International Journal of Current Research and Review
ISSN: 2231-2196 (Print)ISSN: 0975-5241 (Online)
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IJCRR - 5(3), February, 2013

Pages: 37-42

Date of Publication: 18-Feb-2013


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STUDY OF SUDDEN NATURAL DEATHS IN MEDICO-LEGAL AUTOPSIES WITH SPECIAL REFERENCE TO CARDIAC CAUSES

Author: Sandesh H. Chaudhari, Anand Mugadlimath, Mandar Sane, K.U. Zine, D.I. Ingale, Rekha Hiremath

Category: Healthcare

Abstract:This prospective cross-sectional study was carried out at Government Medical College, Aurangabad (M.S.) during a period of one year. Most of the sudden deaths were in 41-50 years of age group. Males predominate the females among all sudden deaths with male to female ratio 4.3:1. Cardiovascular causes were the principle cause followed by the respiratory causes among all sudden deaths. Deaths due to coronary artery disease and myocardial infarction amount to almost half of the cases of sudden natural deaths (40.25%). Confirmation of cause of death by histopathological examination was emphasized.

Keywords: sudden death, natural death, autopsy.

Full Text:

INTRODUCTION

The term sudden death refers to the sudden and unexpected deaths; the external examination fails to elicit cause of death. The majority of these are natural deaths. But very often, natural deaths form the basis of medico-legal investigations, if they have occurred suddenly and unexpectedly in apparently healthy persons and under the suspicious conditions. In such cases, it is usually not possible to certify the cause of death only on external examination of body. In all such cases, an autopsy is imperative to obviate the possibility of unnatural death. After the completion of autopsy the outcome may quite often reveal some natural disease, the presence of which may pose issues like association of the disease with trauma, work, crime, emotion, excitement, etc may suggest suspicion of foul play and its relative contribution towards death. The study of sudden death helps in establishing the precise causes of death and enable in assisting the legal authorities in detection of crime, improve the mortality statistical data and pacify the bereaved and aggrieved relatives where the medical negligence was the sufficient ground for legal proceedings

 MATERIAL AND METHODS

The material for the present study consists of the cases who died suddenly and/or unexpectedly and had been subjected to medico legal autopsy .The criteria for selection of cases was as per definition- “Sudden death is a death which is not known to have been caused by any trauma, poisoning or violent asphyxia and where death occurs all of a sudden or within 24 hours of the onset of the terminal symptoms”.

History about the cases was obtained retrospectively from the police record and meticulous autopsy was carried out in every case and the whole organ or pieces of organ showing gross pathologic changes were retained for histopathological examination and also for chemical analysis (CA). On the basis of histopathological report, final opinion as to cause of death was dispensed.

RESULTS AND OBSERVATIONS

Age wise distribution showed maximum number of cases belonged to 41-50 years age group with male predominance. Amongst these 159 cases, 129 cases (81%) were male and 30 (19%) were female. The male to female ratio was 4.3:1. [Table no.1] Among the causes of sudden death, 71 cases (44.6%) were due to cardiovascular causes (CVS), remaining were due to respiratory causes (25.7%), gastrointestinal causes (11.3%), 6.2% were due to central nervous system (CNS) causes, 5 cases each (3.1%) due to genitourinary (GUT) and miscellaneous causes and 9 (5.6%) showed multiple system involvement. [Table no. 2] Maximum cases of sudden death due to cardiac causes (44.6%) were seen in 41-50 years of age group; coronary artery disease (CAD) (71.83%) was the leading cause with male dominance .On histopathological examination, out of 13 cases of myocardial infarction, 4 cases (30.8%) showed microscopic changes suggestive of recent myocardial infarction and in 9 cases (69.2%), old healed scar of myocardial infarction was seen. It was observed that out of 71 cases of heart disease, biventricular hypertrophy was present in 15 cases (21%), solitary left ventricular hypertrophy in 32 cases (45%) and solitary right ventricular hypertrophy in 3 cases (4%). It was observed that in cardiovascular system, the minimum survival time was least (15 minutes), the mean survival time was also least 4.58 hours. Out of 41deaths(25.7%) due to respiratory diseases, pulmonary Koch’s [18 deaths (43.90%)] account for major cause of sudden death followed by pneumonia [12 cases (29.26%)], COPD [3 cases (7.31%)], pulmonary embolism [2 cases (4.87%)], solitary lung abscess [1 case (2.43%)] and deaths due to combined TB, Pneumonia, Pyothorax and lung abscess include rest of the diseases [5 cases (12.19%)]. In GIT, out of 18 cases, maximum number of cases of sudden death was due to liver pathology [7 cases (38.88%)]. In CNS, maximum numbers of sudden deaths were due to intracranial haemorrhage (60%) with male predominance.In GUT, out of 5 cases, 2 males (40%) died of pyonephrosis and each case of eclampsia, placental separation and pyonephrosis were responsible for female death. Miscellaneous causes of sudden death include septicemia, anemia, cerebral malaria and diabetic nephropathy, total 5 cases (3.14%) [Table no 3].

