第六章 猝死课件

第六章猝死第七章猝死

一、猝死的概念猝死（suddendeath）是指一个貌视健康的人，由于潜在的疾病或机能障碍，发生突然的、出人意外的非暴力死亡。即急速、意外的自然性死亡（suddenunexpectednaturaldeath）。指貌似健康者，因内在疾病发作或恶化而发生的急骤死亡。第六章猝死SuddendeathSuddendeathisadeathwhichisnotknowntohavebeencausedbyanytrauma,poisoningorviolentasphyxia,andwheredeathoccursallonasuddenorwithin24hoursoftheonsetoftheterminalsymptoms.

第六章猝死Thus,bydefinitionsuddendeathsaremostlynaturaldeathswheredeathsoccurimmediatelyorwithin24hoursoftheonsetoftheterminalsymptoms,whichmaybetotallydifferentfromthesymptoms,whichthepatientswerehavingsolong.第六章猝死Thedefinitiondoesnotessentiallyexcludeorruleoutdeathsduetomeansotherthannaturaldiseases,butnounnaturalcausesshouldbeapparent.Ifthecauseisdiagnosedorknowntobeunnaturalone,itcan’tbetermedassuddendeath.第六章猝死二、猝死的特点：1、急速性死亡：WHO:24h；1h～2h；即时死（instantaneousdeath)。2、意外性死亡:突然，出人意料，令人怀疑，可疑暴力死。3、自然性死亡:naturaldeath，non-violentdeath第六章猝死三、猝死的原因各个系统疾病均可引起猝死，其中在成人以心血管系统疾病占首位,其次为中枢神经系统疾病和呼吸系统疾病，消化系统、泌尿系统、生殖系统和内分泌系统等疾病相对较少。不同年龄组引起猝死的常见疾病也有差异，如婴幼儿以呼吸系统疾病最为常见;而青壮年以后则以心血管系统疾病为主。第六章猝死Theincidentsofsuddendeathisabout10%ofallcasesofdeath.Oftheseagainmostofthedeathsareduetocardiovascularorcirculatorycauses.Nextinfrequencyareduetorespiratorycauses.

第六章猝死Ofallcasesofsuddendeathsabout45%areduetopathologyinthecardiovascularsystem,about20%duetopathologyoftherespiratorysystem,about15%duetocentralnervoussystem,about6%duetoalimentarycauses,about4%duetogenito-urinarycausesandrest10%areduetomiscellaneouscauses.第六章猝死1.心血管系统疾病导致猝死

冠心病52.23%高血压性心脏病4.00%肥厚性心肌病5.70%Marfans综合症0.50%心肌炎5.10%细菌性心内膜炎3.60%心脏传导系统疾病2.60%第六章猝死Thelumenislarge,withoutanynarrowingbyatheromatousplaque.Themusculararterialwallisofnormalproportion.正常的冠状动脉第六章猝死冠状动脉严重狭窄的镜下观Thereisaseveredegreeofnarrowinginthiscoronaryartery.Itis"complex"inthatthereisalargeareaofcalcificationonthelowerright,whichappearsbluishonthisH&Estain.Complexatheromahavecalcification,thrombosis,orhemorrhage.

第六章猝死肥厚性心肌病引起猝死病毒性心肌炎引起猝死第六章猝死Amongthecardiaccauses,themostfrequentare-1.Coronaryarteryatheroma，Coronarythrombosisandmyocardialinfarction.冠状动脉粥样硬化、栓塞和心肌梗死2.Stenosisandinsufficiencyofvalves.瓣膜狭窄和关闭不全3.Congenitalheartdiseases.先天性心脏病4.Acuteandconstrictivepericarditis.急性缩窄性心包炎5.Degenerativeconditionsofheartandheartvasculatures心肌和心脏血管的退行性变6.Infectiveconditionsoftheheart心脏的感染性疾病第六章猝死Amongtherespiratorycauses,thefollowingsareimportant--1.Haemoptysisofdifferentorigin各种原因的咯血

-2.Diphtheria,influenza,pneumoniasandotheracuteinfectiveconditions白喉、流感、肺炎及各种感染

-3.Airembolism空气栓塞

-4.Edemaglottis喉水肿

第六章猝死-5.Pulmonaryedema肺水肿

-6.Pleuraleffusionandcollapseofthelungs胸腔积液和肺萎陷

-7.Foreignbodyintherespiratorypassage呼吸道内异物

-8.Lungsabscess,neoplasmandothercauses.肺脓肿、肿瘤及其他原因第六章猝死SuddenDeathfromHypersensitivePulmonaryTuberculosis第六章猝死Amongthecentralnervoussystemcauses,theimportantsare-

