Choose an example of a cause of death in a sudden natural death case. Describe how you would go about determining the cause of death in this case, including findings on-scene, medical records, at autopsy, and further studies.
Instructions
1) Choose an example of a cause of death in a sudden natural death case. Describe how you would go about determining the cause of death in this case, including findings on-scene, medical records, at autopsy, and further studies.
· All assignments must be written in your own words and must include a reference list. Unless otherwise specified, each assignment must be no less than 500 words, not including your works cited information.
2) After completing this module, what do you feel are the 3 most important points discussed? Explain why you feel they are most important. Include in your discussion how the information from this module could be applied to either your current job/or a future job within the forensic sciences.
3) After completing numbers 1 and 2, upload the work so I can upload number 3, which is a simple peer review of 100 words.
RUBRIC
FM Module 2: Sudden Natural Deaths
Overview
· In the investigation of suspected sudden natural deaths, the scene analysis and medical record review will often reveal the greatest amount of information contributing to the cause and manner of death. The MDI must obtain the medical records from the proper healthcare facilities as well as question the family of the decedent for additional health and lifestyle information that may be contributory to the demise. Scene analysis by the MDI is critically important to rule out an external cause of death, such as an unsafe condition. Medication evaluation with prescription information and pill counts is also vital to the investigation. When the medical examiner takes jurisdiction of the body, they may perform an external examination to rule out trauma or look for signs of disease. More typically, they will perform a complete internal examination and evaluate every organ for signs of trauma and/or disease.
· 2.1 What are Sudden Natural Deaths
· Sudden natural death is defined as a non-violent, unexpected death occurring less than 24 hours from the onset of symptoms. The six most common causes of sudden unexpected death are: fatal arrhythmias, acute myocardial infarction, intracranial hemorrhage/massive stroke (cerebrovascular accident), massive pulmonary embolism, diabetic ketoacidosis, and acute aortic catastrophe.
· A fatal dysrhythmia is a condition where the heart beats in an abnormal pattern. The pumping action is severely compromised and blood cannot reach the major organs of the body including the brain. This can lead to unconsciousness and death. Dysrhythmias can be generally divided into four categories: Bradycardia (slow heartbeat), Tachycardia (fast heartbeat), cardiac flutter or fibrillation (irregular heartbeat) and Premature Contraction (early heartbeat). You can also categorize dysrhythmias by whether the atrial or ventricular chambers are affected. It is important to know that these are physiologic events and may produce minimal to no autopsy findings.
· In your reading you’ll find that the word arrhythmia is used synonymously with the word dysrhythmia. These words are essentially used interchangeably in the medical literature despite different Latin root word meanings.
· An acute myocardial infarction or “Heart Attack” is a decrease in blood flow to the heart resulting in damage to the muscular wall, or myocardium, of the heart. The most common cause of an acute myocardial infarction is myocardial ischemia due to a blocked coronary artery. The coronary artery becomes blocked or severely narrowed by an accumulation of cholesterol and calcium. The blood flow to the cardiac muscle is inadequate for the muscle to maintain rhythmic contraction and therefore the heart stops beating.
· Intracranial hemorrhages can occur in various ways but generally hemorrhagic strokes and ischemic strokes are the most common. A hemorrhagic stroke occurs when a blood vessel in the brain ruptures and causes the accumulation of blood in the cerebral tissue. Typically the blood vessel will have a weakness in the wall referred to as an aneurysm. If the person experiences an acute hypertensive incident, such as strenuous exercise, use of central nervous system stimulants such as cocaine or methamphetamine or is placed in an inverted position where the blood flow to the head is increased the aneurysm can rupture causing the hemorrhagic stroke.
· An ischemic stroke occurs in a way similar to an acute myocardial infarction. A blood vessel in the brain becomes narrowed due to the accumulation of cholesterol and calcium. The section of the brain that is supplied by that particular blood vessel becomes ischemic and can lose function, become necrotic and might even start bleeding internally as the tissues soften. This is referred to as hemorrhagic conversion of an ischemic stroke.
