1. LECTURER , FORENSIC MEDICINE,MCST
DEATH
Medicolegal view
Dr. Aly Samy Somaa
MB.ChB,Msc,ABFMD,MD
LECTURER , FORENSIC MEDICINE,MCST
Dr. Aly Samy 2013
Dr. Aly Samy ,PSMCHS

2. Objectives: cont. To know the following
Differentiate properly between the cause of death, the mode and manner of death
Describe different phases of death
Discuss the molecular life
Dr. Aly Samy 2013
Dr. Aly Samy ,PSMCHS

3. Objectives: cont. To know the following
List the diagnostic criteria to diagnose somatic death and sure signs to avoid burial of comatose pt.
Discuss the accurate tests for diagnosis of
brainstem death and s condition of their application.
Discuss sudden death and causes.
Dr. Aly Samy 2013
Dr. Aly Samy ,PSMCHS

4. Objectives: cont. To know the following
Realize the importance of the followings:
- Time of death
- Manner of death
- Difference between natural and unnatural death.
Dr. Aly Samy 2013
Dr. Aly Samy ,PSMCHS

5. Diagnose of death the cause of death, the mode and the manner of death
Covers
the cause of death,
the mode and
the manner of death
Dr. Aly Samy 2013
Dr. Aly Samy ,PSMCHS

6. Any injury, disease or toxic substances that produces
1. Cause of death
Any injury, disease or toxic substances that produces
derangement
of the body function that lead to death of an individual
Dr. Aly Samy 2014
Dr. Aly Samy ,PSMCHS

7. Mode of death : ( mechanism of death):
physiological derangement of the body function that precipitates death of an individual
e.g .coma, hypotension etc.
Dr. Aly Samy 2014
Dr. Aly Samy ,PSMCHS

8. Manner of death: how the death came out
Homicide
Suicide
Accident
Natural
Unclassified.
Dr. Aly Samy 2014
Dr. Aly Samy ,PSMCHS

9. Phases of death 1. Somatic( clinical) death
Definition: irreversible loss of whole body function due to permenant cessation of vital functions ( respiration, circulation and CNS functions).
2. Molecular death
Death of the individual organs and tissue
Molecular life: is the period between somatic death and molecular death.
Dr. Aly Samy 2013
Dr. Aly Samy ,PSMCHS

10. Brain death
Irreversible cessation of cortical brain function (activity), brain stem or whole brain.
Dr. Aly Samy 2013
Dr. Aly Samy ,PSMCHS

11. Diagnosis of somatic or clinical death CRB
1. Cessation of circulation
2. Cessation of respiration
Cessation brain functions
Dr. Aly Samy 2013
Dr. Aly Samy ,PSMCHS

12. Diagnosis of death The diagnosis of death was based on the
finding of any of death signs:
I. Irreversible loss of respiratory function
II. Irreversible loss of cardiocirculatory functions
III. Irreversible loss of brain functions
IV. Algor mortis (postmortem coldness)
V. Livor mortis (postmortem lividity )
VI. Rigor mortis (postmortem rigidity)
VII. Cadaveric spasm
VIII Loss of muscle contractions
IX. Putrefaction
Signs I and II correspond to the classical
respiratory and cardiocirculatory functions. Signs
IV to IX are related to forensic circumstances,and out of the scope of this review.
Dr. Aly Samy 2013
Dr. Aly Samy ,PSMCHS

13. Complete Cessation of Circulatory Function
Magnus’s test
Diaphanous test
Icard’s Fluorescein test
Finger nail test
Heat test
Artery incision test
A flat E.C.G. for a continuous period of five minutes
Dr. Aly Samy ,PSMCHS

14. Magnus’s test
Magnus's Test. This is one of the most reliable tests, and consists of tying a ligature tightly round the base of a finger, sufficient to cut off the venous channels without occluding the arteries. The finger remains white, if circulation has entirely ceased, otherwise the seat of the ligature is marked by a bloodless zone, and the portion beyond it becomes gradually blue and swollen.
Dr. Aly Samy ,PSMCHS

15. Diaphanous test
Diaphanous Test. During life the webs of the fingers appear scarlet or very red and translucent, if the hand with the fingers abducted is held against a strong light, artificial or natural, while they appear yellow and opaque after death. The hand may, however, appear red in carbon monoxide poisoning, and yellow in anaemia or syncope.
Dr. Aly Samy ,PSMCHS