-1.Differentintra-cranialhaemorrhages,thrombosis颅内血肿、栓塞

-2.Meningitis,encephalitis脑膜炎、脑炎

-3.Epilepsy癫痫

-4.Braintumour,brainabscess脑肿瘤、脑脓肿第六章猝死脑出血引起的猝死蛛网膜下腔出血引起的猝死第六章猝死

Amongthegastro-intestinalcauses

1.Haemorrhageinthestomachortheintestineduetovariouspathologicalconditions.不同原因病理性胃肠出血2.Strangulationofhernia绞窄性疝3.Acuteappendicitis急性阑尾炎4.Intestinalobstruction肠梗阻第六章猝死5.Ruptureofliverabscessorenlargedspleen肝脓肿或脾肿大破裂6.Perforationofthestomachortheintestine胃肠穿孔7.Acutehaemorrhagicpancreatitis.急性出血性胰腺炎第六章猝死Amongthegenito-urinarycausesthosementionableare-1.Ruptureofectopicpregnancy异位妊娠破裂2.Toxaemiaofpregnancy妊娠毒血症3.Uterinehaemorrhageduetovariousreasons不同原因的血尿第六章猝死4.Twistingofovariancyst卵巢囊肿扭转5.Nephrolithiasis肾结石6.Chronicnephritisandotherpathologicalconditions慢性肾炎及其他病理状态第六章猝死Amongthemiscellaneouscauses-1.Anaphylacticreactionstodifferentdrugs药物过敏2.Wrongbloodtransfusion错误输血第六章猝死3.Blooddyscrasias恶血质blooddyscrasiaisapathologicalconditionoftheblood,usuallyinvolvingdisordersofthecellularelementsoftheblood.第六章猝死Diseasesofplatelets:ITP(IdiopathicThrombocytopenicPurpura)原发性血小板减少性紫癜--suddenonsetofsmallandlargebleedingpointsintheskin;oftenfollowingavirusinfection,oraspirinuse.Sometimes,thereareNosebleedsorbleedinggums（牙龈）.TTP(ThromboticThrombocytopenicPurpura)血栓性血小板减少性紫癜--anemia,fever,andbleedingasinITP第六章猝死原发性血小板减少性紫癜（Idiopathicthrombocytopenicpurpura，ITP）是一种由外周血小板破坏过多（一般是正常的20倍以上）所引起的常见出血性疾病。其特征为外周血中的血小板数大幅度下降，临床上有出血现象，血小板存活时间缩短以及骨髓中巨核细胞代偿性增生。第六章猝死50年代以来，有很多证据显示ITP的血小板破坏涉及免疫机制，故亦被名为免疫性血小板减少症（Immunethrombocytopenia），或自身免疫性血小板减少性紫癜（Autoimmunethrombocytopenia，ATP）。本病最早由美国科学家Werlholf于1735年报告，古早先曾被称为Werlholf病。原发性（或特发性）血小板减少性紫癜（IdiopathicThrombocytopenicPurpura，ITP）是血液系统一种常见的原因不明的获得性出血疾病。第六章猝死以血小板减少、骨髓巨核细胞数正常或增加，以及缺乏任何原因，包括外源的或继发性因素为特征。目前认为，该病是由于体内产生抗血小板抗体，使血小板破坏过多，血小板寿命缩短，而骨髓中巨核细胞正常或增多，巨核细胞变性、幼稚化，因其发病机制与自身免疫有关，故又称自身免疫性血小板减少性紫癜（AutoimmuneThrombocytopenicPurpura，ATP）。第六章猝死血栓性血小板减少性紫癜(thromboticthrombocytopenicpurpuraTTP)为一种罕见的微血管血栓-出血综合征。这是一组由于微循环中形成了血小板血栓血小板数因大量消耗而减少所形成的紫癜。由于小动脉与微血管的栓死，导致器官缺血性功能障碍乃至梗死，对微循环依赖性强的器官(脑、肾等)最易出现症状本病1925年由Moseh-Cowitz首先报道真正对TTP作出命名是1958年由Singer等提出，并由Amorosi和Utman进一步总结了临床5大特征：①微血管病性溶血性贫血；②血小板减少；③神经系统症状；④发热；⑤肾脏损害；称为五联征，有前三者表现的则称为三联征。本病病情多数凶险，病死率高达54%。第六章猝死Diseasesofclottingfactors:

