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Sudden and unexpected natural death - why is toxicological analysis is necessary in all such cases?

Died "of" a particular disease vs. died "with" a particular disease

Instantaneous death

occurs within seconds of onset of symptoms

Sudden death

Death occurring within minutes of the onset of symptoms

Unexpected death

May occur in an individual with significant natural disease, but the death was not expected at that time

Most common systems involved in sudden unexpected natural death

Cardiovascular system, Respiratory system, Central nervous system

Atherosclerotic coronary artery disease (ASCAD)

Disease in blood vessels that supply the heart. Majority of sudden natural deaths investigated by medical examiner offices


disease of heart muscle

Histology of heart

Look for areas of cell death, scars, lack of blood flow


Fat gets into the wall, can become calcified, can rupture, thrombosis

"Vulnerable" artery

fat is near blood flow and a clot can form

Atherosclerotic coronary artery disease - medical history

Often no history of previously diagnosed coronary disease

Initial presenting symptom in 30% of people with CAD is

sudden death

Most common finding (ASCAD)

at least one coronary artery with at least 75% stenosis. May or may not have evidence of myocardial tissue damage.

The finding of severe atherosclerotic coronary artery disease

does not rule out death due to other causes

ASCAD Mechanism of death

Cardiac arrhythmias, ventricular fibrillation

ASCAD Cause of death

Cardiac arrhythmia due to severe atherosclerotic coronary artery disease (or atherosclerotic cardiovascular disease)

ASCAD Manner of death


Aortic aneurysm

Destruction of aortic wall due to atherosclerosis

Hypertensive cardiovascular disease

Hypertrophy of muscle of heart due to increased work-load

Weight of heart in hypertension

increased above 350 gm

Finding what under microscope can add to diagnosis of hypertension?

hypertrophied nuclei

Hypertension mechanism of death

acute cardiac arrhythmia


Primary diseases of the heart muscle

Hypertrophic cardiomyopathy

Enlarged heart with septum thickened more than left ventricular free wall

Hypertrophic cardiomyopathy victims are often

young athletes dying suddenly during or immediately after physical exertion

Myocarditis (inflammatory cardiomyopathy)

Inflammation of the heart muscle

Most common cause of sudden respiratory death

pulmonary thromboembolism

Pulmonary thromboembolism

Clots arise from deep venous thrombosis in the lower extremities, dislodge, and travel to the pulmonary artery and into the lungs

Thrombosis may be due to blood stasis in the lower extremities

Immbolitiy, bed rest, obesity

If 60% of the pulmonary vasculature is suddenly blocked

the heart cannot pump blood through the lungs, leading to cardiovascular collapse

Saddle embolism

clot goes across right and left pulmonary artery


Invasion of lung tissue by organisms (viral, bacterial)

Pneumonia autopsy findings

Lungs will have areas of consolidation


areas that are filled with inflammatory cells instead of air

Microscopic examination pneumonia

will show alveoli filled with inflammatory cells

Marked swelling (edema) of the epiglottis leads to

mechanical obstruction of the airway

Asthma death is caused by

obstruction of the airways by muscular constriction and mucus production such that air can get into but not out of the lung

Autopsy findings, asthma

Overinflated, billowy lungs; clear mucus plugging the bronchi

Seizure disorder

Uncoordinated abnormal electrical discharge from neurons; a disorder of function


Recurrent seizure disorder

Intracerebral hemorrhage

Hemorrhagic stroke - sudden death depends on anatomic location

'Berry' aneurysm

Sudden onset of severe headache, due to congenital malformation of media of the blood vessel at points of bifurcation

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