第七章 猝死 sudden death 一、猝死的概念 猝死（ sudden death ）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（ sudden unexpected natural death ）。 指貌似健康者，因内在疾病发作或恶化而 发生的急骤死亡。

Sudden death Sudden death is a death which is not known to have been caused by any trauma, poisoning or violent asphyxia, and where death occurs all on a sudden or within 24 hours of the onset of the terminal symptoms.

Thus, by definition sudden deaths are mostly natural deaths where deaths occur immediately or within 24 hours of the onset of the terminal symptoms, which may be totally different from the symptoms, which the patients were having so long.

The definition does not essentially exclude or rule out deaths due to means other than natural diseases, but no unnatural causes should be apparent. If the cause is diagnosed or known to be unnatural one, it can’t be termed as sudden death.

二、猝死的特点： 1 、急速性死亡： WHO: 24h ； 1h ～ 2h ； 即时死（ instantaneous death) 。 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 : natural death ， non- violent death

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。

The incidents of sudden death is about 10% of all cases of death. Of these again most of the deaths are due to cardiovascular or circulatory causes. Next in frequency are due to respiratory causes.

Of all cases of sudden deaths about 45% are due to pathology in the cardiovascular system, about 20% due to pathology of the respiratory system, about 15% due to central nervous system,about 6% due to alimentary causes, about 4% due to genito-urinary causes and rest 10% are due to miscellaneous causes.

1. 心血管系统疾病导致猝死 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 %

The lumen is large, without any narrowing by atheromatous plaque. The muscular arterial wall is of normal proportion. 正常的冠状动脉

冠状动脉严重狭窄的镜下观 There is a severe degree of narrowing in this coronary artery. It is "complex" in that there is a large area of calcification on the lower right, which appears bluish on this H&E stain. Complex atheroma have calcification, thrombosis, or hemorrhage.

肥厚性心肌病引起猝死 病毒性心肌炎引起猝死

Among the cardiac causes, the most frequent are- – 1. Coronary artery atheroma ， Coronary thrombosis and myocardial infarction. 冠状动脉粥样硬化、栓塞 和心肌梗死 – 2. Stenosis and insufficiency of valves. 瓣膜狭窄和关 闭不全 – 3. Congenital heart diseases. – 先天性心脏病 – 4. Acute and constrictive pericarditis. – 急性缩窄性心包炎 – 5. Degenerative conditions of heart and heart vasculatures – 心肌和心脏血管的退行性变 – 6. Infective conditions of the heart – 心脏的感染性疾病

Among the respiratory causes, the followings are important Haemoptysis of different origin 各种原因的咯血 - 2. Diphtheria, influenza, pneumonias and other acute infective conditions 白喉、流感、肺炎及各种感染 - 3. Air embolism 空气栓塞 - 4. Edema glottis 喉水肿

- 5. Pulmonary edema 肺水肿 - 6. Pleural effusion and collapse of the lungs 胸腔积液和肺萎陷 - 7. Foreign body in the respiratory passage 呼吸道内异物 - 8. Lungs abscess, neoplasm and other causes. 肺脓肿、肿瘤及其他原因

Sudden Death from Hypersensitive Pulmonary Tuberculosis

Among the central nervous system causes, the importants are Different intra-cranial haemorrhages, thrombosis 颅内血肿、栓塞 - 2. Meningitis, encephalitis 脑膜炎、脑炎 - 3. Epilepsy 癫痫 - 4. Brain tumour, brain abscess 脑肿瘤、脑脓肿

脑出血引起的猝死 蛛网膜下腔出血引起的猝死

Among the gastro-intestinal causes - 1. Haemorrhage in the stomach or the intestine due to various pathological conditions. 不同原因病理性胃肠出血 - 2. Strangulation of hernia - 绞窄性疝 - 3. Acute appendicitis - 急性阑尾炎 - 4. Intestinal obstruction - 肠梗阻

- 5. Rupture of liver abscess or enlarged spleen - 肝脓肿或脾肿大破裂 - 6. Perforation of the stomach or the intestine - 胃肠穿孔 - 7. Acute haemorrhagic pancreatitis. - 急性出血性胰腺炎