Hemophilia

血友病--significantbleedingduringcircumcision,bleedingintothejointsandmuscles,easybruising,significantbleedingduringsurgeryVonWillebrand'sDisease血管性血友病--frequently,ahistoryoffamilialbleedingtendency;bleedinggums,Nosebleeds,easybruising第六章猝死Diseasesofredbloodcells:Sicklecellanemia镰状细胞贫血--earlysymptomsaresevere,recurrentepisodesofabdominalpain;bleedingintothejoints;andenlargementofthespleen.Diseasesofwhitebloodcells:Leukemia--earlysignsandsymptomsareanemia,bleedingtendency,bonepain,andseriousinfection.第六章猝死4.Statusthymo-lymphaticus胸腺淋巴体质5.Vagalinhibitionoftheheart心脏迷走神经抑制6.Cerebralmalaria脑型疟疾第六章猝死四、猝死的诱因㈠、剧烈的体力活动或过度劳累㈡、精神紧张或情绪激动㈢、过冷过热㈣、暴饮暴食㈤、轻微外伤㈤、吸烟饮酒㈥、猝死也可发生在安静或睡眠状态下第六章猝死五、猝死的法医学鉴定㈠、案情调查1、一般情况2、死亡前一段时间的思想情绪、言语、行为，有无自杀或他杀、意外暴力死的可能性，3、疾病方面，包括既往史、家族史、死亡的诱因、发病时间、死亡时间、临床表现等第六章猝死㈡、现场勘验

勘验时特别注意有无搏斗现象，有无血迹，有无剩余食物、饮料、药物，有无呕吐物，取材做毒物化验。第六章猝死㈢、尸体检查尸表检查：详细检查，有无微小损伤、注射针孔、电流斑等尸体解剖：解剖前的准备：根据案情、病史，选择合适的操作步骤，作好必要的准备解剖：全面、系统解剖，并做病理检验、毒物化验、细菌培养、病毒分离等第六章猝死㈣、死因分析一.死因明确二.自然疾病结合症状确定死因三.轻微病变不足以解释死因四.检见毒物，应分析是猝死，还是中毒死五.检见损伤，应分析是猝死，还是损伤致死1.单纯因损伤致死或虽有疾病,死因应归于损伤2.单纯因疾病致死或虽有损伤,死因应归于疾病3.损伤是主要死因,疾病是潜在的辅助因素4.疾病是主要死因,损伤是促发因素第六章猝死SuddencardiacdeathSuddencardiacdeathisnaturaldeathfromcardiaccauses,heraldedbyabruptlossofconsciousnesswithinonehouroftheonsetofacutesymptoms.Itisimportanttomakeadistinctionbetweenthistermandtherelatedtermcardiacarrest,whichreferstocessationofcardiacpumpfunctionwhichmaybereversible.Thephrasesuddencardiacdeathisapublichealthconceptincorporatingthefeaturesofnatural,rapid,andunexpected.Itdoesnotspecificallyrefertothemechanismorcauseofdeath.第六章猝死第六章猝死Themostcommoncauseofsuddencardiacdeathinadultsovertheageof30iscoronaryartery

