medicolegal aspects of death & brain death

1. Medicolegal Aspects of death And brain death

2. Death • Definition :It is the cessation of life in a previously viable organism . • This occurs as a result of permenant stoppage of all vital functions of the body

3. Phases of death

4. Diagnosis of death 1- diagnosis of somatic death: • Very difficult • Should be differentiated from “death like state or suspended animation “ which may be : - voluntary : as in yoga - involuntary as in shock,electrical shock, drowning and poisoning by barbiturate or narcotics. 2- diagnosis of molecular death

5. 1-Diagnosis of somatic death

6. A-Signs of circulatory arrest • Auscultation : • No heart beat • Prolonged auscultation for 3 min at least , on apex of heart • Flat ECG • *Do not depend of absence of pulse .

7. B-Signs of respiratory arrest • -Cessation of repiratory movement by Inspection • -Auscultation :absence of respiratory sounds • Made by prolonged auscultation over trachea or lung fields • Absent spontaneous respiration :tested by Apnea test

8. C-Signs of arrest of function of CNS • 1-Unconsciousness , loss of all reflexes &there is no reaction to painful stimuli • 2-Flat EEG • 3-Primary muscular flaccidity : • due to loss of muscle tone • Voluntary & involuntary muscles - Dropping of mandible , disappearance of wrinkles of the face causing peaceful experssion

9. Cont… • 4-Contact flattening: • - due to loss of muscle elasticity and compression • - its site changes if the position of the body is changed after death.

10. Cont.. • 5-Diagnostic tests: • cough & gag reflex :absent reflex. • Caloric testing” Barany test”: Absent nystagmus when first cold then warm water run in the ear. • Oculocephalic reflex ( Cantellis sign or doll eye movement):Eyes follow head in direction when rotated.

13. D-Eye (ocular ) sign

17. 2-Diagnosis of molecular death Postmortem changes as: • Cooling • hypostasis • rigor mortis

18. Medical investigation of death • I- Medicolegal deaths : • Violent deaths • Suspicious deaths • Sudden & un expected deaths • Unattenededdeaths • Death in custody • Deaths of medical practice

19. Brain death • Historically death was that of “heart and respiration death”,however have changed this medically in favour of a new concept “brain death” that is irreversible loss of cerebral function. • It is of 3 types • Cortical/cerebral death • Brain stem death • Whole brain death • The concept of brain death: • Advances in medical science • Organ transplantation

20. CORTICAL DEATH (persistent vegetative state) • Cerebral death with an intact brain stem • This produces a vegetative state in which the patient is indeep coma but respiration continues. • This state of deep coma can be produced by cerebral hypoxia, toxic conditions or widespread injury.

21. BRAIN STEM DEATH • The victim has irreversible loss of consciousness (comatose) and incapable of spontaneous breathing • The loss of vital centres that control respiration and of the ascending reticular activating system that sustains consciousness,cause the victim to be irreversibly comatose and incapable of spontaneous breathing, however heart is still beating by its own rhythm. • This can be produced by raised intracranial pressure,cerebraloedema,intracranialhaemorrhage • Artificial ventilation maintain full oxygenation

22. WHOLE BRAIN DEATH Permanent cessation of functions of cerebrum, cerebellum and brain stem

24. Diagnosis of brain death • By 2 doctors (treating not transplanting) • 1-Preconditions: • Patient must be in apneic coma • Diagnosis with certanity of structural brain damage causing brain stem death.

25. Diagnosis of brain death • 2-Exclusion : • Exclude other causes of coma , apenic coma as hypothermia,poisoning by sedative & sever metabolic disturbances. • 3-Diagnostic tests: • Barany test & doll eye movement

26. Medicolegal Implications • 1-Harvesting of organs :after family permission • 2-Maintanance or removal of life support measures: decision made by treating doctors based on medical ethics • 3-Confusion of documentation of date of death