· A massive pulmonary embolism is a condition where blood clots that form in the legs (deep venous thrombosis) break off and travel to the lungs via the bloodstream. When the blood supply to the lungs is sufficiently blocked the ability to exchange carbon dioxide for oxygen is compromised. Difficulty breathing, unresponsiveness and death often follow.
· Diabetic ketoacidosis typically occurs in patients who have diabetes mellitus type I. It is a result of the pancreas not producing enough insulin for the cells of the body to uptake glucose. As a result the ketone concentration of the blood rises. Lethargy, unresponsiveness, coma and death is the typical progression.
· An acute aortic catastrophe is a rupture of the aorta. The aorta is the large artery that originates directly from the heart. Secondary to several diseases (atherosclerosis, Marfan Syndrome, syphilis) an aneurysm may develop in a section of the aorta. Over time the aneurysm will expand and a laceration in the aortic wall will develop, the blood being pumped through the aorta begins flowing out through the laceration. This causes massive blood accumulation in the abdominal cavity or around the heart (cardiac tamponade).
· The Florida State Statue 406.11 states an autopsy must be performed on a decedent who is unattended by a licensed physician in the event of a sudden death. This means that if the death of an individual, even if by natural causes, did not occur under the direct care and supervision of a physician, that individual must be autopsied to determine why they suddenly died. Even if said individual had a physician he or she saw regularly or recently, if the death was not expected, the legal mandate for performing an autopsy comes into effect. The final decision to perform an autopsy in these cases is at the discretion of the pathologist on service for that day.
2.2 Natural Deaths with Known Medical History
There are instances where a patient can have an extensive medical history and experience a sudden death. The person may have had a physician in the past and been treated for their diseases. Over the course of time the patient decided not to continue medical care for their condition(s). Subsequently they were found suddenly deceased. In this event the death investigator would determine the death was unattended by a physician and the medical examiner would take jurisdiction. The medical records would be reviewed and the decision to perform a complete autopsy or external exam would be determined.
Consider the case of a 75-year-old man who was diagnosed with partial blockages in his coronary arteries (atherosclerotic cardiovascular disease) and hyperlipidemia. At 10A.M. he complained to his wife about difficulty breathing, chest pain and diaphoresis. Within a half hour his wife found him unresponsive on the floor of the bedroom. Comprehensive medical record review would most likely conclude the cause of death was a myocardial infarct.
The medical records are consistent with the clinical presentation of the disease and therefore a complete autopsy is not necessary. The body may be unclothed in the morgue and viewed by the medical examiner to rule out trauma in a process called an external exam. Another situation where the medical examiner can take jurisdiction of a body is when a person’s primary physician office is located in a state different from where the person died. This is not unusual in the state of Florida where tourism is very common and residents of the northern states would vacation in the state of Florida for weeks or months at a time, especially during the winter months.
Figure 2.2
2.2.1 Case Example
Consider the case of a 67-year-old female who complains about the “worst headache of her life”. One hour later she is having difficulty walking and is experiencing weakness in her right arm and right leg. Her speech becomes slurred and she is soon discovered unresponsive sitting in a reclining chair. Her previous medical history includes hypertensive cardiovascular disease. Based on her clinical presentation and supporting medical history the diagnosis of cerebrovascular accident is most likely. In this instance, an aneurysmal blood vessel ruptured in her cerebrovascular distribution and she hemorrhaged into her brain. This is more likely in patients with hypertensive cardiovascular disease. This condition is commonly known as a “massive stroke”.
2.3 Natural Deaths without Known Medical History
When a medical investigator investigates a death for the medical examiner’s office, they initiate a medical records search on the decedent. They may inquire at local hospitals and medical care facilities to send copies of the medical records to them. In cases where a decedent has no known medical history and the death is unwitnessed, an autopsy would provide the best evidence for the cause and manner of death. It is then necessary for the medical examiner to take jurisdiction of the body and arrange transportation to the morgue. An accurate manner of death determination requires a careful external examination of the body to rule out traumatic injuries. Once the external examination is completed an internal examination is initiated to reveal the natural disease or diseases that caused the fatal outcome. Common diseases of the heart, brain, and lungs are responsible for a large percentage of the natural deaths in patients without a known medical history. An undiagnosed cancer or metabolic disease, such as diabetes mellitus may also be the cause of death.
