第六章 猝死課件

第六章猝死第七章猝死

一、猝死的概念猝死（suddendeath）是指一個(gè)貌視健康的人，由于潛在的疾病或機(jī)能障礙，發(fā)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，因內(nèi)在疾病發(fā)作或惡化而發(fā)生的急驟死亡。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、猝死的特點(diǎn)：1、急速性死亡：WHO:24h；1h～2h；即時(shí)死（instantaneousdeath)。2、意外性死亡:突然，出人意料，令人懷疑，可疑暴力死。3、自然性死亡:naturaldeath，non-violentdeath第六章猝死三、猝死的原因各個(gè)系統(tǒng)疾病均可引起猝死，其中在成人以心血管系統(tǒng)疾病占首位,其次為中樞神經(jīng)系統(tǒng)疾病和呼吸系統(tǒng)疾病，消化系統(tǒng)、泌尿系統(tǒng)、生殖系統(tǒng)和內(nèi)分泌系統(tǒng)等疾病相對(duì)較少。不同年齡組引起猝死的常見(jiàn)疾病也有差異，如嬰幼兒以呼吸系統(tǒng)疾病最為常見(jiàn);而青壯年以后則以心血管系統(tǒng)疾病為主。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.心血管系統(tǒng)疾病導(dǎo)致猝死

冠心病52.23%高血壓性心臟病4.00%肥厚性心肌病5.70%Marfans綜合癥0.50%心肌炎5.10%細(xì)菌性心內(nèi)膜炎3.60%心臟傳導(dǎo)系統(tǒng)疾病2.60%第六章猝死Thelumenislarge,withoutanynarrowingbyatheromatousplaque.Themusculararterialwallisofnormalproportion.正常的冠狀動(dòng)脈第六章猝死冠狀動(dòng)脈嚴(yán)重狹窄的鏡下觀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.冠狀動(dòng)脈粥樣硬化、栓塞和心肌梗死2.Stenosisandinsufficiencyofvalves.瓣膜狹窄和關(guān)閉不全3.Congenitalheartdiseases.先天性心臟病4.Acuteandconstrictivepericarditis.急性縮窄性心包炎5.Degenerativeconditionsofheartandheartvasculatures心肌和心臟血管的退行性變6.Infectiveconditionsoftheheart心臟的感染性疾病第六章猝死Amongtherespiratorycauses,thefollowingsareimportant--1.Haemoptysisofdifferentorigin各種原因的咯血

-2.Diphtheria,influenza,pneumoniasandotheracuteinfectiveconditions白喉、流感、肺炎及各種感染

-3.Airembolism空氣栓塞

-4.Edemaglottis喉水腫

第六章猝死-5.Pulmonaryedema肺水腫

-6.Pleuraleffusionandcollapseofthelungs胸腔積液和肺萎陷

-7.Foreignbodyintherespiratorypassage呼吸道內(nèi)異物

-8.Lungsabscess,neoplasmandothercauses.肺膿腫、腫瘤及其他原因第六章猝死SuddenDeathfromHypersensitivePulmonaryTuberculosis第六章猝死Amongthecentralnervoussystemcauses,theimportantsare-