DISCUSSION

The definition of a sudden death varies according to authority and convention. In this medico legal study of sudden death, the duration of death process ranged from 1 to 20 hours, but it was difficult to determine how long the fatal symptoms had been present, as death often occurs before the victim reaches hospital, the situation in which no data on the symptoms are available for want of eye witnesses. In the present study, incidence of sudden death was 9% amongst the medico legal autopsies conducted during the study period. The finding of incidence of sudden death in the present study is somewhat consistent with the study of Sarkoija T. et al (5%) 1 and Siboni A. et al (4.06%) 2 . The present study do not match with that of Nordrum I. et al (27.8%) 3 , Meina Singh et al (2.66%) 4 , Azmak A.D. (28.98%) 5 , and Ambade V.N. (15.48%) 6. Age distribution for the present study showed most of the cases (30.81%) belonged to 41 to 50 years age group with male predominance (Table no.1). This finding matches with the studies of Meina Sing A. et al (34.5%) 4 and Ambade V N. (20%) 6 . In the present study, out of 159 total sudden deaths, 129 (81%) were male and 30 cases (19%) were female with male to female ratio 4.3:1(Table no1). This finding is consistent with the study of Azmak A D (males 83.4%, females 16.6%)5 Sarkoija T. et al (males 82%, females 18%)1 ,Nordrum I. et al (males 79.67%, females 20.32%)3 , Thomas A.C. et al (males 73.9%, females 26%)7 and Ambade V. N. (males 79.27%, females 20.73%)6 . Although there are numerous causes of sudden death, cardiovascular causes [71 cases (44.6%)] were the principle cause among sudden death in the present study. (Table no 3). Dr Narayan Reddy10 and Apurva Nandy11 stated that, most of the sudden deaths were due to cardiovascular causes, about 45 -50%. Similar findings were seen in the study of Kuller L. et al (49.5%)12 , Siboni A. et al (46.2%)2 , Di Maio V.J.M. et al (60.9%)13, Sarkojia T. et al (61%)1 , Luke J.L. et al (38%)14, Nordrum I. et al (69.15%)3 , Azmak A D (55%)5 . Coronary artery disease was not only the principle cause among cardiovascular causes, [54 cases (76.05%)] but also important cause among all sudden deaths amounting to 33.96%, with male preponderance, which is consistent with previous studies1, 2,3,4,6,7,12,13,14. This is because underlying heart disease is nearly always found in victims of sudden cardiac death. Typically in adults it takes the form of atherosclerosis or scarring from a prior heart attack. Therefore, risk factors for sudden cardiac death include similar risk factors for atherosclerosis, such as smoking, high blood pressure (B.P.), indiscriminate use of alcohol, sedentary life style, and stress and strain in life and lack of regular medical check up. In young victims, a thickened heart muscle from any cause, typically high B.P., or valvular heart disease is important predisposing factor for sudden cardiac death. Adrenaline released during intense physical or athletic activity often acts as a trigger for sudden cardiac death when less often, inborn blood vessel abnormalities of coronary arteries and aorta, may be present in young sudden death victims In the present study, out of 159 cases of sudden death, 41 cases (25.78%) were due to respiratory causes. The important were pulmonary tuberculosis 18 (43.90%) and pneumonia 12 cases (29.26%) (Table no. 3). The findings of deaths due to respiratory diseases are comparatively higher as compared to all above studies2, 3, 4, 7,9,12,13.. Most important causes of gastrointestinal diseases in our studies were gastroenteritis, cirrhosis of liver and peritonitis. The incidence of deaths due to liver pathology, 5 cases (27.7%) in our study nearly matches with the study of Kuller L. et al13 (27.7%) It is observed that in cardiovascular system, the minimum survival time was least (15 minutes); the mean survival time was also least 4.58 hours. This means that, when the lesion is in cardiovascular system the death sets in rapidly as compared to other systems. Study demonstrates the importance of histopathology in autopsy diagnosis of sudden deaths. Samples were taken for histopathological examination from the site showing gross pathological changes of heart, lung tissue, inflamed peritoneum, meninges, and brain tissue. Microscopic changes confirmed the gross diagnosis.