Among the genito-urinary causes those mentionable are Rupture of ectopic pregnancy - 异位妊娠破裂 - 2. Toxaemia of pregnancy - 妊娠毒血症 - 3. Uterine haemorrhage due to various reasons - 不同原因的血尿

- 4. Twisting of ovarian cyst - 卵巢囊肿扭转 - 5. Nephrolithiasis - 肾结石 - 6. Chronic nephritis and other pathological conditions - 慢性肾炎及其他病理状态

Among the miscellaneous causes Anaphylactic reactions to different drugs - 药物过敏 - 2. Wrong blood transfusion - 错误输血

- 3. Blood dyscrasias 恶血质 - blood dyscrasia is a pathological condition of the blood, usually involving disorders of the cellular elements of the blood.

Diseases of platelets: – ITP (Idiopathic Thrombocytopenic Purpura) 原发性血 小板减少性紫癜 -- sudden onset of small and large bleeding points in the skin; often following a virus infection, or aspirin use. – Sometimes, there are Nosebleeds or bleeding gums （牙 龈）.Nosebleeds – TTP (Thrombotic Thrombocytopenic Purpura) 血栓性 血小板减少性紫癜 -- anemia, fever, and bleeding as in ITP

原发性血小板减少性紫癜（ Idiopathic thrombocytopenic purpura ， 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。

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（ Immune thrombocytopenia ），或自身免 疫性血小板减少性紫癜（ Autoimmune thrombocytopenia ， 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（ Idiopathic Thrombocytopenic Purpura ， ITP ）是血液系统一种常见的原因不明的获得 性出血疾病。血小板减少性紫癜疾病

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 （ Autoimmune Thrombocytopenic Purpura ， ATP ）。

血栓性血小板减少性紫癜 (thrombotic thrombocytopenic purpura TTP) 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% 。

Diseases of clotting factors: – Hemophilia 血友病 -- significant bleeding during circumcision, bleeding into the joints and muscles, easy bruising, significant bleeding during surgery Hemophilia – Von Willebrand's Disease 血管性血友病 -- frequently, a history of familial bleeding tendency; bleeding gums, Nosebleeds, easy bruising Von Willebrand's Disease Nosebleeds

Diseases of red blood cells: – Sickle cell anemia 镰状细胞贫血 -- early symptoms are severe, recurrent episodes of abdominal pain; bleeding into the joints; and enlargement of the spleen. Diseases of white blood cells: – Leukemia -- early signs and symptoms are anemia, bleeding tendency, bone pain, and serious infection. Leukemia

- 4. Status thymo-lymphaticus - 胸腺淋巴体质 - 5. Vagal inhibition of the heart - 心脏迷走神经抑制 - 6. Cerebral malaria - 脑型疟疾

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

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

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。

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

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

Sudden cardiac death Sudden cardiac death is natural death from cardiac causes, heralded by abrupt loss of consciousness within one hour of the onset of acute symptoms.natural deathconsciousness It is important to make a distinction between this term and the related term cardiac arrest, which refers to cessation of cardiac pump function which may be reversible. The phrase sudden cardiac death is a public health concept incorporating the features of natural, rapid, and unexpected. It does not specifically refer to the mechanism or cause of death.cardiac arrestpublic health

The most common cause of sudden cardiac death in adults over the age of 30 is coronary artery atheroma. The most common finding at postmortem examination is chronic high-grade stenosis of at least one segment of a major coronary artery, the arteries which supply the heart muscle with its blood supply. coronary arteryatheromastenosis

A significant number of cases also have an identifiable thrombus (clot) in a major coronary artery which causes transmural occlusion of that vessel. Death in these cases is thought to result from a period of transient or prolonged ischaemia (lack of blood supply) in the myocardium (muscle of the heart wall) which induces an arrhythmia (a conduction disturbance), usually a ventricular arrhythmia, which terminates into ventricular fibrillation.thrombusmyocardiumventricular arrhythmiaventricular fibrillation

As a consequence there may be no changes in the myocardium. The absence of the histological signs of acute necrosis and a healed infarct are a common finding. Chronic high-grade stenosis may have caused previous episodes of ischaemia and areas of focal fibrosis may been seen histologically in the myocardium. Ventricular arrhythmias may arise from a myocardium which has been previously scarred by episodes of ischaemia.stenosis

Left ventricular hypertrophy is the second leading cause of sudden cardiac death in the adult population. This is most commonly the result of longstanding raised high blood pressure which has caused secondary damage to the wall of the main pumping chamber of the heart, the left ventricle. Once again, hypertrophy is associated with cardiac arrhythmias.

