Postmortem changes -Immediate

Tests of circulation: (1) Magnus test (ligature test): Fingers fail to show congestion & swelling to a ligature applied at their base. (2) Diaphanous test (transillumination test):  Failure to show redness in the web-space between the fingers on transillumination from behind. (3) I card’s test: Fluorescein dye on being injected at a given site in a dead body fail to produce yellowish-green discolouration in a dead body. Tests of respiration: Winslow’s test– No movement of reflection of light shone on mirror, or surface of water in bowl, kept on the chest.

A i.e. Common phenomenon in yogic person; B i.e. Can be voluntary

B i.e. Fixed dilated pupil not responding to light

Cooling of body & rigor mortis is a sign of molecular or cellular death. 

– Somatic (systemic, clinical or brain) death is cessation of spontaneous breathing, circulation and brain activity (as indicated by flat isoelectric EEG, deep unconsciousness with no response to external stimuli or internal need). Surest sign of brain stem death is fixed dilated pupil not constricting (responding) to light.Q

A i.e. It is a condition of apparent death when no signs of life are discovered as the functions are interrupted for sometimes or are reduced to minimum

Answer is B (Absent pupillary light reflex and dilated pupils):

Brainstem death is defined by the absence of all brainstem mediated cranial nerve reflexes.

Pupillary Light Reflex is a brainstem mediated cranial nerve reflex that is absent in brainstem death. The pupils are usually midsized but may be dilated (should not however be small).

Occulo-cephalic (Doll’s eye) reflex and Vestibulo-ocular (Caloric) reflex are both brainstem mediated cranial nerve reflexes that should be absent in Brainstem death.

Criteria for Brain Death/Brainstem death

The definition of Brain stem death requires simultaneous demonstration that the patient has irreversibly lost the capacity of consciousness (Coma) and the capacity to breathe (Apnoea) both of which are dependent on the intact brainstem.

Clinical assessment of the integrity of Brainstem has two components including assessment of the integrity of brainstem mediated cranial nerve reflexes and the Apnea test.

Deep Unresponsive Coma

Patients with brain death show the deepest coma possible with total unresponsiveness to all stimuli.

• No spontaneous movement
• No response to external stimuli (Verbal/ Deep pain)

Absence of all Brainstem Cranial Reflexes

All reflexes mediated by cranial nerve must be absent

• Absent Pupillary Light reflex (CN II, III)

(Pupils are usually midsized but may be enlarged but they should not be small)

• Absent Corneal Reflex (CN V, VII)
• Absent Vestibulocochlear Reflex (CN III, IV, VI, VIII) (No eye movement in response to caloric irrigation of ears)
• Absent Oculocephalic Reflex

(Absent Doll’s eye reflex) Eyes will move with the head

(No ocular movements on the rapid turning of head).

• Absent Gag Reflex (CNIX, X)
• Absent Tracheal Cough Reflex (CNX)
• Absent Central Motor Response to Pain (CN V, VII) (No response to deep somatic stimulation).

Complete Apnea in the pressure of hypercarbia (Absence of Brainstem Respiratory Reflex)

• No respiratory effort in response to hypercarbia needs to be demonstrated to show that apnea is due to brainstem (medullary) damage
• Absent respiratory movement during disconnection from the ventilator with the PaCO2 > 60 mm Hg is required for the test to be valid

Ans. B: Brain stem functions

The cardinal diagnostic criteria for brain death are: (1) profound coma with total unresponsiveness, (2) apnea despite induced hypercapnia, (3) absence of all reflexes subserved by the brainstem and cranial nerves, (4) presence of a structural brain lesion sufficient to produce the clinical findings, and (5) irreversibility

Areflexia of those reflexes subserved by the cranial nerves must be present for brain death to be determined. There can be no pupillary light reflexes, vestibulo-ocular reflexes, corneal reflexes, gag reflexes, or cough reflexes.

Ans. Can be voluntary

Ans. is- It usually lasts for 6 hrs

Suspended animation (sudden death)

It is apparent death, i.e. signs of life are not found as the functions are interrupted for some time or are reduced to a minimum. The person is not dead i.e. there is no somatic death, brain death or molecular (cellular) death. Life continues and resuscitation is successful in such cases. The condition lasts from a few seconds to 1/2 an hour or more. It may be found in :

• Electrocution
• After anaesthesia
• Cerebral concussion
• Yogis (voluntary)
• Drowning
• Shock
• Narcotic poisoning
• Cholera

Ans. is ‘d’ i.e., Delirium tremens

Suspended animation may be seen in electrocution, drowning, cholera, after anesthesia, shock, sunstroke, cerebral concussion, narcotic poisoning, new born infants and yogis/voluntary.

Ans. d. Absence of stretch reflex from all extremities is essential

The definition of Brain stem death requires simultaneous demonstration that the patient has irreversibly lost
the capacity of consciousness (Coma) and the capacity to breathe (Apnea), both of which are dependent on intact
brainstemo.
. Clinical assessment of the integrity of Brainstem has two components including assessment of the integrity of
brainstem-mediated cranial nerve reflexes and the Apnea test9

  Ans. is ‘c’ i.e., Non-responding muscles

• Death denotes death of human being (46 IPC). It is defined as cessation of life or cesation to exist. Death is of two types (1) somatic death (systemic death or clinical death) and (2) molecular death (cellular death).

Somatic death (systemic death or clinical death)

• It is the complete and irreversible stoppage of the circulation, respiration and brain functions (bishop’s tripod of life). Somatic death is associated with immediate signs of death :‑

1. Permanent and complete cessation of function of brain and flat electric EEG with no response to external stimuli; i.e. brain death.
2. Permanent and complete cessation of function of heart and flat ECG.
3. Permanent and complete cessation of function of lungs.

• Somatic death is due to stopped aerobic processes. However, anaerobic enzymatic processes are still continuing, hence (i) muscles still respond to mechanical, electrical and thermal stimuli, (ii) pupils still respond to miotics and mydriatics.

Molecular death (cellular death)

• It occurs after somatic death. It refers to death of all individual cells. It occurs when even anaerobic processes stop, due to non availability of ATP. At this stage :

1. Muscles do not respond to stimuli.
2. Pupils do not respond to stimuli or drugs.
3. There are early signs and late signs of death :

• Early signs : Changes in skin and eye, cooling of the body, post-mortem lividity, changes in muscles (e.g. primary relaxation, rigor mortis).
• Late signs : Decomposition (putrefaction), adipocere fromation and mummification.

4.  Molecular death of various organs occur at different intervals after somatic death :

1. Nervous tissue —> After 5 minutes.
2. Liver —> After 15 minutes.
3. Heart —> After 45 minutes.
4. Kidney —> After 1 hours.
5. Muscles —> After 3 hours.
6. Cornea —> After 6 hours.
7. Blood After 6 hours.