Sudden unexpected death

Dr David Chumba
MBcHB, MMED (Human
Pathology), Dip. For Med (SA)
• Sudden unexpected death is defined as death
occurring 24 hr after the onset of symptoms
(WHO).
• It can be due to natural or unnatural causes
• They are medicolegal cases because a death
certificate cannot be signed and a cause of
death must be ascertained. Sudden death may
be associated with injuries either falls or cut
wounds and homicide or suicide must be ruled
out
• A specific type of sudden death is seen in
infants called SIDS
• The majority of sudden death in adults arise
from heart and vascular diseases
• Autopsy considerations: These are approached
systematically according to ste guidelines. The
cause of death is dependent on several factors
including age, race, sex and appearance and
the autopsy may indicate one of the following:
– The presence of structural abnormalities that
establish that establish the cause of death as it is
incompatible with life
– Autopsy changes seen is sufficient to account for
the cause of death
– The cause of death is established by the aid of
negative anatomical, histological, biochemical,
toxicological and other investigations
• The cause of death is 90% cardiovascular, pulmonary
and central nervous systems
• When there is negative structural findings the following
is followed in trying to establish the cause of death.
Biochemistry, histology, toxicological analysis for
illegal and other drugs from blood and stomach
contents, the liver and one kidney
• In our set up there are about 90% of sudden deaths
occur above 30 years of age, the commonest cause is
cardiovascular sytstem disorders and is mainly due to
myocardail infarction arising from prolonged
hypertension.
• There is also a common finding of pulmonary
thromboembolism in women
• Heart and blood vessel diseases:
– Acute MI account for 46% of sudden deaths, commonly due to
atherosclerosis, thrombosis and at least 75% of the lumen must be
occluded before an infarct can occur
– High blood pressure: This is the major risk factor for atherosclerosis and
sudden cardiac death
– Cardiomyopathy hypertrophic, constrictive etc
– Myocarditis : This is usually due to a virus histology will confirm infection
– Heart valve diseases mainly RHD, prolapsed mitral valve narrowed
aortic valve due to calcium deposition
– Disease of the large vessels e.g. aneurisms due to syphilis
• Lung and airway diseases
– Pulmonary thromboembolism, this means the source must be sort
including dissection of the calf muscle
– Heamoptysis mainly due to TB and lung cancer can also be a cause of
death
– Bronchial asthma, this leads to hypoxia which will cause arythmias and
death
– Pneumonia. This is the most frequent cause of death in alcoholics
• Brain
– Stroke. This refers to a blood clot or hemorrhage. The cause of death is
due to direct damage to the parts of brain controlling breathing or
circulation
– Inflammation of the brain (encephalitis) or its covering meningitis by
viruses, bacteria may lead to sudden death
– Fits and epilepsy
• Stomach and intestines
– Ulcers :Duodenal ulcers are by far the commonest leading to perforation
and acute peritonitis. Hemorrhage may also lead to death
– Pancreatitis: This common in women who are fat and age fourty and
excessive alcohol intake or bile stones
– Chronic liver diseases leading to oesophageal varices which can cause
severe and fatal hemorrhage
• Kidney and reproductive system:
– Complications of pregnancy including severe hemorrhage due to ectopic
pregnancy, perforated uterus seen in criminal abortions and retained
placenta leading to uterine atony
– Pyelonephritis may lead to septiceamia and sudden death
• Endocrine system:
– Diabetes may lead to coma and death
– Adrenal gland failure due to prolonged use of steroids
• Post mortem diagnosis of MI:
– 12-24 hrs show no naked eye changes, there might be
edema of the affected muscles cut sections show a dry matt
appearance
– 2-3 days there a demarcated area which is seen to turn
yellowish in colour
– After the third day the myocardium becomes friable referred
to as ‘myomalacia cordis’ and the risk of myocardial rupture
is much higher
– From the third week the centre of the lesion becomes
gelatinous and healing and replacement by fibrosis stes in
– Enzyme histochemistry of the myocardial muscle shows
variation of the cardiac enzyme activity in the affected area
6-8 hours
– Histologically early lesions are seen as swelling and more
pinkish appearance with granular cytoplsam
• Complications of MI: Rupture of the heart is the
commonest complication leading to hemopericardium
and cardiac tamponade
• Mural thrombosis: This is more common on the left
ventricle
• Pericarditis usually early in after an MI
• Myocardial fibrosis
• Cardiac aneurysms
• Hypertensive heart disease: This may kill in several
ways, renal failure, ruptured aneurysm, cerebral
hemorrhage or acute cardiac failure
• The upper limit of heart size is 360-380 g but in
hypertensive heart disease the heart is usually 500-
700 g. Hearts bigger than this are due to valvular
disease or cardiomyopathy. Diagnosis is based on
concentric hypertrophy in the absence of valvular
diesis
• Sudden death from cardiomyopathy: The heart is usually more
than 700 g. There is congestive cardiomyopathy where the
heart is globular both hypertrophy and dilatation of the
chambers
• Hypertrophic obstructive cardiomyopathy usually due to
hypertrophy of the interventricular septum with obstruction of
the out flow
• The heart is more than 700 g when measured and it can be
either dilated or restrictive cardiomyopathy
• It relatively rare
• Coronary artery spasms are not easy to prove at post mortem
but is known to be a cause of MI
• In young adults coronary artery disease and atherosclerosis is
leading followed by hypertensive left ventricular hypertrophy.
Viral myocarditis has been found especially in HIV patients,
dilated cardiomyopathy especially due to alcohol is seen.
Dissecting aneurysms have also been reported though rare
than adults
• In the elderly over 75 yrs have cardiac failure and 30% due to
hypertension
• Sudden death due respiratory
– Thromboembolism
– Heamoptysis
– Acute bronchial athma
– Pneumonia confluent brochopneumonia
– Respiratory obstruction eg acute epiglotitis due h. influenza
• Sudden death due CNS
– Massive subarachnoid hemorrhage is the commonest due to rupture of a
berry aneurysm of the cycle of Willis, rarely arteriovascular malformation
can also present with sudden death
– Epilesy: Epileptics may die suddenly due to predisposition to drowning,
accidents, asphysxia
– Meningitis, this is rapidly fatal unless treated fast
– Spontaneous intracerebral hemorrhage: This is due to atherosclerosis
and hypertension. The most common artery is lenticulo-striate branch of
middle cerebral artey and is seen as hemorrhages into the nuclear
• A special type of sudden death is seen in infants known as
Sudden Infant Death (SIDS)
• SIDS has been defined as sudden of an infant under one year
of age which remains unexplained even after a compete
autopsy, examination of the scene of death and review of the
case history
• If the above has been satisfied then the cause of death can just
be attributed to SIDS. If the criteria is not fully met the it can be
attributed to presumed SIDS or the consistent with SIDS
• Theories of causation of SIDS:
– It is thought to be multifactorial and there is no single cause
– There may one overwhelming factor which causes the death
– The mechanism is usually due to respiratory failure with ventilatory
abnormalities e.g. prolonged abnea
– Mechanical obstruction as seen in food chocking in prone position,
hence the recommendations of side sleeping positions
– These factor usually act synergistically with biochemical, microbiological,
and other pathogenic mechanism to cause death