16. Icard’s Fluorescein test
The hypodermic injection of a solution of fluorescin
does not produce any discoloration of the skin, if circulation has stopped ;
but it renders the neighbouring skin yellowish- green, if circulation is still going on. The substance may also be detected in the blood drawn by pricking the skin at some distance from the seat of injection. If some white silk threads are immersed in the blood, and then boiled in a test-tube containing distilled water, the threads will "become greenish in colour
Dr. Aly Samy ,PSMCHS

17. Complete Cessation of Circulatory Function-cont.
On the application and withdrawal of pressure to the finger nail
It opaque not assumes alternately a white and a pink color as in life.
Finger nail test
, e.g. a burning match or melted sealing-wax to the skin will not produce- a true blister with a red line of demarcation,If circulation has stopped .
The application of heat
, there will be no jerky flow of blood, if
Circulation has stopped.
If a small artery is cut
Dr. Aly Samy 2013
Dr. Aly Samy ,PSMCHS

18. Entire and permanent cessation of respiratory function
Mirror test
Feather test
Winslow’s glass water test.
Dr. Aly Samy ,PSMCHS

19. The tests to determine the stoppage of respiration are
(a) The surface of a cold, bright looking-glass held in front of the open mouth and nostrils becomes dim, due to the condensation of warm moist air exhaled from the lungs, if respiration is still going on, but not otherwise. This test is useful in the cold weather.
 (b) There will be no movement of a feather or cotton fibers held in front of the mouth and nostrils if respiration has stopped, but this is not a reliable
test as the slightest draught of air or nervousness on the part of an observer will move the feather or cotton fibers.
Dr. Aly Samy ,PSMCHS

20. The tests to determine the stoppage of respiration cont.
(c) Winslow's Test. There will be no movement of an image formed by reflecting artificial or sun light on the surface of water or mercury contained in a saucer and placed on the chest or abdomen, if respiration has ceased.
Similarly, water will not be spilt from a vessel filled to the brim and placed on the chest or abdomen, if respiration has stopped
Dr. Aly Samy 2013
Dr. Aly Samy ,PSMCHS

21. What is Brain Death?
Irreversible end of all brain functions, including the brain stem
NOT the same as:
Coma
Usually some evidence of interaction
with environment
Reflexes, painful stimuli
EEG
Persistent Vegetative State
Sustained autonomic function
Heart, lungs, sleeping and waking cycles
Dr. Aly Samy ,PSMCHS

22. The patient must be comatose state at least six hours.
Brain –stem death:
The patient must be comatose state at least six hours.
All brain-stem reflexes must be absent.
Dr. Aly Samy ,PSMCHS

23. PERSISTENT VEGETATIVE STATE
Definition : Patient with severe brain damage in whom coma has progressed to
State of wakefulness without awareness.
Mechanism:Loss of the higher cerebral power but the brain stem functions as resp. circul . Are relatively intact.
Causes: massive cerebral infarction, head trauma,hypoxic encphalopathy and severe hypoglycemia.
Dr. Aly Samy 2013
Dr. Aly Samy ,PSMCHS

24. Basic exam 1 Pain Cerebral motor response to pain
Supra-orbital ridge, the nail beds, trapezius
Motor responses may occur spontaneously during apnea testing (spinal reflexes)
Spinal reflex responses occur more often in young
If pt had NMB, then test w/ train-of-four
Spinal arcs are intact!

25. Basic exam 2- Pupils Round, oval, or irregularly shaped
Midsize (4-6 mm), but may be totally dilated
Absent pupillary light reflex
Although drugs can influence pupillary size, the light reflex remains intact only in the absence of brain death
IV atropine does not markedly affect response
Paralytics do not affect pupillary size
Topical administration of drugs and eye trauma may influence pupillary size and reactivity
Pre-existing ocular anatomic abnormalities may also confound pupillary assessment in brain death

26. Basic exam 3-Eye movement
Oculocephalic reflex = doll’s eyes
Vestibulo-ocular = cold caloric test

27. Doll’s eyes Oculocephalic reflex
Rapidly turn the head 90° on both sides
Normal response = deviation of the eyes to the opposite side of head turning
Brain death = oculocephalic reflexes are absent (no Doll’s eyes) = no eye movement in response to head movement

28. Vestibulo-ocular reflexes; Oculocephalic
Oculocephalic reflexes are bilaterally absent.(Doll’s eye test)-eyes don’t move opposite to the head movement
Dr. Aly Samy ,PSMCHS

