

B) Signs due to brain stem

death:
1.The pupils are fixed in diameter and do
not respond to changes in the intensity of
light.

2.There is no corneal reflex.

3.The vestibulo-ocular reflexes are absent,
i.e. no eye movement occurs after the
installation of cold water into the outer
ears.

4.No motor responses within the

cranial nerve distribution can be
elicited

by

painful

or

other

sensory stimuli, i.e. the patient

does not grimace in response to a
painful stimulus applied to the
face or to the limbs.

5.There is no gag reflex to bronchial

stimulation by a suction catheter
passed down the trachea.

6. No respiratory movements occur

when the patient is disconnected from
the ventilator for long enough to
ensure that the carbon dioxide
concentration in the blood rises above
the
threshold
for
stimulating
respiration i.e. after giving the patient
100% oxygen for 5 minutes the
ventilator is disconnected for up to 10
minutes. If no spontaneous breathing
of any sort occurs within that 10
minutes the brain stem is incapable of
reacting to the presence of the carbon
dioxide and is thus dead.

Brain stem death:

It is permanent, i.e. irreversible stoppage of all
vital centers in the brain stem, which
maintain
spontaneous
breathing
and
circulation of the blood,
In other words it could be defined as the
irreversible cessation of the brain-stem
functions. It does not include, for example,
death of cortical areas of the brain, so brain
death does not mean cortical death therefore
a flat EEG is not diagnostic of death.

Conditions to be excluded before

diagnosis of brain death

1- core temperature below 35 c

2- toxic coma by hypnotics e.g
barbiturate
3- apparent death

IV- primary flaccidity

*Definition:
-Generalized
muscular
relaxation
(voluntary and involuntary) with loss of
reflexes due to loss of muscle tone
-Occur immediately after death and last
for 2 h
-muscles are responding to electrical
stimulation

*Characters:

*Dropped lower jaw.

*Disappearance of wrinkles in the face
*Dilated pupils

V-Contact flattening
*Definition
Flattening of body on pressure
areas due to loss of the muscle
tone and elasticity

*Example
When the body is kept in supine
position on a solid surface, its
convex parts (i.e. buttocks, and
calves) become flat.

VI. Ocular signs of death:

1.Loss of light reflex
2.Loss of corneal reflex
3.Reduction of the intra-ocular pressure (due
to cessation of circulation in retinal vessels
and softening of the anterior chamber).
4.Clouding (haziness) or loss of corneal
luster except in cases of death from
asphyxia or poisoning by cyanide or CO.

Clouding (haziness) of cornea.

VI. Ocular signs of death:

5. Ophthalmoscopic examination reveals
segmentation of the retinal veins and
empty retinal arteries.

VI. Ocular signs of death:

6. "Taches de Noir " appear on the sclera
within 3 hours from death, if the eyes
remained open. These are areas of
brownish discoloration formed on the
exposed sclera. These spots are
triangular, based directly on the
cornea, often on the outer more than
the inner side of the globe. They are
possibly due to desiccation of tissues or
formation of cellular debris.

VI. Ocular signs of death:

6. Taches de Noir de la sclerotic

VI. Ocular signs of death:

1. Loss of light reflex
2. Loss of corneal reflex
3. Reduction of the intra-ocular pressure (due to
cessation of circulation in retinal vessels and
softening of the anterior chamber).
4. Clouding (haziness) or loss of corneal luster except
in cases of death from asphyxia or poisoning by
cyanide or CO.
5. Ophthalmoscopic examination reveals segmentation
of the retinal veins and empty retinal arteries.
6. "Taches de Noir " appear on the sclera within 3 hours
from death, if the eyes remained open. These are
areas of brownish discoloration formed on the
exposed sclera. These spots are triangular, based
directly on the cornea, often on the outer more than
the inner side of the globe. They are possibly due to
desiccation of tissues or formation of cellular debris.

Medicolegal importance of
death diagnosis :

 Medicolegal importance of death

1. To prevent premature diagnosis
burial or :
storage in the refrigerator in
cases of apparent death.

2. Organ transplantation.
3. Inheritance.

Legal steps for diagnosis of

death before
ORGAN TRANSPLANTATION

* Organs may be transplanted from:

Living donor, it is possible to transplant
one kidney.
A

cadaver,
pancreas,
heart.

the
small

eyes,

kidneys,

intestine,

liver,

lungs

&

*Preconditions of diagnosis:

1. The

patient

must

be

deeply

comatose.

2. The patient must be maintained on a

ventilator.

3. The cause of the coma must be

known.

*Exclusions:

1. Where the patient may be under

the
effects
of
drugs
e.g.
therapeutic drugs or overdoses

2. Where the core temperature of the

body is below 35C.

3. Where the patient is suffering from

severe

metabolic

or

endocrine

disturbances which may lead to severe

but reversible coma e.g. diabetes.

*Personnel:

1. The brain stem death tests must be

performed by two medical practitioners.

2. The doctors involved should be experts

in this field. Under no circumstances are
brain stem death tests performed by
transplant surgeons.

