THANATOLOGY

Thanatology
 Thanatology (Greek,thanatos = death, logus = science)
is that branch of science that studies death in all its
aspect.

 Section 2 (b) of the Registration of Births and Death Act

1969 defines death as “permanent disappearance of
all evidences of life at any time after live birth.

 “Tripod of life”.
Tripod of life

life
Medicolegal Implications of Death
1. Declaration of death
2. Certification of death
3. Disposal of the body
4. Organ transplantation
STAGES / TYPES OF DEATH

Somatic death / Clinical death

Brain dead
 STAGES / TYPES OF DEATH

Antimortem injury

Perimortem 2-3 hr
(Transplantation)

Molecular death
(cellular death)
Postmortem
Errors in Diagnosis of Death
1. Case of apparent death
2. Hypothermia
3. CNS depressants, e.g. barbiturate poisoning
4. Metabolic and endocrine disturbances.
 Apparent death/
suspended animation
“a state of body in which the vital functions are at such a low
pitch that the body functions cannot be determined by
ordinary methods of clinical examination”.

The metabolic rate of life is so reduced that the O2

requirement of individual cell is satisfied through oxygen
dissolved in body fluids.
Testing for brain stem reflexes would establish that victim is
not dead.
Apparent death/
suspended animation
Voluntarily Involuntarily
 Anesthesia
 Barbiturates
 Coma, Cholera
 Drowning
 Elecrocution
 Frozen state
(Hypothermia)
MODES OF DEATH
“an abnormal physiological state that pertained at the
time of death”.
Coma
Coma refers to unconscious state of a person
characterized by complete insensibility or
unarousability .
Causes of coma-
 Head injury

 Intracranial hemorrhage

 Encephalitis

 Opium/barbiturate poisoning

 Alcohol intoxication

 Epilepsy

 Heat stroke
Syncope
 Syncope results from stoppage of functioning of heart with
consequent cessation of circulation.
 In syncope there occurs loss of consciousness with postural
collapse due to an acute decrease in cerebral blood flow.
Causes of syncope-
Vagal inhibition
Massive myocardial infarction
Pulmonary hypertension
Pulmonary embolism
Cardiac tamponade
Blow on epigastrium
Adelson defined asphyxia

as “a state in living organism in

which there is acute lack of oxygen
available for cell metabolism
associated with inability of body
to eliminate
excess of carbon dioxide.”
Asphyxia
 Stages of asphyxia

Dyspnea

Convulsion

Exhaustion and
Respiratory failure
 Rule of thumb
• The breathing stops within 20 seconds of
cardiac arrest and
Heart stops within 20 minutes of stoppage of
Breathing

<20 sec

<20 min
Patho physiology of asphyxia
 Asphyxia Triade
Congestion & Edema

Petechial hemorrhage Cyanosis

MANNER OF DEATH
Definition
Manner of death refers to the way (or design/fashion)
in which the cause of death comes into being.
Tests for circulation
Tests for circulation
 Magnus test
Tests for circulation
 Magnus test
 Diaphanous test
(transillumination test)
Tests for circulation
 Magnus test
 Diaphanous test (transillumination test)

 Icard’s test – in this test, 1 ml of 20% alkaline dye

fluorescence solution is injected either in the dermis

or subcutaneous tissue.
In case of continuing circulation , the solution injected in
the dermis spread locally at the site of injection whereas in
case of subcutaneous tissue injection, the dye will travel to
the farther part of body and even yellowish discolouration
may appear in conjunctiva.
Tests for circulation
 Magnus test
 Diaphanous test (transillumination test)

 Icard’s test –

 Pressure test – in case of continuing circulation, if

pressure is applied over the nail of finger then the

area of nail becomes pale but soon becomes red on
relieving pressure. No such phenomenon is observed
in dead persons.
Tests for circulation
 Magnus test
 Diaphanous test (transillumination test)
 Icard’s test –
 Pressure test –
 Cutting of small artery
 Heat test-( blister appear in life)
Tests for respiration

Inspection – no respiratory
movements will be visible
Palpation – respiratory movements
cannot be appreciated
Auscultation – no breath sound can
be heard from any part of either
lung
Tests
Tests for respiration
Inspection –
Palpation –
Auscultation –
Winslow’s test - a small bowl with water is placed
over the chest of the person with arrangement of
some light rays falling on the surface of water in the
bowl. If the person is respiring then due to respiration
his chest will move and slightest movement of chest
wall will disturb the plain surface of water in bowl
and that can be viewed as the rays of light reflected
from the surface of water
 Tests for respiration
Inspection –
Palpation –
Auscultation –
Winslow’s test –
Mirror test – if the surface of mirror is held in front
of mouth and nostrils, the surface gets dense due to
condensation of warm and moist air exhaled from
lungs. The phenomenon suggests on-going respiration
and indicates person is alive.
 Tests for respiration

Inspection –
Palpation –
Auscultation –
Winslow’s test –
Mirror test –
Feather test – if feather is held in front of
nose, no movement of feather will be
noted if a person is dead.
Stoppage of Function of Nervous System

 With somatic death all functions of nervous system

ceases.
 The subject is insensible with loss of sensory and
motor functions.
 There is loss of reflexes with flaccid muscle. The
pupils are widely fixed and dilated and not
reacting to the light.
SUDDEN DEATH
 death occurring within 24 hour from the
onset of symptom was considered as symptoms
sudden death.