Figure 2.3: According to a 2013 study conducted by the Centers for Disease Control and Prevention on the most common causes of “natural” death, the leading “natural” cause of death is heart disease, with cancer being the second most common.
2.3.1 Case Example
Consider a case of a 60-year-old man who is slightly obese and leads a sedentary lifestyle. He has no primary physician and has not seen a doctor since he joined the military service 40 years ago. Over the course of a few hours he is finding it increasingly more difficult to breathe, he is experiencing tachycardia and is diaphoretic. He collapses to the floor of his kitchen and cardiopulmonary resuscitation fails to revive him.
Because he has no recent medical records, the body is taken to the medical examiner where it was discovered he succumbed to cardiac tamponade. This is a condition where blood accumulates within the pericardium surrounding the heart. The source of the blood can be either a ruptured myocardial wall or ruptured coronary artery. The blood then surrounds the heart and – as more and more of it accumulates – it compresses the heart. The heart has difficulty expanding and the pumping function is reduced. This will continue to a point to where the beating heart will come to a standstill and the patient will become unresponsive.
In the accompanying picture, we can see the open chest at autopsy and abdominal cavity exposing the internal organs. The lungs are visible with streaks of anthracotic pigment present. The dark purple-red area in the center of the chest is the cardiac tamponade consisting of clotted blood surrounding the heart impeding its ability to function.
2.4 Expected Findings
The expected findings in a natural sudden death case are often very minimal. This is true for the immediate area surrounding the scene and also for the body itself. Quite often the decedent is found lying in their bed with no evidence of trauma. Other times the body can be found lying on the floor of a residence, sitting in the living room with the television playing or in the backyard of the property. Oddly, one of the more common areas of the house to find a victim of a sudden natural death is on the seat of the commode. Sudden natural deaths can also occur while the victim is driving a motor vehicle, performing strenuous physical activity (especially after a long sedentary period) or sitting at their desk studying for an exam. Important to remember is the investigator must analyze the scene for hazards that may have caused the death to be anything other than natural.
2.4.1 Investigative Findings
When a MDI investigates a case suspected to be a sudden natural death a detailed analysis of the medical history of the decedent is critical. The medical records must be requested, an interview with the family and/or friends with regard to the health of the decedent must be conducted and a collection of the medications the decedent was prescribed is necessary. It is not only important to collect and record the type of medications present, the individual pills must be counted and compared with the date of the prescription and the amount of pills to be taken per day. This can help the medical examiner determine if the decedent was compliant with their medications. The pill count will determine if too many or too few pills remain in the medication container. If too few pills remain in the medication container the medical examiner cannot rule out an overdose without ordering a toxicology analysis of the decedent’s blood.
In these cases, appropriate specimens should be drawn at autopsy. An experienced MDI will look for medications in the usual areas of the residence including the night stand of the bedroom, the kitchen cabinets and counter, the pockets and purse of the decedent and in the refrigerator. If medications are refrigerated then the function of the refrigeration unit must be assessed. Patients with insulin dependent diabetes must store their medications under refrigeration or it will degrade and become less effective or possibly non-effective. This can lead to diabetic ketoacidosis and other complications which may be fatal. Other important pieces of evidence the MDI must be aware of at the death scene is the presence of empty liquor bottles, beer cans, carbon monoxide producing devices, suicide notes, illicit paraphernalia and other generalized heath hazards such as exposed electrical wires and open household/pool chemicals.
The body needs to be carefully inspected for trauma, burns and atypical discoloration. Importantly the extremities, especially the arms, must be inspected for needle puncture marks. This may be challenging after cardiopulmonary resuscitation since the first responders often try to establish intravenous access in the upper extremities. These needle punctures can look similar to those of an intravenous drug abuser (IVDA), keep in mind that the needle punctures of an IVDA are numerous and are often observed to be at different stages of healing.