-1.Differentintra-cranialhaemorrhages,thrombosis顱內(nèi)血腫、栓塞

-2.Meningitis,encephalitis腦膜炎、腦炎

-3.Epilepsy癲癇

-4.Braintumour,brainabscess腦腫瘤、腦膿腫第六章猝死腦出血引起的猝死蛛網(wǎng)膜下腔出血引起的猝死第六章猝死

Amongthegastro-intestinalcauses

1.Haemorrhageinthestomachortheintestineduetovariouspathologicalconditions.不同原因病理性胃腸出血2.Strangulationofhernia絞窄性疝3.Acuteappendicitis急性闌尾炎4.Intestinalobstruction腸梗阻第六章猝死5.Ruptureofliverabscessorenlargedspleen肝膿腫或脾腫大破裂6.Perforationofthestomachortheintestine胃腸穿孔7.Acutehaemorrhagicpancreatitis.急性出血性胰腺炎第六章猝死Amongthegenito-urinarycausesthosementionableare-1.Ruptureofectopicpregnancy異位妊娠破裂2.Toxaemiaofpregnancy妊娠毒血癥3.Uterinehaemorrhageduetovariousreasons不同原因的血尿第六章猝死4.Twistingofovariancyst卵巢囊腫扭轉(zhuǎn)5.Nephrolithiasis腎結(jié)石6.Chronicnephritisandotherpathologicalconditions慢性腎炎及其他病理狀態(tài)第六章猝死Amongthemiscellaneouscauses-1.Anaphylacticreactionstodifferentdrugs藥物過(guò)敏2.Wrongbloodtransfusion錯(cuò)誤輸血第六章猝死3.Blooddyscrasias惡血質(zhì)blooddyscrasiaisapathologicalconditionoftheblood,usuallyinvolvingdisordersofthecellularelementsoftheblood.第六章猝死Diseasesofplatelets:ITP(IdiopathicThrombocytopenicPurpura)原發(fā)性血小板減少性紫癜--suddenonsetofsmallandlargebleedingpointsintheskin;oftenfollowingavirusinfection,oraspirinuse.Sometimes,thereareNosebleedsorbleedinggums（牙齦）.TTP(ThromboticThrombocytopenicPurpura)血栓性血小板減少性紫癜--anemia,fever,andbleedingasinITP第六章猝死原發(fā)性血小板減少性紫癜（Idiopathicthrombocytopenicpurpura，ITP）是一種由外周血小板破壞過(guò)多（一般是正常的20倍以上）所引起的常見(jiàn)出血性疾病。其特征為外周血中的血小板數(shù)大幅度下降，臨床上有出血現(xiàn)象，血小板存活時(shí)間縮短以及骨髓中巨核細(xì)胞代償性增生。第六章猝死50年代以來(lái)，有很多證據(jù)顯示ITP的血小板破壞涉及免疫機(jī)制，故亦被名為免疫性血小板減少癥（Immunethrombocytopenia），或自身免疫性血小板減少性紫癜（Autoimmunethrombocytopenia，ATP）。本病最早由美國(guó)科學(xué)家Werlholf于1735年報(bào)告，古早先曾被稱為Werlholf病。原發(fā)性（或特發(fā)性）血小板減少性紫癜（IdiopathicThrombocytopenicPurpura，ITP）是血液系統(tǒng)一種常見(jiàn)的原因不明的獲得性出血疾病。第六章猝死以血小板減少、骨髓巨核細(xì)胞數(shù)正?；蛟黾?，以及缺乏任何原因，包括外源的或繼發(fā)性因素為特征。目前認(rèn)為，該病是由于體內(nèi)產(chǎn)生抗血小板抗體，使血小板破壞過(guò)多，血小板壽命縮短，而骨髓中巨核細(xì)胞正?；蛟龆?，巨核細(xì)胞變性、幼稚化，因其發(fā)病機(jī)制與自身免疫有關(guān)，故又稱自身免疫性血小板減少性紫癜（AutoimmuneThrombocytopenicPurpura，ATP）。第六章猝死血栓性血小板減少性紫癜(thromboticthrombocytopenicpurpuraTTP)為一種罕見(jiàn)的微血管血栓-出血綜合征。這是一組由于微循環(huán)中形成了血小板血栓血小板數(shù)因大量消耗而減少所形成的紫癜。由于小動(dòng)脈與微血管的栓死，導(dǎo)致器官缺血性功能障礙乃至梗死，對(duì)微循環(huán)依賴性強(qiáng)的器官(腦、腎等)最易出現(xiàn)癥狀本病1925年由Moseh-Cowitz首先報(bào)道真正對(duì)TTP作出命名是1958年由Singer等提出，并由Amorosi和Utman進(jìn)一步總結(jié)了臨床5大特征：①微血管病性溶血性貧血；②血小板減少；③神經(jīng)系統(tǒng)癥狀；④發(fā)熱；⑤腎臟損害；稱為五聯(lián)征，有前三者表現(xiàn)的則稱為三聯(lián)征。本病病情多數(shù)兇險(xiǎn)，病死率高達(dá)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鐮狀細(xì)胞貧血--earlysymptomsaresevere,recurrentepisodesofabdominalpain;bleedingintothejoints;andenlargementofthespleen.Diseasesofwhitebloodcells:Leukemia--earlysignsandsymptomsareanemia,bleedingtendency,bonepain,andseriousinfection.第六章猝死4.Statusthymo-lymphaticus胸腺淋巴體質(zhì)5.Vagalinhibitionoftheheart心臟迷走神經(jīng)抑制6.Cerebralmalaria腦型瘧疾第六章猝死四、猝死的誘因㈠、劇烈的體力活動(dòng)或過(guò)度勞累㈡、精神緊張或情緒激動(dòng)㈢、過(guò)冷過(guò)熱㈣、暴飲暴食㈤、輕微外傷㈤、吸煙飲酒㈥、猝死也可發(fā)生在安靜或睡眠狀態(tài)下第六章猝死五、猝死的法醫(yī)學(xué)鑒定㈠、案情調(diào)查1、一般情況2、死亡前一段時(shí)間的思想情緒、言語(yǔ)、行為，有無(wú)自殺或他殺、意外暴力死的可能性，3、疾病方面，包括既往史、家族史、死亡的誘因、發(fā)病時(shí)間、死亡時(shí)間、臨床表現(xiàn)等第六章猝死㈡、現(xiàn)場(chǎng)勘驗(yàn)