3. At least one of the doctors should be of

consultant status. Junior doctors are not
permitted to perform these tests.

4. Each doctor should perform the tests

twice.

so:
- Two qualified medical practitioners ,
not included in the team of
transplantation
- One of them at least is consultant
( no junior doctors)
- Each one should do the test twice

Once two doctors have performed

these tests twice with negative results
the patient is pronounced dead and a
death certificate can be issued. It is at
this stage that a decision concerning
the use of organs for transplantation
purposes may be raised & the decision
made as to the whether the corpse
should be maintained on the ventilator
until the organs may be harvested.

Tests include:1- fixed dilated pupils

2- absent corneal reflex
3- absent vestiblo-ocular reflex
4- absent gag reflex
5- absent response to painful
stimuli
6- absent spontaneous respiration

Apparent death
(suspended animation)

Apparent death (suspended animation)

Definition:
*It is death like state, in which there is:1-temporal suspension of circulation and
respiration.
2-depression of vital processes to a
minimum compatible with life.
*However respiration does not stop at
cellular level, so resuscitation is possible
It may persist from few seconds to several
minutes.

Apparent death (suspended

animation):

It may occur in the following conditions:

1.Electrocution.
2.Drowning especially in cold water.
3.Hypothermia,
4.Starvation

Apparent death (suspended

animation):

It may occur in the following conditions:

1.Electrocution.
2.Drowning especially in cold water.
3.Hypothermia,
4.Starvation
5.Heat stroke.

Apparent death (suspended

animation):

It may occur in the following conditions:

1.Electrocution.
2.Drowning especially in cold water.
3.Hypothermia,
4.Starvation
5.Heat stroke.
6.Shock following accident or anaesthesia.
7.Poisoning with narcotics causing deep coma.
8.Cerebral concussion.
9.Newborn.

Apparent death (suspended

animation):

It may occur in the following conditions:

1.Electrocution.
2.Drowning especially in cold water.
3.Hypothermia,
4.Starvation
5.Heat stroke.
6.Shock following accident or anaesthesia.
7.Poisoning with narcotics causing deep coma.
8.Cerebral concussion.
9.Newborn.
10.It can be induced voluntarily by some
persons (Yogist) and they can continue it for
longer periods.

Voluntary apparent death

(Yogist)

SUDDEN DEATH
Definition:
Unexpected death of an apparently
healthy person due to a disease which has
developed in a silent manner.
In such cases:
The medicolegal expert should perform
postmortem examination to :
- Exclude trauma and poisons
- Prove that death is due to pathology

Causes:
A-Pathological causes
I) Acute circulatory failure:
1-Cardiac causes
*Congenital heart diseases.
*Coronary insufficiency
*Cardiac tamponade
*Valvular heart diseases
*Pericardial or myocardial diseases
*Reflex vagal inhibition of the heart
2-Peripheral causes
*Fulminating viral infection
*Pathological hemorrhage

II) Respiratory failure:

*Pulmonary embolism.
*Laryngeal edema
III) Diseases of the central nervous
system:
*Intracranial hemorrhages.
*Diseases of the brain (congenital or tumor or
abscess)
b- Traumatic causes
c- Poisoning causes
d- Unexplained causes (-ve autopsy)

Death Certificate
Cause of death:
traumatic
pathological
toxic
natural

Death Certificate
Manner (Mode) of death:
It is the way in which the cause of death was
produced. It may be:
Natural: if death occurs exclusively from
disease.
Unnatural or violent: if death occurs
exclusively by injury or is hastened due to
injury in a person suffering from natural
disease. Violence may be suicidal, homicidal,
accidental or of undetermined or unexplained
origin. Manner of death is established mainly
by the investigational information and also by
the pathological findings.

Death Certificate
Mechanism of death:
It is the physiological or biochemical
disturbance produced by the cause
of death which is incompatible with
life e.g., shock, sepsis, toxaemia,
severe metabolic acidosis and
alkalosis, ventricular fibrillation,
respiratory paralysis, etc.

Quiz 1

1
Apparent death may be
associated with the following
except:
A.
B.
C.
D.
E.

Intact brain stem reflexes.

Segmentation of retinal veins.
Subnormal temperature.
Cerebral concussion.
Shock.

2
The most common cause of
sudden death is:
A.
B.
C.
D.
E.

Cardiovascular disease.
Pulmonary embolism.
Intracranial haemorrhage.
Perforated peptic ulcer.
Acute pneumonia.

4
Cortical brain death is diagnosed
by:
A.
B.
C.
D.
E.

Absent corneal reflex.

Falling of blood pressure.
Absent spontaneous respiration.
Flat EEG for 6 hours.
Absent vestibule-ocular reflex.

5
Brain stem death is
characterized by the following
except:
A.
B.
C.
D.
E.

Absent gag reflex.

Absent spontaneous respiration.
Segmentation of retinal veins.
Falling of blood pressure.
None of the above.

sohayla@msu.edu.my