Figure 2.4.1
2.4.2 Autopsy Findings
At autopsy the external exam is often negative for traumatic findings but there may be clues as to the overall health of the individual that can be elucidated. A morbidly obese person (BMI greater than 35) may have metabolic, cardiac and/or pulmonary disease. A person with a vertical scar overlying their sternum may have had open heart surgery to bypass blocked coronary arteries or to replace a defective heart valve. A person with a two-inch horizontal scar in their left upper chest may have a cardiac pacemaker/defibrillator placement. Various surgical scars on the abdomen can indicate abdominal surgery, organ transplants or previous trauma. An arterial-venous fistula on the upper extremities can indicate renal dialysis due to kidney failure. Surgical amputation of a portion of the lower extremities can indicate peripheral vascular disease (PVD). PVD is associated with hyperlipidemia, diabetes, atherosclerotic cardiovascular disease and cerebrovascular disease all of which can be fatal.
Most commonly the cause of death in a sudden natural death of a person over the age of 45 is cardiac related. Typically, the mechanism of death is ischemic cardiomyopathy, that is to say one or more of the three main coronary arteries become blocked or partially blocked by atherosclerotic plaque. This blockage consists mainly of cholesterol and calcium, it can be soft or firm and has a yellow appearance. The Left Anterior Descending coronary artery, located in the front of the heart, is most commonly blocked. This is why it is often called “The Widowmaker.”
Hyper inflated lungs and an expanded thoracic cavity are indicators of chronic obstructive pulmonary disease and is usually associated with pulmonary anthracotic pigment deposition secondary to smoking.
Figure 2.4.2: An example of a coronary artery blockage.
An enlarged heart is an indicator of hypertensive cardiovascular disease especially if it is associated with nephrosclerosis of the kidneys. Hemorrhage within the cortex of the brain can be a result of a ruptured cerebral aneurysm. Hemorrhage within the brainstem can be a result of a hypertensive stroke and areas of liquefactive necrosis within the cerebral hemispheres are indicators of ischemic strokes due to blockages within the cerebrovasculature. Blood clots within the lung will lead to progressive shortness of breath. These can be the result of blood clots in the legs (deep venous thrombosis) breaking off and traveling to the lungs via the bloodstream. They become lodged in the smaller blood vessels of the lungs and block blood flow leading to difficulty breathing.
2.4.3 Further Studies
There may be instances of a sudden natural death where the external exam and the internal exam are both negative at autopsy. Further studies must be ordered outside of the standard procedures commonly used by the medical examiner. Serum glucose and electrolyte analysis of the ocular vitreous humor can reveal elevated serum glucose in cases of undiagnosed or non-compliant diabetes mellitus. Electrolyte imbalances leading to fatal cardiac arrhythmias can be discovered as well. Genetic studies can reveal chromosomal anomalies leading to fatal outcomes within many organ systems. Expert consultation, most typically in cardiac and brain cases, can reveal rare and subtle diseases that can establish a cause and manner of death.
Figure 2.4.3: Collecting ocular vitreous humor to test serum glucose levels can help determine cause of death in an otherwise negative autopsy.
Summary
The most important portion in the investigation of a sudden natural death is the scene and medical record analysis. The evaluation of the scene is necessary to determine the types of medications the decedent had available and if they were using them as prescribed. It will also help determine if the death was associated with any unsafe conditions nearby the body. Cases that are taken under the jurisdiction of the medical examiner may undergo an external or complete examination at autopsy. The findings in each of these procedures, when taken in context with the scene and medical record review, is vital in determining an accurate cause and manner of death.
There are occasions where further testing of the body is necessary because an objective conclusion cannot be reached with the accumulated data available. Genetic testing of biologic material, expert consultation and electrolyte analysis can assist greatly in determining the cause and manner of death.
