Sudden Death in Adults: A Practical Flow Chart for Pathologist Guidance

The medico-legal term "sudden death (SD)" refers to those deaths that are not preceded by significant symptoms. SD in apparently healthy individuals (newborn through to adults) represents a challenge for medical examiners, law enforcement officers, and society as a whole. This review aims to introduce a useful flowchart that should be applied in all cases of SD. Particularly, this flowchart mixes the data obtained through an up-to-date literature review and a revision of the latest version of guidelines for autopsy investigation of sudden cardiac death (SCD) in order to support medico-legal investigation. In light of this review, following the suggested flowchart step-by-step, the forensic pathologist will be able to apply all the indications of the scientific community to real cases. Moreover, it will be possible to answer all questions relative to SD, such as: death may be attributable to cardiac disease or to other causes, the nature of the cardiac disease (defining whether the mechanism was arrhythmic or mechanical), whether the condition causing SD may be inherited (with subsequent genetic counseling), the assumption of toxic or illicit drugs, traumas, and other unnatural causes.

Teaching the Forensic Autopsy

The performance of the autopsy is the major procedural skill of the forensic pathologist. It is expected that trainees enter forensic pathology with a basic foundation in the principles and practice of autopsy pathology; however, declining hospital autopsy rates have translated into resident trainees having limited autopsy experiences. Thus, the educator in forensic pathology must also often teach basic human anatomy and autopsy skills prior to any attempt to convey the procedural and cognitive skills specialized to the performance of the forensic autopsy. With advances in technology such as postmortem genetic testing and imaging modalities, training programs must also evolve to accommodate the changing needs of trainees for the future practice of forensic pathology. A number of recommendations are put forth to assist the educator in the teaching of the forensic autopsy.

Toddler Fatalities: The Terrible Twos

The majority of childhood deaths investigated by medical examiners and coroners are under the age of one, and medical examiners and coroners are well-versed in the challenges involved in investigating these fatalities. As infants mature to toddlers, there is a paradigm shift with a decrease in both the number of fatalities and the number of undetermined causes of death. A subset of these, however, remain undetermined, causing frustration for both the parents and medical examiner/coroner. In an effort to facilitate a differential diagnosis in these cases, death certificate data from the New York City Office of Chief Medical Examiner for deaths from one to four years of age over a five year period was examined. Of the 230 deaths investigated by the New York City Office of Chief Medical Examiner, the manner was natural in 39%, accident in 32%, homicide in 19%, therapeutic complication in 5%, and undetermined in 5%. Diligent scene investigation and a thorough histologic examination are key components to the investigation. While the lack of a cause of death in a portion of these undetermined deaths is due to limits in current postmortem techniques, a differential diagnosis for these deaths should include channelopathies, seizure disorders, and accidental injuries involving asphyxial mechanisms and inadvertent drug/toxin ingestion.