 “a death which is not known to be caused 24 hr

by any trauma, poisoning or violent
asphyxia and where death occurs all of
sudden or within 24 hour of the onset of
terminal symptoms”.
10% Death
Causes of sudden natural death
 Cardiovascular system
 - IHD/- Valvular disorders
 - Congenital heart disease
 - Cardiac tamponad /- Aortic
dissection
 Central nervous system
 - Hemorrhage
 - Ischemia/thrombosis
 - Epilepsy/- Meningitis
 Respiratory system
 - Pulmonary embolism
 - Pneumonia/- Bronchial asthma
 - Spontaneous Pneumothorax
 Gastrointestinal system
 - Acute Pancreatitis/-
Hematemesis
 - Strangulated hernia
 - Perforation peritonitis
 Genito-urinary system
 - Twisted ovarian cyst
 - Amniotic fluid embolism
 - Uterine rupture
 - Rupture of ectopic pregnancy
 Miscellaneous
 - Vagal inhibition
 - Diabetic coma
 - Anaphylaxis
 Gordon’s Classification of Death

1) Anoxic anoxia
2) Anaemic anoxia
3) Stagnant anoxia
4) Histotoxic anoxia
 1) Anoxic anoxia
 Prevention of oxygen entering to lungs /
 Inability of lung to oxygenate the blood

It include-
 Lack of O2 in inspired air eg. High altitude
 Inspiration of inert gas
eg. Methane, sewer gas
 Interference with respiration eg . Hanging
 Interference with respiratory movement .
 Eg. Penetrating chest injury/ paralysis
 Congenital defect of lung/ heart/ blood vessel
2)Anemic anoxia
 It indicates reduced oxygen carrying capacity of
blood
May be due to-
 Anemia

 CO poisoning

 Hemorrhage

 Sulphemoglobin , methhemoglobin
3)Stagnant anoxia
 Slowing down of circulation with impaired O2
delivery to tissue.

Seen in-
 CCF
 Peripheral circulatory failure/ shock
 Acute corrosive/irritant poisoning
 Heat stroke
4)Histotoxic anoxia
 Interference with tissue oxygenation
Cyanide poisoning
Reduced permeability
eg. barbiturate, halothane, ether
- there is inadequate food for efficient metabolism by
the cell eg.Hypoglycemia
- toxic effect of accumulated end product of cell
metabolism eg. uraemia
BRAIN DEATH
Death
 Traditionally : Asystole and Apnoea
Coma vs. Brain Death
Coma
 Profound state of unconsciousness

 Person is not aurousable

 Fails to respond normally to pain, light or sound

 No voluntary actions

Reversible or irreversible –
Depends on cause and severity
 Coma vs. Brain Death

Brain Death
 Irreversible cessation of all brain activity

 Brain is not capable of maintaining life without

advanced life support
 Brainstem death is considered equivalent to brain death,
because brainstem is essential to maintain life
 Heartbeat may continue!

What happens to patients in coma?

 Some recover

 Some enter persistent vegetative state

 Some become brain dead

 Coma vs. Brain Death

Frog heart experiment:

 Heart continues to beat

after taking it out of the
body

 Thus:
Brain activity is not
necessary for heart beat
 Concept of Brain Death

 1968: Ad Hoc Committee of Harvard Medical School

defined brain death as ‘irreversible coma’: - totally
unresponsive, no cranial reflexes, no respiratory efforts
Brain Stem Death
 Definition
 As per Transplantation of Human Organs Act, 1994, ‘Brain Stem Death’ is
defined as,
“Brain Stem Death means the stage at which all functions of the brainstem
have permanently and irreversibly ceased; and is so certified”.
 Conditions
To diagnose Brain Stem Death, the following conditions should be met:
 The patient must be in deep coma and the cause of coma should be
‘irreversible structural brain stem damage’ (i.e. prolonged hypoxia, trauma,
illness or toxic insult)
 Following causes of coma should be excluded:
 Hypothermia (core body temperature is less than 900 F or 320 C)
 CNS depressant drugs such as Barbiturates, Benzodiazepines etc. poisoning.
 Metabolic or endocrine disturbances
 Intoxication (alcohol)
Brain Stem Death
 Demonstration of the absence of the following Brain Stem Reflexes
 Pupillary response
 Corneal reflex
 Vestibule-ocular reflex (Caloric response)
 Grimace
 Cough / Gag reflex
 Cranial motor nerve response to painful stimuli
 Spontaneous respiration
 There should be no spontaneous respiration
 This examination has to be done twice at an interval of 6 hrs.
 Thus, by following the above mentioned protocol, Brain Stem Death
is diagnosed.
 Concept of Brain Death

