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Sudden unexpected death
WHO definition: Death which occur within 24 hours of the onset of
symptoms. But in Forensic sense, most sudden deaths occur within
minutes or even seconds of the onset of symptoms.
It's important to remember that a sudden death is not necessary unexpected
and unexpected death is not necessarily sudden, but these two factors are
often combined.
A death occurring suddenly, in an individual in whom death was
unexpected; “Sudden” implies death usually within 24 hours of the first
symptom, or those resuscitated from cardiac arrest and dying during the
same hospital admission. Most such deaths occur over a few seconds or
minutes. “Unexpected”, this refers to prior circumstances, particularly of
someone who was believed to have been in good health or who had a
stable chronic condition (e.g. hypertrophic or dilated cardiomyopathy, a
neurological condition such as epilepsy, or a respiratory condition such as
asthma), in whom sudden death was not expected. It also includes a sudden
death occurring in the presence of an illness which would not be expected
to cause death.
Sudden death may occur as a result of:1- Trauma: e.g. head injuries, electric shock, burns.
2- Poisoning: e.g. Co, insecticides, cyanide, or narcotics.
3- Disease (natural death): Natural death means that the death was
entirely by the disease and the trauma or poison did not plays any
part in bringing the action
Sudden Unexpected Death due to Natural Diseases
Cardiovascular System
(I)Diseases of the heart
Diseases of the cardiovascular system account for the majority of
cases of sudden natural death worldwide, usually accounting for
approximately 90% of such cases. Cardiovascular deaths include:
1- Coronary artery disease (CAD):
 Account the majority of all sudden deaths, and about 25% die
without any preceding history or signs. Coronary artery disease
includes: Coronary artery atherosclerosis, coronary artery
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thrombosis which usually associated with atheroma and coronary
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artery spasm.
 CAD is narrowing of the coronary arteries caused by atheroma
(atherosclerosis) which is comprised of fatty deposits (plaque) which
develop on the inner lining of the arteries. The plaques are made up
of cholesterol, vascular smooth muscle cells and inflammatory cells.
Mechanism of death :
The simple stenosis and the complications of atheroma are both
sufficient to cause death.
(a) Coronary stenosis: Having 75% or greater blockage in any of the
coronary vessels is considered critical stenosis. It may lead to chronic
ischemia of the muscle supplied by that coronary vessel and hypoxia
of the myocardium. Hypoxic myocardium is electrically unstable and
liable to arrhythmias and ventricular fibrillation. Thus the ischemia
can lead to:
 Sudden death from fatal cardiac arrhythmias.
 Myocardial infarction: occurs when there is severe stenosis or
complete occlusion of coronary arteries. The area of muscle
damaged is further weakened by the process of cellular death and
inflammatory response to these necrotic cells.
 Fate of myocardial infarction :
(1) The area of myocardial infarction is weakest and soft
between 3 days and 1 week after the clinical onset of
infarction and it's the time that the weakened area may
rupture and cause sudden death from hemopericardium and
cardiac tamponade.
(2) Healing by fibrosis: fibrotic area in the wall of the ventricle
or septum may interfere with physical and electrical
function. Cardiac aneurysms may form at the site of
infarction; they may calcify and may rupture.
(b) Complications of atheroma:
(1) Bleeding into a plaque and this can be seen as a subintimal
hemorrhage at autopsy.
(2) Rupture of atheromatous plaque: when it occurs, the extruded
cholesterol, fat, fibrous debris will be washed downstream in
the coronary arteries and impact distally causing many
‫م عبير عبدالوهاب شرف الدين‬.‫د‬.‫أ‬
infarctions. Mural thrombus may be developed which will
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further reduce the vessel lumen.
2- Hypertensive heart disease:
 This condition may lead to sudden death from left ventricular
hypertrophy. At rest, when diastole is relatively long, the whole
myocardium can be adequately perfused, but if the heart rate
increases, diastolic time is reduced and the perfusion of
endocardial cells is reduced. These cells become unstable and
irritable and may produce arrhythmia and fibrillation.
 Sudden death in people with hypertensive heart disease may be
due to an arrhythmia as mentioned before or one of the other
complications of hypertensive cardiovascular disease, such as a
rupture of the aorta or a hemorrhage in the brain.
 Atheroma is often associated with hypertension, so that the
enlarged heart may also be deprived of a normal blood flow in
the coronaries and become ischemic.
3- Valvular disorder:
 Aortic stenosis: is a disorder of aging, and is characterized by
hard calcification with associated stenosis causing left
ventricular hypertrophy similar to hypertension. Sudden death
is common in these patients.
 Mitral valve prolapse “floppy mitral valve syndrome”: is a
myxomatous degeneration of the mitral valve characterized by
a floppy, rubbery mitral valve, with redundant (excess) tissue,
such that, on gross exam, the valve leaflets appear ballooned or
prolapsed (into the left atrium). The disorder is actually
common and is typically an incidental autopsy finding.