CONCLUSIONS

Incidence of sudden death among the total medico legal autopsies performed is 9%. Most of the sudden deaths are in the age group of 41-50 years (30.81%) with marked preponderance of males. Cardiovascular disease accounts for the maximum number of sudden deaths, in which Coronary artery disease is not only the main cause of cardiovascular deaths, but also among all sudden deaths.

Almost half of the sudden deaths show a strong correlation with chronic habits like smoking, tobacco chewing and alcoholism. The death sets in very rapidly in cardiovascular disease, as mean survival time is 4.58 hours. The most common causes of sudden deaths are coronary artery disease, tuberculosis, pneumonia and intracranial hemorrhage. Histopathological study helps in confirmation of the cause of death in sudden deaths.

ACKNOWLEDGEMENT

Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors, editors and publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.

References:

1 Sarkioja T, Hirvonen J. Causes of sudden unexpected deaths in young and middle aged persons. Forensic Sci Int 1984; 24:247-61.

2 Siboni A, Simonsen J. Sudden unexpected natural death in young persons. Forensic Sci Int 1986; 31:159-66.

3 Nordrum I, Eide TJ, Jorgensen L. Unexplained and explained natural deaths among persons above one year of age in a series of medico-legal autopsies. . Forensic Sci Int 1998; 93:89-98.

4 Meina Singh A, Subadani Devi S, Nabachandra H, Fimate L. Sudden death in Manipur – A preliminary study. J Forensic Med Toxicol 2002; 19(2): 26-28.

5 Azmak A.D. Sudden natural deaths in Edirne, Turkey from 1984 to 2005. Med Sci Law 2007; 47(2): 147-55. PMID: 17520960.

6 Ambade V. N. Study of natural deaths in Nagpur Region. J Medicolegal Association of Maharashtra. 2002; 14(2): 11-14.

7 Thomas A.C, Knapman PA, Krikler DM, Davis MJ. Community study of the causes of “Natural” sudden death. Br Med J 1988; 297(3): 1453-56. 999

8 Clark JC. Sudden death in chronic alcoholic. Forensic Sci Int 1988; 36; 105-111

9 De la Grandmaison, Durigon M. Sudden adult death: A Medicolegal series of 77 cases between 1995 and 2000. Med Sci Law 2003; 43(1): 89.

10 Reddy Narayan KS. The Essentials of Forensic Medicine and Toxicology. Medical Book Co. Hyderabad 27th edi.2008:133-134.

11 Nandy Apurba. Principles of Forensic Medicine,2nd edi.New Central Book Agency (P) Ltd., Calcutta 2007 :136-37.

12 Kuller L, Lilienfeld A, Fisher R. Sudden and unexpected deaths in young adults. JAMA 1966;198(3): 248-52.

13 Di Maio Vincent JM, Di Maio Dominick JM. Natural death as viewed by the medical examiner. A Review of 1000 consecutive autopsies of individuals dying of natural disease. J Forensic Sci 1991; 36(1): 17-24.

14 Luke JL, Helpern M. Sudden unexpected death from natural causes in young adults. Arch Pathol 1968;85:10-16.

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One article from every issue is selected for the ‘Best Article Award’. Authors of selected ‘Best Article’ are rewarded with a certificate. IJCRR Editorial Board members select one ‘Best Article’ from the published issue based on originality, novelty, social usefulness of the work. The corresponding author of selected ‘Best Article Award’ is communicated and information of award is displayed on IJCRR’s website. Drop a mail to editor@ijcrr.com for more details.

Women Researcher Award:

This award is instituted to encourage women researchers to publish her work in IJCRR. Women researcher, who intends to publish her research work in IJCRR as the first author is eligible to apply for this award. Editorial Board members decide on the selection of women researchers based on the originality, novelty, and social contribution of the research work. The corresponding author of the selected manuscript is communicated and information is displayed on IJCRR’s website. Under this award selected women, the author is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.

