RCSI Forensics: Part 1 - The Body After Death (2023) PDF

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Forensics: Part 1 - The Body After Death Class Year 2 Course Pathology Lecturer Dr SA Collis Office of the State Pathologist, Dublin Date th 7 December 2023 LEARNING OUTCOMES THE BODY AFTER...

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Forensics: Part 1 - The Body After Death Class Year 2 Course Pathology Lecturer Dr SA Collis Office of the State Pathologist, Dublin Date th 7 December 2023 LEARNING OUTCOMES THE BODY AFTER DEATH – Describe the methods of estimating time of death – Describe the early changes of death, rigor mortis, livor mortis and algor mortis – Describe the factors affecting the rate of cooling after death – Describe the various types of decomposition including adipocere, mummification and skeletonisation. WARNING This lecture contains graphic images that involve deceased individuals, post mortem changes and anatomical pathology. Any starred images are from cases - please do not copy or share. Death.... “is a process not an event" [Knight] “is the absence of life” “is the suspension or cessation of vital processes of the body, as heartbeat and respiration” [THREE DEFINITIONS OF DEATH on JSTOR  Estimating the time of death (Post mortem interval) PMI = the time that has passed since the death of a person until found Forensic significance – PMI may aid an investigation into the death. Useful elements in determining PMI Environmental - last contact, dates on letters, food, social media activity Physical - the changes in the body File:Lord Byron on his Death-bed c. 1826.jpg - Wikipedia  Clinical Diagnosis of Death “Apnoea with no pulse and no heart sounds, and fixed pupils.” Absence of response to tactile stimuli Absence of pupil response to light Absence of spontaneous respiration Absence of heart sounds or pulse Why do the pupils dilate at the moment of death? - Quora Changes after death Immediate post mortem changes Cessation of cardiovascular, respiratory and nervous systems. Early (few hours) Rigor mortis, livor mortis (hypostasis) and algor mortis (body cooling) Eye changes (clouding, reduced intraocular pressure and tache noire formation) Late (24hours+) Decomposition and putrefaction Elements that can be uses to estimate the post mortem interval Rigor mortis Body temperature - touch/measurement Hypostasis Stomach emptying Muscle excitability Electrical excitability of the iris  Rigor mortis ‘stiffening of the muscles’ Normal muscle contraction occurring after death and fixed by the lack of ATP No definite sequence through the various https://mollybateman.files.wordpress.com/2017/05/img_4561.jpg muscles or joints Flaccid period (variable) Tend to develop in smaller muscle groups Factors will delay / accelerate Knight’s Forensic Pathology Cooling of the body after death Normal human body temperature 34.2- 37.6 oC Body equilibrates with environmental temperature by conduction, convection, radiation and evaporation Post mortem temperature plateau (1-3 hours) then a linear decrease in temperature of 0.5-1.5oC/hr for next 10- 16 hours with the rate slowing as the body temperature becomes close to https://mlt.gov.np/post-mortem-changes/early-post-mortem- environmental temperature. [Rattenbury interval/algor-mortis/ A. Forensic Economics 2018] Henssge’s nomogram Henssge C. Death time estimation in case work. I. The rectal temperature time of death nomogram. Forensic Sci Int. 1988 Sep;38(3- 4):209-36. doi: 10.1016/0379-0738(88)90168-5. PMID: 3192144. Yang AS, Quan GL, Gao YG, Wang J, Sui P, Li GF, Long DF, Lin SL, Wu XF, Luo B. Rectal Temperature of Corpse and Estimation of Postmortem Interval. Fa Yi Xue Za Zhi. 2019 Dec;35(6):726-732. English, Chinese. doi: 10.12116/j.issn.1004-5619.2019.06.015. Epub 2019 Dec 25. PMID: 31970962. http://www.zikmund.org/henssge/HenssgeNomog ram-upto23C.pdf Body temperature (algor mortis) and rigor mortis A quick guide for use in average temperate conditions If the body feels: Warm and flaccid < 3 hours Warm and stiff 3-8 hours Cold and stiff 8 - 36 hours Cold and flaccid > 36 hours Factors that affect cooling of a body and onset of post mortem changes Environment Individual Temperature Temperature - concurrent illness/trauma/ physical activity Wind/rain/sun Body habitus Exposed/ covered Sex Posture Clothing/coverings Hypostasis (livor mortis/ lividity) Pooling (settling) of blood in vessels (and organs) in dependant areas of the body due to gravity. Usually pink/purple/blue in colour. https://www.google.co.uk/search?biw=1302&bih=851&tbm=isch&sa=1&q=hypostasis&oq=hypostasis&gs_l=psy- Knight’s Forensic Pathology ab.3..0l8j0i30k1j0i5i30k1.4681.6362.0.6552.10.10.0.0.0.0.112.989.5j5.10.0....0...1.1.64.psy- ab..0.10.980...0i67k1j0i10i67k1.0.eh981T2yYw4#imgrc=rHA5jrAk82DXuM:&spf=1508174476114  