The mechanism of death in a the majority of patients dying of sudden cardiac death is ventricular fibrillation and as a consequence there may be no prodromal symptoms associated with the death. These patients may be going about their daily business and suddenly collapse without the typical features of myocardial infarction such as chest pain and shortness of breath.

There are a number of cases in which patients feel the effect of myocardial ischaemia. Myocardial ischaemia is associated with referred pain, classically to the front of the chest, the left arm and the jaw. Patients may feel generally unwell, with nausea, dizziness and vomiting. These symptoms may precede the death for any length of time between a few minutes and several hours.

Non-atherosclerotic coronary artery abnormalitiescoronary artery Hypertrophy of ventricular myocardium Hypertrophy Myocardial diseases and heart failureheart failure

Inflammatory, infiltrative, neoplastic, and degenerative processesneoplastic Diseases of the cardiac valvescardiac valves Congenital heart disease Primary electrophysiological abnormalities

Long QT syndrome, both congenital and acquired Long QT syndromecongenital Sick sinus syndrome Brugada syndrome Brugada 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. Brugada syndrome Catecholaminergic polymorphic ventricular tachycardia Catecholaminergic polymorphic ventricular tachycardia

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 （Ｖ 1 － 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 Brugada P 和 Brugada J 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 。基因心脏 亚洲

Magnesium deficiency Rhythm instability related to neurohumoral and central nervous system influencescentral nervous system Commotio cordis Mechanical interference with venous return Aortic dissection Toxic/metabolic disturbances

青壮年猝死综合征（ sudden manhood death syndrome ， SMDS ） 青壮年猝死综合征（ sudden manhood death syndrome ， SMDS ） 一种至今原因不明的猝死，又称睡眠中猝死， Sudden unexplained nocturnal death syndrome （ 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。

Sudden Unexplained Nocturnal Death Syndrome in Southern China: An Epidemiological Survey and SCN5A Gene Screening. Cheng J, Makielski JC, Yuan P, Shi N, Zhou F, Ye B, Tan BH, Kroboth S. Cheng JMakielski JCYuan PShi NZhou FYe BTan BHKroboth S From the *Department of Forensic Pathology, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, Guangdong, China; daggerDivision of Cardiovascular Medicine, Department of Medicine, University of Wisconsin, Madison, WI; and double daggerDepartment of Epidemiology, School of Public Health, Sichuan University, Chengdu, Sichuan, China.

Abstract Based on autopsy data collected in Southern China from , 975 cases of sudden unexplained nocturnal death syndrome (SUNDS) were surveyed. Genetic screening of SCN5A gene encoding the voltage dependent cardiac sodium channel was performed in 74 SUNDS cases. The annual occurrence rate of SUNDS in the area was estimated to be about 1 per 100,000 people. About 80.6% of deaths occurred between the ages of 21 to 40 years and the case number peaked at age 30 years. In 75.4% of cases with witnesses, victims died asleep between 11 PM and 4 AM and they showed predominantly abrupt respiratory distress shortly preceding death.

婴幼儿猝死综合征 sudden infant death syndrome 指婴儿突然地、出乎意料的死亡，死亡原因不 明，欧美国家称之为 “ 摇篮死 ” 。特点：①死者 生前身体健康，发育营养良好；② 发病年龄以 出生后２周至２岁为多，２月至４月是高峰； ③性别差异不大，男略多于女；③多死在睡眠 当中；④死亡快速，多为即时死，突然死于摇 篮中、床上甚至母亲的怀抱中；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。

Sudden Infant Death Syndrome is also called Crib Death, Cot Death, or SIDS. It usually happens while the baby is sleeping. In SIDS, the baby suddenly dies without any symptoms of illness, and an autopsy provides no reasons for the death.