勘驗(yàn)時(shí)特別注意有無(wú)搏斗現(xiàn)象，有無(wú)血跡，有無(wú)剩余食物、飲料、藥物，有無(wú)嘔吐物，取材做毒物化驗(yàn)。第六章猝死㈢、尸體檢查尸表檢查：詳細(xì)檢查，有無(wú)微小損傷、注射針孔、電流斑等尸體解剖：解剖前的準(zhǔn)備：根據(jù)案情、病史，選擇合適的操作步驟，作好必要的準(zhǔn)備解剖：全面、系統(tǒng)解剖，并做病理檢驗(yàn)、毒物化驗(yàn)、細(xì)菌培養(yǎng)、病毒分離等第六章猝死㈣、死因分析一.死因明確二.自然疾病結(jié)合癥狀確定死因三.輕微病變不足以解釋死因四.檢見(jiàn)毒物，應(yīng)分析是猝死，還是中毒死五.檢見(jiàn)損傷，應(yīng)分析是猝死，還是損傷致死1.單純因損傷致死或雖有疾病,死因應(yīng)歸于損傷2.單純因疾病致死或雖有損傷,死因應(yīng)歸于疾病3.損傷是主要死因,疾病是潛在的輔助因素4.疾病是主要死因,損傷是促發(fā)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綜合征是以暈厥和猝死為首發(fā)表現(xiàn),心臟結(jié)構(gòu)"正常",心電圖有特征性改變的一種無(wú)器質(zhì)性心臟病變的室性心律失?；蚍Q之為心臟電疾病.Catecholaminergicpolymorphicventriculartachycardia

第六章猝死

Brugada綜合征是一種編碼離子通道基因異常所致的家族性原發(fā)心電疾病。病人的心臟結(jié)構(gòu)多正常，心電圖具有特征性的“三聯(lián)征”：右束支阻滯、右胸導(dǎo)聯(lián)（Ｖ1－V3）ST呈下斜形或馬鞍形抬高、T波倒置，臨床常因室顫或多形性室速引起反復(fù)暈厥、甚至猝死。本病于1992年由西班牙學(xué)者BrugadaP和BrugadaJ兩兄弟首先提出，1996年日本Miyazaki等將此病癥命名為Brugada綜合癥。Brugada綜合征多見(jiàn)于男性，男女之比約為8:1，發(fā)病年齡多數(shù)在30～40歲之間。主要分布于亞洲，尤以東南亞國(guó)家發(fā)生率最高，故有東南亞夜猝死綜合癥（ＳＵＮＤＳ）之稱。近年來(lái)世界各地均有報(bào)道。Brugada綜合癥的準(zhǔn)確發(fā)病率尚不清楚。第六章猝死Magnesiumdeficiency

RhythminstabilityrelatedtoneurohumoralandcentralnervoussysteminfluencesCommotiocordis

MechanicalinterferencewithvenousreturnAorticdissection

Toxic/metabolicdisturbances第六章猝死青壯年猝死綜合征（suddenmanhooddeathsyndrome，SMDS）

一種至今原因不明的猝死，又稱睡眠中猝死，Suddenunexplainednocturnaldeathsyndrome

（SUNDS）夜間猝死癥候群，多見(jiàn)于青壯年，其特點(diǎn)為：①死者生前身體健康，發(fā)育營(yíng)養(yǎng)良好；②絕大多數(shù)為20～49歲的青壯年；③男多于女，比例11:1；③多死在睡眠當(dāng)中；④死亡快速，多為即時(shí)死；⑤完整的尸檢和輔檢查不出足以說(shuō)明死因的器質(zhì)性疾病，也無(wú)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