29. Cold calorics Irrigate both tympanic membranes with iced water
Observe pt for 1 minute after each ear irrigation, with a 5 minute wait between testing of each ear
Facial trauma involving the auditory canal and petrous bone can also inhibit these reflexes

30. Cold calorics interpretation
Nystagmus both eyes slow toward cold, fast to midline
Not comatose
Both eyes tonically deviate toward cold water
Coma with intact brainstem
Movement only of eye on side of stimulus
Internuclear ophthalmoplegia
Suggests brainstem structural lesion
No eye movement
Brainstem injury / death

31. Basic exam 4 Facial sensory & motor responses
Corneal reflexes are absent in brain death
Corneal reflexes - tested by using a cotton-tipped swab
Grimacing in response to pain can be tested by applying deep pressure to the nail beds, supra-orbital ridge, TMJ, or swab in nose
Severe facial trauma can inhibit interpretation of facial brain stem reflexes

32. Examination of the eyes
pupils are fixed not respond to intense light.
pupils stop reacting to light
(Light reflex abolished
No corneal reflex
Corneal Changes;
Loss of Clear Glistening
Dry, Cloudy and opaque
Dr. Aly Samy 2013
Dr. Aly Samy ,PSMCHS

33. Basic exam 5 Pharyngeal and tracheal reflexes
Both gag and cough reflexes are absent in patients with brain death
Gag reflex can be evaluated by stimulating the posterior pharynx with a tongue blade, but the results can be difficult to evaluate in orally intubated patients
Cough reflex can be tested by using ETT suctioning, past end of ETT

34. APNEA TEST FOR DETERMINATION OF CLINICAL BRAIN DEATH
It is recommended that the apnea test be performed as follows:
1. Prerequisites:
Core Temperature 36.5°C or 97°F
Systolic blood pressure 90 mm Hg
Normal PCO2 (Arterial PCO2 of mm Hg)
2. Preoxygenate with 100% O2 for 30 minutes
3. Connect a pulse oximeter and
disconnect the ventilator
Dr. Aly Samy 2013
Dr. Aly Samy ,PSMCHS

35. APNEA TEST FOR DETERMINATION OF CLINICAL BRAIN DEATH
4. Place a nasal cannula at the level of the carina and deliver 100% O2, 8 L per minute
5. Look closely for respiratory movements (abdominal or chest excursions that produce adequate tidal volumes)
6. Measure PO2, PCO2, and pH after 10 minutes and reconnect the ventilator
7. If respiratory movements are absent and arterial PCO2 is 60 mm Hg (option: 20 mm Hg increase in PCO2 over a baseline normal PCO2), the apnea test result is positive (supports the diagnosis of brain death)
Dr. Aly Samy 2013
Dr. Aly Samy ,PSMCHS

36. Diagnosis of brain death
Cases should be excluded before declaring brain death
o Patients under effects of drugs.
o Core temp. of the body shouldn’t be less than 36.5
o Shouldn’t be suffering from endocrine or metabolic disturbance
Dr. Aly Samy 2013
Dr. Aly Samy ,PSMCHS

37. 1. Tests: Examination of the eyes
Intra Ocular tension falls, eye balls
become flaccid and sink in the orbit
Blood flow in the retina becomes dotted and segmented look(fragmentation
of columns of blood)
Dr. Aly Samy ,PSMCHS

38. Tests: Additional No motor response. No gag reflex. Apnea test:
Dr. Aly Samy 2013
Dr. Aly Samy ,PSMCHS

39. Confirmatory Tests Electrical activity Electroencephalography (EEG)
Cerebral blood flow = perfusion scan
Cerebral Angiography
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40. Early changes Changes in the eye Changes in the skin
Cooling of the body/Algor mortis
Post mortem lividity/Hypostasis
Rigor mortis/Cadaveric rigidity
Dr. Aly Samy ,PSMCHS

41. Severe hypothermia (31-32) Hypostasis Lab findings
Early signs of postmortem changes as: Supporting evidence of somatic (clinical death)
Severe hypothermia (31-32)
Hypostasis
Lab findings
Hyperkalemia ≥8 mmol/l
Severe acidosis ≤ 6.7
Dr. Aly Samy 2013
Dr. Aly Samy ,PSMCHS

