DEATH DIAGNOSIS

The duty of a doctor is not limited to just treating his patients, but there are also various other duties that he has to perform. One of them is the diagnosis of death and, in the event of unnatural death, reporting it to the corresponding authorities. When a person loses consciousness, a doctor must examine the victim to diagnose the condition and do what is necessary. If the victim is dead, it is the duty of the doctors to declare that the person is dead. If there is no doctor available on site, the situation has to be handled even by a layman. Hence, it is very essential to know the basic techniques of first aid and diagnosis of death.

We all know that death is the termination of the biological functioning of the living organism. It is the last of every living creature on earth. Once we are born, it is definite that one day our soul will leave the material body forever. Scientifically, death is due to the complete and irreversible cessation of the vital functions of the brain, heart and lungs.

STAGES OF DEATH

Death occurs in two stages:
1. Somatic, systemic or clinical death
2. Cellular or molecular death

In somatic death, although life ceases in the organism as a whole, it can persist in different parts of the body, organs, tissues, and cells. Cells in the body can survive for variable periods and can respond to various chemical, thermal, and electrical stimuli. The survival period of the cells depends on the demand for oxygen. And when cells and tissues die, it’s considered molecular death. Typically, molecular death is complete within 3 to 4 hours after somatic death. However, in common parlance, death means somatic death.

WHAT CAUSES DEATH?
Regardless of remote causes, a person dies as a result of the failure of any of these organs such as the brain, heart, or lungs. This is called the immediate cause of death. Remote causes may be due to injury, infection, blood loss, poisoning, drugs, tumors, malnutrition, dehydration, starvation, etc. A sudden death can be due to system failures such as respiratory, CNS, abdominal, endocrine, iatrogenic, special cases in children, malnutrition, disease, accident, injury, predation, suicide, homicide, war, and also due to some undetermined causes. .

SIGNS OF DEATH
Signs of death can be studied under three headings: immediate signs, early signs, and late signs.

Immediate signs: These signs indicate somatic or clinical death.
– Insensitivity (Loss of sensation, movements and reflexes)
– Loss of EEG rhythm
– Cessation of circulation indicated by flat ECG and absence of respiration.

But signs like loss of sensation, movements, loss of breathing, absence of pulse and heart sounds, etc. they are also seen in conditions such as prolonged fainting, vagal inhibition, epilepsy, narcosis, electrocution. Therefore, such signs cannot be considered with one hundred percent certainty. However, they could be taken as conclusive only when associated with a total loss of EEG rhythm for a continuous period of 5 minutes and a flat ECG for 5 minutes.

Early Signs: These signs denote molecular or cell death, which follows for about 12 to 24 hours.
– Algor motris: It is the cooling of the body after death.
– Postmortem lividity: It is the discoloration after death. It starts within 1-3 hours and fixes itself in 6-8 hours.
– Rigor mortis: It is the rigidity of the body after death. It begins 2-3 hours after death and takes 12 hours to develop, persists for another 12 hours, and takes 12 hours to completely disappear.

Late signs: These signs represent the decomposition or decay of the corpse, or in certain situations, the modification of the corpse into adipocere or mummification. Late signs continue after approximately 24 hours. Putrefaction of the body is indicated by the appearance of a greenish discoloration that appears 12 to 24 hours after death. Marbling is web like markings on the skin, appearing after 12 hours and becoming prominent 36-48 hours after death. Worms also begin to appear as a result of rot.

BRAIN DEATH
It is the irreversible end of all brain activity, but the brain stem continues to function. When brain death occurs, the victim can stay alive by keeping the heart and lungs functioning with the help of sophisticated instruments and some drugs. The body can survive by maintaining the supply of oxygenated blood to the brain stem. When the brain stem also stops working, it is taken as a major indication of death.

suspended animation
This condition is also called apparent death. Here, the vital functions of the body are at such a low level that they cannot be detected by routine methods of clinical examination. Suspended animation can persist from a few seconds to several minutes. This condition can be noticed in apparently drowning, newborns, after anesthesia, brain grant, electrocution, heat stroke, mesmeric trance, barbiturate overdose, opium, deep shock, etc. Suspended animation can be revived through reanimation techniques.

DIAGNOSIS OF DEATH
The diagnosis of death is not easy when made immediately after death, especially by an inexperienced person. On rare occasions, some difficulty may arise due to suspended animation, excessive doses of sedatives and hypnotics, hypothermia, alcoholic intoxication, etc. When you are asked to make the diagnosis of death, the situation must be handled skillfully. The room where the victim rests should not be overcrowded. Allow only a few people to be present on the site. There must be adequate light, air intake and be free of noise and other disturbances.

Inspection: The inspection should be finished in a few seconds without wasting a lot of time. Look at the victim from head to toe and look for any movement of the body in the chest, abdomen, wings of the nose, etc. Then feel for the radial pulse. If not felt, look for a carotid pulse lateral to the thyroid cartilage (never press on both carotids at the same time, feel only one side without pressing too hard). Then take the stethoscope and listen to the chest for heart and breath sounds. If there are signs of cardiorespiratory failure, administer mouth-to-mouth or mouth-to-nose resuscitation along with external cardiac massage to resuscitate cardiorespiratory function.

If there is no response even after cardiac resuscitation, it is the duty of doctors to confirm the death of the victim. Once again confirm cessation of breathing by holding the stethoscope to the chest/larynx for 5 minutes and also cessation of cardiac activity by holding the stethoscope to the precordium for 5 minutes. A feather test can be done to see if there is any draft through the nose. Open your eyelids and move your head from side to side. If the eyeball is fixed and moves along with the head, it is a sign of death.

Take a clinical flashlight and check for pupillary constriction in the eye when the light enters the eye. When the body dies, the pupil dilates and the cornea loses its shiny appearance. But this may not be clear immediately after death. And in those who have eye injuries, especially the elderly with diabetes, the findings can be confusing. When a person dies, the pallor appears within a few minutes. Look for the capillary filler after you bleach the victim’s nails. In a cadaver you don’t see the capillary filler.

In case of doubt, ECG and EEG monitoring can be performed. A flat ECG for 5 minutes is accepted evidence of death. The absence of EEG waves for five minutes confirms death. However, EEG and ECG are not required to give a death certificate, since the diagnosis of death is possible by clinical examination in most cases. However, these tests are having confirmatory value.

LEGAL ASPECTS OF DEATH

The legal aspects of death vary between different countries. There are differences of opinion on the definition of brain death. However, according to modern thought, a person is presumed dead if they cannot spontaneously recover and survive when the artificial means are removed. Irreversible brain damage can be confirmed by a flat EEG.

In case of any sign of unnatural death or when death is unexpected, the cause of death must be confirmed by a medico-legal autopsy. Unnatural death can be an accident, suicide, homicide, or it can even be a natural but unexpected death that occurs under questionable circumstances. All cases of unnatural death must undergo a medico-legal autopsy to identify the exact cause of death, time of death, position of the body at the time of death, etc. Therefore, it is the duty of a doctor to inform the authorities whenever he encounters an unnatural death.