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‘Emerging Researcher Award’ is instituted to encourage student researchers to publish their work in IJCRR. Student researchers, who intend to publish their research or review work in IJCRR as the first author are eligible to apply for this award. Editorial Board members decide on the selection of student researchers for the said award based on originality, novelty, and social applicability of the research work. Under this award selected student researcher is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.


Best Article Award

A study by Dorothy Ebere Adimora et al. entitled \"Remediation for Effects of Domestic Violence on Psychological well-being, Depression and Suicide among Women During COVID-19 Pandemic: A Cross-cultural Study of Nigeria and Spain\" is awarded Best Article of Vol 14 issue 23
A study by Muhas C. et al. entitled \"Study on Knowledge & Awareness About Pharmacovigilance Among Pharmacists in South India\" is awarded Best article for Vol 14 issue 22
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A study by Alice Alice entitled \"Strengthening of Human Milk Banking across South Asian Countries: A Next Step Forward\" is awarded Best article of Vol 14 issue 20
A study by Sathyanarayanan AR et al. entitled \"The on-task Attention of Individuals with Autism Spectrum Disorder-An Eye Tracker Study Using Auticare\" is awarded Best article of Vol 14 issue 19
A study by Gupta P. et al. entitled \"A Short Review on \"A Novel Approach in Fast Dissolving Film & their Evaluation Studies\" is awarded Best Article of Vol 14 issue 18.
A study by Shafaque M. et al. entitled \"A Case-Control Study Performed in Karachi on Inflammatory Markers by Ciprofloxacin and CoAmoxicillin in Patients with Chronic Suppurative Otitis Media\" is awarded Best Article of Vol 14 issue 17
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A study by Singh R. et al. entitled \"A Prospective Study to Find the Association of Astigmatism in Patients of Vernal Keratoconjunctivitis (VKC) in a Tertiary Health Care Centre in India (Vindhya Region MP)\" is awarded Best Article for Vol 14 issue 15
A Study by Humaira Tahir et al. entitled "Comparison of First Analgesic Demand after Major Surgeries of Obstetrics and Gynecology between Pre-Emptive Versus Intra-Operative Groups by Using Intravenous Paracetamol: A Cross-Sectional Study" is awarded Best Article for Vol 14 issue 14
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A Study by M. Muthu Uma Maheswari et al. entitled "A Study on C-reactive Protein and Liver Function Tests in Laboratory RT-PCR Positive Covid-19 Patients in a Tertiary Care Centre – A Retrospective Study" is awarded Best Article of Vol 13 issue 06 Special issue Modern approaches for diagnosis of COVID-19 and current status of awareness
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A Study by Kumari PM et al. entitled "Study to Evaluate the Adverse Drug Reactions in a Tertiary Care Teaching Hospital in Tamilnadu - A Cross-Sectional Study" is awarded Best Article for Vol 13 issue 05
A Study by Anu et al. entitled "Effectiveness of Cytological Scoring Systems for Evaluation of Breast Lesion Cytology with its Histopathological Correlation" is awarded Best Article of Vol 13 issue 04
A Study by Sharipov R. Kh. et al. entitled "Interaction of Correction of Lipid Peroxidation Disorders with Oxibral" is awarded Best Article of Vol 13 issue 03
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A Study by Mohita Ray et al. entitled "Accuracy of Intra-Operative Frozen Section Consultation of Gastrointestinal Biopsy Samples in Correlation with the Final Histopathological Diagnosis" is awarded Best Article for Vol 13 issue 01
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A Study by Sindhu Priya E S et al. entitled "Neuroprotective activity of Pyrazolone Derivatives Against Paraquat-induced Oxidative Stress and Locomotor Impairment in Drosophila melanogaster" is awarded Best Article for Vol 12 issue 23
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A Study by Ghaffar UB et al. entitled "Correlation between Height and Foot Length in Saudi Population in Majmaah, Saudi Arabia" is awarded Best Article for Vol 12 issue 21
A Study by Siti Sarah Binti Maidin entitled "Sleep Well: Mobile Application to Address Sleeping Problems" is awarded Best Article for Vol 12 issue 20
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A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for  Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for  Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09

List of Awardees

A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award


A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award


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International Journal of Current Research and Review (IJCRR) provides platform for researchers to publish and discuss their original research and review work. IJCRR can not be held responsible for views, opinions and written statements of researchers published in this journal

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