Sudden Unexpected Natural Death

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The largest category of deaths handled by most medical examiner's offices is natural deaths (Table 1.1). Most of these are sudden and unexpected deaths.

Table 1.1 Breakdown of Medical Examiner Cases as to Manner of Death:

Bexar County Texas (1983 -1998)

Table 1.1 Breakdown of Medical Examiner Cases as to Manner of Death:

Bexar County Texas (1983 -1998)

Total

Naturals

Homicides

Suicides

Accidents

Other

31,502

14,718

4,893

3,440

7,693

758

(100%)

(46.7%)

(15.6%)

(10.9%)

(24.4%)

(2.4%)

These are individuals out functioning in the community, whose deaths are not expected, who suddenly collapse and die. Stress should be put on the sudden nature of these deaths, as many of these individuals may actually have a history of a serious disease.

The medical examiner's office will also see individuals who die as a result of a chronic or terminal disease, but who have elected to die at home. These individuals may be in a hospice or under hospice care. Some elderly individuals with chronic end-stage disease may have been cared for at home for years without seeing a physician. The absence of medical supervision means that these deaths become medical examiner's cases. In the case of hospice individuals, one of the authors (VJMD) has adopted a policy of pre-registra-tion in his office. The hospice personnel send the office information on patients while they are still alive. This includes the name of the attending physician who has already agreed to sign the death certificate as well as the expected cause of death. When the individual eventually dies, the hospice just informs the office of the death; the time of death, and who made the pronouncement.

Sudden deaths can be instantaneous; sudden but not instantaneous, or cases where the individual is found dead. Most people, when talking about sudden death, envision instantaneous deaths. The best illustration of this is an individual walking along who suddenly collapses and is dead upon hitting the ground. The most common cause for this is a ventricular arrhythmia due to coronary artery disease. The individual will often show impact abrasions of the face, indicating that as he was going down, he was unconscious and was not even able to put his arm up in front of his face to prevent impacting the ground (Figure 1.1).

The sudden, but not instantaneous, death is illustrated by the individual who begins to complain of chest pain, difficulty in breathing, weakness, sweating, nausea, and vomiting, and then collapses. He is then transported to the hospital. On the way to the hospital, he goes into cardiac arrest and by the time he reaches the emergency room he is not resuscitatable. Another individual with the same initial symptoms may arrive conscious at the hospital only to experience his fatal cardiac arrhythmia 2 h after admission. Is this still a sudden death? This depends upon one's definition of sudden death. Many, if not most, medical examiners limit classification of sudden deaths as those occurring instantaneously or within 1 h of the onset of symptoms.

Figure 1.1 Impact abrasions of face indicating individual was unconscious or unable to protect his face from impact with ground. Such abrasions tend to overlie bony ridges.

If the individual complaining of chest pain and difficulty breathing survives long enough to get to the emergency room of a hospital, where an EKG shows an acute myocardial infarct and laboratory tests reveal elevated enzymes, then a diagnosis of myocardial infarct can be made and the case is not a medical examiner's case.

There is a third category of sudden unexpected deaths. These are the individuals in whom the death was unexpected, but was found dead in what may or may not have been an instantaneous manner. Sometimes, one can tell how rapid the death was by the how the individual was found. Someone found sprawled on the kitchen floor with impact-type abrasions of the face is most likely an instantaneous death. In the case of a person found dead in bed, death may have been sudden but not instantaneous. The great majority of sudden, unexpected natural deaths seen at a medical examiner's office are due to cardiovascular disease. Less common are deaths due to central nervous system lesions, pulmonary disease, and sepsis. The whole spectrum of natural disease associated with sudden death is discussed in Chapter 3.

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  • nile
    Is carbon monoxide black out sudden and unexpected?
    3 years ago

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