Anterior hypostasis with pressure pallor indicating a face down position and the arm positioned under the body Decomposition/ putrefaction Decomposition Breakdown of cells and body tissues due to lack of oxygen Cell autolysis and rupture releasing nutrient rich fluids Putrefaction The destruction of tissues by action of micro-organisms Rate of decomposition/putrefaction affected by Environmental temperature/humidity Body size/ coverings/ systemic infection Different types of decomposition/putrefaction Mummification (dry decomposition) Adipocere (waxy substance) Tannin (peat bogs) Maceration (aseptic autolysis) Predation (insect - entomology/animal) Delayed decomposition due to snow Mummification Drying of tissues Usually dry and warm environment Inhibition of bacterial growth Desiccated appearance Mould formation Adipocere grave wax corpse wax A ‘fatty wax type of mummification’ an ‘anomaly in the normal decomposition process’ where ‘human fat is converted into a complex of saturated fatty acids’ Predominantly occurs in damp environments but also in dry conditions and water Presence of bacteria (gram positive) promotes formation Can occur relatively soon after death but more advanced cases occur after weeks - thereby confusing estimation of the post mortem interval Ubelaker DH, Zarenko KM. Adipocere: what is known after over two centuries of research. Forensic Sci Int. 2011 May 20;208(1-3):167-72. doi: 10.1016/j.forsciint.2010.11.024. Epub 2010 Dec 23. PMID: 21185137. Tannin http://news.nationalgeographic.com/news/2014/07/140 718-bog-bodies-denmark-archaeology-science-iron- age/ https://www.museum.ie/en-IE/Collections-Research/Irish-Antiquities-Division-Collections/Collections-List-(1)/Iron-Age/Bog-Bodies-Research-Project  Maceration Maceration is an autolytic postmortem process that occurs in intrauterine deaths. https://oska.uk.com/what-is-maceration/ It is caused by endogenous enzymes not putrefactive bacteria. https://emedicine.medscape.com/article/1680032-overview https://webpath.med.utah.edu/PEDHTML/PED153.html Animal predation (post mortem) Skeletonisation The final stage of decomposition with loss of the soft tissues of the body and exposure of the underlying skeleton. Time to full skeletonisation varies depending on environment body is in. WARNING ⚠️ GRAPHIC IMAGES OF DECOMPOSITION Body recovered from locus Maggots (larvae) on decomposed body with evidence of insect associated damage. Skull and jaw Careful examination of hyoid bone and thyroid cartilage as well as rest of skeleton Corpse fauna https://australian.museum/learn/science/decomposition-corpse-fauna/ Bacteria Flies (house flies/blow flies) Beetles Mites Moths (clothes moths - Tineidae) Parasitic wasps Entomology = scientific study of insects Forensic entomology is the study of insects and other arthropods in criminal investigations/legal matters. http://itsgov.com/forensic-entomology-basics.html Decomposition of organs Dependent on same factors as body cooling: environment, exposure, clothing, underlying pathology Different organs decompose at different rates In summary Post mortem interval/ time of death is an estimate at best Factors associated with the body and the environment in which it was found have a huge impact on decomposition. Forensic pathologists need to have an understanding of ‘natural’ decomposition processes in order to determine if anything suspicious about the case. References Knights Forensic Pathology - Sakko & Knight Handbook of Forensic Pathology - DiMaio Forensic Entomology - Byrd and Tomberlin Estimation of the Time Since Death - Made  RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Forensics: Part 2 – Natural Death Define the commonest causes of sudden death in different age groups. Describe the causes of sudden cardiac death (including cardiomyopathies, channelopathies and inflammatory conditions). Describe the commoner causes of sudden death other than due to cardiac disease. WARNING This lecture contains graphic images that involve post mortem changes and anatomical pathology. Sudden Deaths WHO definition of sudden death = ‘death within 24 hours of onset of symptoms’ Sudden cardiac deaths ‘unexpected death due to known or unknown cardiac causes and generally occurs within 1 hour of the onset of symptoms’ ‘Unexpected’ Sudden deaths may be witnessed (ie. in hospital) or unwitnessed (ie. at home or outdoors). Causes of sudden death vary with age Children Teenager/young adult Adults/elderly Still birth, congenital Natural disease, suicide, Natural disease, suicides, accidents & homicides abnormalities, SIDS, accidents & homicide infection, malignancy, accidents & homicide Causes of Death - Worldwide  external respiratory causes diseases 4% malignant 11% neoplasms 30% Central Statistics Office https://www.cso.ie/en/releasesandpublications/ep/p- vsys/vitalstatisticsyearlysummary2020/ remainder 28% circulatory diseases 28% Causes of death in Ireland Sudden Cardiac Death Ischaemic heart disease/ valve disease/ pericarditis/myocarditis/cardiomyopathies/congestive cardiac failure/tumours/aneurysms/conduction system defects/ haemorrhage Coronary artery disease and ischaemic heart disease Michaud K et al. Diagnosis of myocardial infarction at autopsy:AECVP reappraisal in the light of the current clinical classification. Virchows Archiv https://doi.org/10.1007/s00428-019-02662-1 Haemopericardium Inherited cardiomyopathies Miles C, Fanton Z, Tome M & Behr E BMJ 4 May 2019  SADS (sudden arrhythmic death syndrome) https://www.bhf.org.uk/informationsupport/conditions/sudden-arrhythmic-death-syndrome Sudden cardiac death (SCD) is Causes of SADS: a sudden death, usually Hypertrophic cardiomyopathy caused by a heart condition; however, if no cause of death Dilated cardiomyopathy is identified following a PM ARVC (arrhythmogenic right ventricular cardiomyopathy) examination and toxicology then it may have been due to Long QT syndrome sudden arrhythmic death Brugada syndrome syndrome (SADS) related to an CPVT (Catecholaminergic polymorphic underlying inherited cardiac ventricular tachycardia) condition. PCCD (progressive cardiac conduction defect) Sudden cardiac death in athletes BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h1218 (Published 18 March 2015) Basso C et al. Cardiac arrest at rest and during sport activity: causes and prevention, European Heart Journal Supplements, Volume 22, Issue Supplement_E, June 2020, Pages E20–E24, https://doi.org/10.1093/eurheartj/suaa052 Useful cardiac pathology text books & references Hill SF & Sheppard MN Non-atherosclerotic coronary artery disease associated with sudden cardiac death. Heart 2010;96:1119-1125 Basso C et al Association for European Cardiovascular Pathology. Guidelines for autopsy investigation of sudden cardiac death: 2017 update from the Association for European Cardiovascular Pathology. Virchows Arch. 2017 Dec;471(6):691-705. doi: 10.1007/s00428-017-2221-0. Epub 2017 Sep 9. PMID: 28889247; PMCID: PMC5711979. Valve related pathologies associated with sudden death https://www.escardio.org/static-file/Escardio/education/live- events/courses/imaging/Pathological-Database-Sudden-Cardiac-Deaths- Sheppard.pdf Aortic stenonis Floppy mitral valve Bacterial endocarditis Ischaemic rupture of mitral valve papillary muscle https://www.heart-valve-surgery.com/valve-leaflets-calcified-heart-stenosis.php Ruptured papillary muscle Other vascular causes Ruptured aortic aneurysm (AAA) Central nervous system (CNS) Aneurysm/ CVA/ haemorrhage/infection/ tumour/ epilepsy Cerebral artery aneurysms Subarachnoid haemorrhage Superior saggital sinus thrombosis and associated infarction Epilepsy  Bacterial meningitis Meningitis = inflammation of the meninges Meningococcal (Neisseria meningitidis - groups B&C most common in Ireland) Pneumococcal Streptococcal Haemophilus influenza (Viral meningitis) Respiratory Pulmonary embolism/ tension pneumothorax/ obstruction/ asthma/ COPD/ tumours/ haemoptysis/ infection Pulmonary thromboembolism https://cfch.com.sg/pulmonary- embolism/ https://static-cambridge-org.ezproxy.is.ed.ac.uk/binary/version/id/urn:cambridge.org:id:binary-alt:20200709160324-89998-mediumThumb-17777fig31_2.jpg?pub-status=live  Tension pneumothorax https://www.osmosis.org/a nswers/tension- pneumothorax Bullous emphysema  Airway obstruction Gastrointestinal/Hepatobilary Haemorrhage/ mesenteric thrombosis or infarction/ strangulated bowel/ hernias/ tumour/ inflammatory/ perforation/ cirrhosis  Yajima S et al. Necrosis of small intestine leading to a diagnosis of polyarteritis nodes: a case report. Journal of Medical Case Reports 2019;13:55 http://histocutup.co.uk/Gastrointestinal/Bowel-Obstruction.aspx  Peritonitis Perforation - stomach ulcer, appendix Inflammatory bowel disease - Crohn's disease, UC or diverticulitis. Pancreatitis Iatrogenic - medical intervention Trauma to stomach/ bowel Infection - pelvic inflammatory disease Cirrhosis https://static-cambridge-org.ezproxy.is.ed.ac.uk/binary/version/id/urn:cambridge.org:id:binary-alt:20200709160324-73527-mediumThumb-17777fig31_8.jpg?pub-status=live Noritake K et al. Autopsy findings of a patient with rapidly progressive massive ascites caused by alcoholic cirrhosis. Legal Medicine 2011;13(3):148-150 Other Pancreatitis/ pyelonephritis/ tumour/ haemorrhage/ infection/haematological malignancy/ pregancy/ old age Pancreatitis Renal infarct/ polycyclic kidney disease Pyelonephritis Conclusions Sudden natural deaths can be due to a myriad of pathology affecting almost all organs. Cardiovascular disease is the most common cause of death in adults with potential genetic elements occurring in some cases. Any questions?