 Infective endocarditis or bacterial endocarditis, refers to a
bacterial infection of the heart valves, The disorder may be
subacute, and usually responds to antibiotic therapy, or acute,
in which there is very rapid valve destruction with associated
heart failure and systemic infection.
 Other valve disorders include rheumatic heart disease.
‫م عبير عبدالوهاب شرف الدين‬.‫د‬.‫أ‬
4-Primary myocardial disease:
 Myocarditis: The term “myocarditis” specifically refers to
inflammation of the heart occur in many infective diseases such
as diphtheria and virus infections including influenza.
 Cardiomyopathies: this disease usually associated with areas of
disordered myocardial fibers.
5-Senile myocardial degeneration:
 The cause of death in these elderly individuals can be very
difficult to determine.
 Senile heart is small, the surface vessels are tortuous, and
myocardium is soft and brown due to lipofuscin in the cells.
(II)Diseases of the arteries
The most common lesions of the arteries themselves that is associated
with sudden death include:
1- Atheromatous aneurysm of the aorta.
2- Dissecting aneurysm of the aorta.
3- Syphilitic aneurysms.
Central nervous system
Very few disorders of the CNS cause sudden and unexpected death, for
examples:
1- Intracranial hemorrhage of varying etiologies (will be discussed in
head injuries).
 Intracerebral hemorrhage.
 Subarachnoid hemorrhage.
2- Brain tumors can cause sudden death, but patients usually present
to a physician with signs and symptoms of their disease prior to
death.
3- Intracranial infections: e.g. Meningitis, encephalitis and brain
abscess..
4- Epilepsy: epileptics can die suddenly in a variety of circumstances,
unconsciousness can leave the individual in a position that
compromises the airway, a more common variation of this is the
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epileptic who drowns as a result of having a seizure while taking a
bath. Seizures may also lead to secondary trauma including falls, 5
fires, and motor vehicle accidents. Apart from these trauma-related
deaths, status epilepticus is a recognized medical emergency that
can cause death if the seizures are not brought under control. The
actual mechanism by which these deaths occur is not currently
understood, but would appear to be related to some physiologic
disruption of brainstem, cardiac and/or respiratory function.
Autonomic dysfunction has been also proposed as a mechanism.
5- Cerebral thrombosis and infarction.
Respiratory system
1- Pulmonary embolism: is very common and is the most clinically
under-diagnosed cause of death. In almost every cause, the source
of emboli is in the leg veins.
2- Massive hymoptysis from cavitating pulmonary tuberculosis or
from malignant tumors.
3- Lobar pneumonia.
4- Pneumocystis carinii pneumonia: Forensic pathologists must be
aware of the numerous infections that can arise secondary to
human immunodeficiency virus (HIV) infection and attempt to
confirm the diagnosis with postmortem serology. Public health
officers must be notified of either a possible or a confirmed
diagnosis of HIV infection so that follow-up of close contacts of
the decedent can be undertaken.
5- Rapid (but not sudden) deaths can also occur from fulminating
chest infections.
6- Bronchial asthma is also associated with rare unexplained and
unexpected deaths even there is no evidence of status asthmaticus.
Gastrointestinal system
Diseases of the gastrointestinal system tend not to present as sudden
death. In some cases, however, avoidance of physicians, ignoring of
symptoms, or vagueness of symptoms can create situations where the
death was sudden.
‫م عبير عبدالوهاب شرف الدين‬.‫د‬.‫أ‬
1- Severe bleeding from a gastric or duodenal peptic ulcer.
2- Ruptured esophageal varices most commonly encountered in 6
patients with portal hypertension.
3- Mesenteric thrombosis and embolism may result in infarction of
the gut. Rapid but not sudden death is expected if the infarction
remains undiagnosed.
4- Pancreatitis: A variety of conditions can induce pancreatitis,
including chronic alcoholism, various toxins, severe body trauma,
and elevated blood fat levels.
5- Intestinal infarction due to strangulated hernia.
6- Peritonitis arising from perforated carcinoma.
Gynecological causes
1- A natural complication of pregnancy as rupture ectopic pregnancy
or an induced complication as an abortion.
2- Eclampsia.
Post mortem diagnosis
The diagnosis of sudden unexpected death may be one of
exclusion. Aims of investigation of sudden death victims are:
1- Establishing the cause, mechanism and manner of death.
2- Excluding an unnatural death, violence and poisoning.
3- Proofing that the death is due to natural causes.
The diagnosis depends on:
1- Circumstances: including clinical and family history and witness.
2- All cases of sudden unexpected death in young people should have
an autopsy.
3- Complete autopsy: all body cavities are to be opened and organs
examined very carefully.
4- Obtain blood and urine for complete toxicological analysis.