 1994: “Transplantation of Human Organ Act” in

India
 Defined brain death
 Formalized brain death certification
Preconditions
Personnel
Protocol
Time scale
Types of organ donor
1. Natural-Eyes, skin & fascia, heart valves, Bones &
tendons, cartilage, vein & arteries
2. Living- blood
3. Brain death- kidneys, Liver, lungs, Pancreas, small
intestine
Contraindications to organ donation
 Prolonged hypotension with evidence of
impaired organ perfusion
 Prolonged severe hypothermia
 Malignancies other than confined to the CNS
or the skin
 Systemic viral and bacterial infections
 HbsAg and / or HIV positivity
 Severe collagen vascular or hematological
disorders
Establish the underlying cause
Look for confounders before
proceeding for brain death verification
 Severe electrolyte abnormalities
 Hypoglycemia
 Acid – base abnormalities
 Severe hypothermia (< 32 C)
 Severe Hypotension
 Drug intoxication
 Alcohol, sedative, NM blocking agents
 How do we establish brain death?
1. Preconditions

 Patient comatose, on ventilatory support.

 Cause of irreversible structural brain damage known.
How do we establish brain death?
2. Cranial nerve reflexes
 Absence of pupillary reflex response to light
 Absence of corneal reflexes

 Absence of vestibulo-ocular reflex

 Absence of cranial nerve response to pain

 Absence of gag and cough reflexes

 Absence of facial grimacing (cranial nerve) in

response to painful stimulation (anywhere on

body)
 How do we establish brain death?
Pupillary reflex

 Shining a bright light causes pupil to constrict

 Pupils are fixed and dilated in brain death.
 Reflex path – optic nerve and oculomotor nerve
 How do we establish brain death?
Corneal reflex

 Cornea touched with cotton swab rolled into ball

 No corneal reflexes in brain death.
 Reflex path: Trigeminal nerve and facial nerve
How do we establish brain death?
Vestibulo-ocular reflex

Doll’s eye movements

 Head rotated from side to side

 Both eyes should move in opposite direction

 Absence in brain death

 Reflex path: III, VI and VIII cranial nerves

 How do we establish brain death?
Vestibulo-ocular reflex

Cold Caloric test

 Otoscopy – check
eardrum
 Inject 50 ml ice cold
saline into ear
 Nystagmus, fast
component to opposite
side (COWS)
 Absence in brain death

 Reflex path: III, VI and

VIII cranial nerves
 Cold calorics
 Nystagmus both eyes slow toward cold, fast to
midline
 Not comatose
 Both eyes tonically deviate toward cold water
 Coma with intact brainstem
 Movement only of eye on side of stimulus
 Internuclear ophthalmoplegia
 Suggests brainstem structural lesion
 No eye movement
 Brainstem injury/death

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How do we establish brain death?
Gag and Cough reflexes
 Insertion of suction catheter into
oropharynx, for gag reflex
 Movement of endotracheal tube, for
cough reflex
 No reflex response in brain death.

 Reflex path: Glossopharyngeal and

Vagus nerves
How do we establish brain death?
Apnoea testing
 Measure ABG before starting test
 On ventilator, 100% oxygen for 5 minutes
 Disconnect from ventilator
 Oxygen insufflation through suction catheter in
endotracheal tube
 Watch for any respiratory efforts, monitoring SaO2
and b.p.
 After 10 minutes, repeat ABG
 No respiratory efforts despite PaCO2 >60 mmHg or
rise >20 mmHg – positive apnoea test
 Stop test if there is hypoxia, hypotension or arrhythmia
 Practice parameters for determining brain death in adults
NEUROLOGY 1995;45:1012-1014

 Pitfalls in the diagnosis of brain death

A. Severe facial trauma

B. Preexisting pupillary abnormalities
C. Toxic levels of any: sedatives, aminoglycosides, anticholinergics,
chemotherapeutic agents, or NM blocking agents
D. Chronic CO2 retention
Confirmatory tests

• Measuring neuronal electrical output viz-EEG

• Tests of Global intracranial flow Viz—
Cerebral Angiography-DSA,MRA or CT-
Angio showing absence of intracranial flow.
• Isotope angiography,
• Transcranial Doppler.
Transplantation of Human Organs Act
1994
Aim-
 To regulate removal ,storage & transplantation of

human organ for therapeutic purpose.

 To prevent commercial dealing in organ
 How do we establish brain death?
Procedure according to Transplantation of Human Organs
Act
 Brain death certification to be done by a team of 4
doctors
 One of them should be a neurologist or neurosurgeon
 One of them should be on a panel of doctors approved
for brain death testing by the appropriate authority
 The other members are the treating physician and
member of hospital administration
 Certification to be repeated after 6 hours interval
Informed consent of family is crucial to cadaver organ
donation
 Unusual social situation-

 2 wives

 No relatives available for consent.

 How to make it clear
 Say “dead”, not “brain dead”
 Say “artificial or mechanical ventilation”, not
“life support”
 Time of death = neurologic determination
 NOT when ventilator removed
 NOT when heart beat ceases

 Do not say “kept alive” for organ donation

 Do not talk to the pt as if he’s still alive

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