42. Changes in the Skin Loss of its translucency
Pale and Ashy white appearance
Loss of Elasticity
Wounds will not gape if it is inflicted after death
Wounds caused during life will retain their characteristic features.
Dr. Aly Samy ,PSMCHS

43. Changes in the Skin cont.
paleness of the skin, conjuctivae and mucous membranes due to fall of blood pressure and cessation of circulation of the blood
Skin of the face and the lips may remain red or blue in hypoxic/congestive deaths
Dr. Aly Samy ,PSMCHS

44. Changes in the Muscles Primary relaxation/ Flaccidity
Rigor mortis/Cadaveric rigidity
Secondary relaxation
Dr. Aly Samy ,PSMCHS

45. Primary relaxation(flaccidity)
Starts immediately after death with generalised relaxation of muscle tone:
Drop of lower Jaw
Eye balls lose their tension
Pupils are dilated
Joints are flabby
Smooth relaxation- incontinence of Urine and Faeces.
Dr. Aly Samy ,PSMCHS

46. Early changes; primary flaccidity
complete loss of tone
loss of muscle tone in the sphincters
(voiding of urine)
emission of semen
regurgitation
very common feature of terminal collapse
common complication of resuscitation
Dr. Aly Samy ,PSMCHS

47. Early changes;primary flaccidity cont
may retain reactivity
may respond to touch and other forms of stimulation hours after cardiac arrest
focal twitching decreases with time (discharges of dying motor neurons)
Dr. Aly Samy ,PSMCHS

48. Postmortem Lividity; Livour mortis.
It means discolouration or staining of the skin and organs after death due to accumulation of fluid blood in the dependent parts of the body hr. Starts 6-8 hr. Fixes.
Dr. Aly Samy ,PSMCHS

49. Postmortem Lividity Commencement of Lividity Development of lividity
Fixation of lividity
Site of distribution
Pattern
Extent
Difference between lividity and bruise.
Dr. Aly Samy ,PSMCHS

50. Medico-Legal Importance
It is a reliable sign of death
It gives the information about the position of the body at the time of death
Time since death can be estimated
Colour suggest the cause of death
Distribution of lividity may give the information about the manner of death
Dr. Aly Samy ,PSMCHS

51. Rigor Mortis/ Cadaveric rigidity :
This phenomenon comes immediately after the muscles have lost the power of contractility and is irreversible changes in the muscles of the body, both voluntary and involuntary. Myofibrils Myosin and Actin Adenosine Triphosphate – A.T.P.?
Dr. Aly Samy ,PSMCHS

52. Rigor Mortis/ Cadaveric rigidity :
Time of Onset :
Temperate climates – 3-6 hours
Tropical climates – 1-2 hours
Rigor mortis generally occurs when body is cold.
Not related to nerves action
Develops in paralysed limbs also
First appear in involuntary muscles
Last to be affected finger and toes muscles.
Dr. Aly Samy ,PSMCHS

53. Rigor Mortis/ Cadaveric rigidity :
Duration :
* Temperate climate – lasts for 2-3 days.
Tropical climate – 24 – 48 hours in winter
hours in summer
In general – 1-2 hours sets on
for , 12 hours develops
for hours maintaines
and after 12 hours passes of
Dr. Aly Samy ,PSMCHS

54. Rigor Mortis/ Cadaveric rigidity :
Circumstances modifying the
Onset and Duration of Rigor mortis.
Age- Rigor Mortis is very rare in premature infants. Rigor –mortis is slow in adolescent and healthy adults Muscular condition and activity before death. Onset is slow and duration is longer in muscular and healthy body at rest.
Dr. Aly Samy ,PSMCHS

55. The effect of manner of death :
Rigor Mortis/ Cadaveric rigidity :
The effect of manner of death :
In wasting disease and great exhaustion- cholera, plague, typhoid, T.B. Cancer etc. the onset is early and disappears soon.
In diseases – Pneumonia, asphyxia and nervous conditions- onset is delayed Atmospheric conditions:
In dry and cold air-onset slow and lost for long time. Warm and moist air onset is rapid and duration short.
Dr. Aly Samy ,PSMCHS

56. Conditions Simulating Rigor-Mortis
Heat Stiffening
Cold Stiffening
Cadaveric Spasm
Dr. Aly Samy ,PSMCHS

57. Secondary Relaxation :
Muscles become soft and Flaccid
Do not respond to a mechanical and electrical stimulus.
Dr. Aly Samy 2013