1. Death and postmortem changes (II)
Dr. Asmaa Fady
Ph D., MSC., M.B, B.Ch

2. Learning objectives: By the end of the lecturer, the students should
Recognize Postmortem changes, under each one we have to know, its definition, mechanism, medico-legal importance & factors affecting it.
Give hint about Brain death: definition, types, causes, diagnosis, precautions before certifying it.
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5/19/2019

3. Primary flaccidity of skin
How to Diagnose Death
Diagnosis of death
Immediate signs
Skin and eye changes
Primary flaccidity of skin
Cessation of
RS, CVS & CNS
Postmortem changes
*Coolness
*Hypostasis
*Rigor Mortis
*Putrefaction
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4. Postmortem changes IV) putrefaction
Definition:
It is the last stage that takes place in the dead body with its resolution from organic to inorganic state.
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5. Postmortem changes IV) putrefaction
Mechanism:
Proteolytic, glycolytic, and lipolytic enzymes released from the cells act on body tissues  their softening and liquefaction (auto digestion of organs).
Aerobic & Anaerobic organisms present in intestinal tract invade mucous membranes shortly after death and spread all over the body. They produce enzymes that breakdown body tissues with gas evolution.
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6. Postmortem changes IV) putrefaction
The liberated gases are a mixture of bad odorous gases like hydrogen sulphide, ammonia, methane with a bad odor froth coming from mouth and nose.
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7. Putrefaction and PM interval:
1- After 24 hours in summer or 36 hours in winter:
Greenish discoloration of skin of the anterior abdominal wall starts opposite to the right iliac fossa, due to the presence of caecum in this place which contains fluid full of bacteria.
2- After 2 days:
Formation of gases inside the blood vessels causing their distention (arborization) under the skin and mucous membranes (marbling phenomenon).
3- After 1-3 days:
Green discoloration is all over.
The face is swollen, the features are difficult to recognize.
Distention of the abdomen and scrotum
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8. Putrefaction and PM interval:
4- After one week:
Putrefactive bullae under the skin.
Protrusion of the eyes & tongue.
Foul coarse bloody froth at the mouth and nostrils.
5- After two weeks:
Peeling of the skin
Abdominal wall will burst due to putrefactive gases.
Viscera are liquefied to a dark doughy mass which percolates into the ground.
Eggs of flies will become larvae .
The body color gets black and the hairs and nails fall.
6- After 6 months:
Smelly bones attached with ligaments are present.
7- After one year:
Ligaments dissolve leaving nothing but loose bones.
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9. 5/19/2019
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11. اسم ورقم المقرر – Course Name and No.
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12. Conditions that may replace putrefaction: 1)Adipocere formation
Definition:
It is a PM change replacing putrefaction. It occurs in cases of bodies kept under water for long time.
It begins to form after 3 weeks, completed after 6 months.
Mechanism:
It is due to hydrogenation of the non-saturated body fats (palmitic and oleic) into saturated (stearic) hard fat forming adipocere which is yellow, greasy, wax-like substance with a rancid smell.
Site:
It develops usually in cheeks, breast, buttocks and abdomen. It is common in females..
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5/19/2019

13. Medico-legal importance of adipocere formation:
1- It denotes long submersion under water. 2- Estimation of the time passed since death (from 3 weeks to 6 months). 3- Identify the person as it preserves the body features. 4- It gives an indication about the cause of death as it preserves the pre-existing injuries or trauma.
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15. Adipocere formation
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16. Conditions that may replace putrefaction: 2- Mummification
Definition: - It is PM change replacing putrefaction. It is natural process for preservation of the body by natural causes (high temperature, dry atmosphere and sandy soil). Mechanism: - It is due to dryness of the body by the high temperature and absence of the humidity (as in Upper Egypt) prevents growth of organism and preserves the body Site: - It starts in the most exposed parts of the body (lips, tip of nose, fingers & toes) and then the process extends to the rest of the body. - The body is shriveled, odorless and often black in color. The skin is hard, leathery and adheres to the shrunken tissue.
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18. Medico-legal importance of mummification:
1- Estimation of the time passed since death (from 3 weeks to 1 year).
2- Identify the person as it preserves the body features.
3- It gives an idea about the cause of death as it preserves the pre-existing injuries or trauma.
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19. Conditions that may replace putrefaction: 3- Maceration
 Definition:
It is a PM change replacing putrefaction. It is due to aseptic autolysis that occurs in the body for a fetus that had died in uterus and remains in the membranes in a sterile condition.
Characters:
- Brown red discoloration of the skin with blisters.
- Flaccidity of the body.
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20. BRAIN DEATH Definition:
Irreversible loss of all functions of the brain.
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21. Types of brain death:
(1) Cortical or cerebral death: With an intact brain stem (vegetative state/life).
It is characterized by:
Deep irreversible coma
Unresponsive to external stimuli (visual, auditory, tactile stimuli except, possibly, pain stimuli)
Spontaneous respiration & cardiac functions.
Such cases are not considered dead and can live without resuscitation for long periods amounting to years if they receive good nursing care and nutritional support.
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22. Types of brain death: (2) Brain stem death: It is characterized by:
Deep irreversible coma
Absence of spontaneous respiration followed by cardiac arrest.
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23. Causes of brain death:
Intracranial hemorrhage (traumatic/pathological)
Cerebrovascular accidents: emboli, ruptured aneurysm, infection
Cerebral ischemia: sudden cardiac arrest, thrombosis
Cerebral edema.
Cerebral laceration: gunshot injuries
Cerebral anoxia: drowning, respiratory diseases, toxicity (CO, CNS depressants)
Cerebral tumors.
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24. Precautions taken before certifying brain death:
1- Tests should be carried out by three specialists as neurologist, anesthetist, intensive care physician or neurosurgeon.
2- Tests should be carried out twice separated by an interval (as mentioned before).
3- If there are any doubts about the diagnosis, the patient support must be continued.
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25. Precautions taken before certifying brain death:
4- After confirmation of brain death, death certificate can be issued while any continual ventilation (to allow organ donation) does not constitute life.
5- Exclude any physician relationship between those involved in the diagnosis of brain death and the transplantation team or the recipient.
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