atheroma.Themostcommonfindingatpostmortemexaminationischronichigh-gradestenosisofatleastonesegmentofamajorcoronaryartery,thearterieswhichsupplytheheartmusclewithitsbloodsupply.第六章猝死Asignificantnumberofcasesalsohaveanidentifiablethrombus(clot)inamajorcoronaryarterywhichcausestransmuralocclusionofthatvessel.Deathinthesecasesisthoughttoresultfromaperiodoftransientorprolongedischaemia(lackofbloodsupply)inthemyocardium(muscleoftheheartwall)whichinducesanarrhythmia(aconductiondisturbance),usuallyaventriculararrhythmia,whichterminatesintoventricularfibrillation.第六章猝死Asaconsequencetheremaybenochangesinthemyocardium.Theabsenceofthehistologicalsignsofacutenecrosisandahealedinfarctareacommonfinding.Chronichigh-gradestenosismayhavecausedpreviousepisodesofischaemiaandareasoffocalfibrosismaybeenseenhistologicallyinthemyocardium.Ventriculararrhythmiasmayarisefromamyocardiumwhichhasbeenpreviouslyscarredbyepisodesofischaemia.第六章猝死Leftventricularhypertrophyisthesecondleadingcauseofsuddencardiacdeathintheadultpopulation.Thisismostcommonlytheresultoflongstandingraisedhighbloodpressurewhichhascausedsecondarydamagetothewallofthemainpumpingchamberoftheheart,theleftventricle.Onceagain,hypertrophyisassociatedwithcardiacarrhythmias.第六章猝死Themechanismofdeathinathemajorityofpatientsdyingofsuddencardiacdeathisventricularfibrillationandasaconsequencetheremaybenoprodromalsymptomsassociatedwiththedeath.Thesepatientsmaybegoingabouttheirdailybusinessandsuddenlycollapsewithoutthetypicalfeaturesofmyocardialinfarctionsuchaschestpainandshortnessofbreath.第六章猝死Thereareanumberofcasesinwhichpatientsfeeltheeffectofmyocardialischaemia.Myocardialischaemiaisassociatedwithreferredpain,classicallytothefrontofthechest,theleftarmandthejaw.Patientsmayfeelgenerallyunwell,withnausea,dizzinessandvomiting.Thesesymptomsmayprecedethedeathforanylengthoftimebetweenafewminutesandseveralhours.第六章猝死Non-atheroscleroticcoronaryarteryabnormalitiesHypertrophyofventricularmyocardiumMyocardialdiseasesandheartfailure第六章猝死Inflammatory,infiltrative,neoplastic,anddegenerativeprocessesDiseasesofthecardiacvalves

Congenitalheartdisease

Primaryelectrophysiologicalabnormalities第六章猝死LongQTsyndrome,bothcongenitalandacquiredSicksinussyndrome

BrugadasyndromeBrugada综合征是以晕厥和猝死为首发表现,心脏结构"正常",心电图有特征性改变的一种无器质性心脏病变的室性心律失常或称之为心脏电疾病.Catecholaminergicpolymorphicventriculartachycardia

第六章猝死

Brugada综合征是一种编码离子通道基因异常所致的家族性原发心电疾病。病人的心脏结构多正常，心电图具有特征性的“三联征”：右束支阻滞、右胸导联（Ｖ1－V3）ST呈下斜形或马鞍形抬高、T波倒置，临床常因室颤或多形性室速引起反复晕厥、甚至猝死。本病于1992年由西班牙学者BrugadaP和BrugadaJ两兄弟首先提出，1996年日本Miyazaki等将此病症命名为Brugada综合症。Brugada综合征多见于男性，男女之比约为8:1，发病年龄多数在30～40岁之间。主要分布于亚洲，尤以东南亚国家发生率最高，故有东南亚夜猝死综合症（ＳＵＮＤＳ）之称。近年来世界各地均有报道。Brugada综合症的准确发病率尚不清楚。第六章猝死Magnesiumdeficiency

RhythminstabilityrelatedtoneurohumoralandcentralnervoussysteminfluencesCommotiocordis

MechanicalinterferencewithvenousreturnAorticdissection

Toxic/metabolicdisturbances第六章猝死青壮年猝死综合征（suddenmanhooddeathsyndrome，SMDS）

一种至今原因不明的猝死，又称睡眠中猝死，Suddenunexplainednocturnaldeathsyndrome

（SUNDS）夜间猝死症候群，多见于青壮年，其特点为：①死者生前身体健康，发育营养良好；②绝大多数为20～49岁的青壮年；③男多于女，比例11:1；③多死在睡眠当中；④死亡快速，多为即时死；⑤完整的尸检和辅检查不出足以说明死因的器质性疾病，也无中毒或暴力死亡原因。第六章猝死SuddenUnexplainedNocturnalDeathSyndromeinSouthernChina:AnEpidemiologicalSurveyandSCN5AGeneScreening.ChengJ,MakielskiJC,YuanP,ShiN,ZhouF,YeB,TanBH,KrobothS.Fromthe*DepartmentofForensicPathology,ZhongshanSchoolofMedicine,SunYat-senUniversity,Guangzhou,Guangdong,China;daggerDivisionofCardi