The lethal assault, fall trauma or cardiac arrhythmia? – diagnostic difficulties associated with determining the cause of death in a patient with an ICD

Szymon Rzepczyk, Paweł Świderski, Bartosz Bijata, Damian Rusek, Beata Bożek, Czesław Żaba

Abstract


The number of patients with implantable cardioverter-defibrillators (ICDs) is steadily increasing. Postmortem interpretation of the data recorded and stored by the device provides vital information about the time and cause of death. In this paper, we describe a case of a 67-year-old man found on the stairs. He had pulseless electrical activity and multiple fresh injuries, notably to the head. Despite an hour-long resuscitation attempt, it was unsuccessful. The subsequent postmortem examination revealed significant myocardial hypertrophy with post-infarction scarring in the left ventricle, and no significant central nervous system injuries were observed. The patient’s ICD was dissected and submitted for analysis. Evaluation of the recorded data revealed the presence of ventricular fibrillation (VF) and tachycardia shortly before the patient was found. Analysis of all the evidence gathered during the investigation led to the conclusion that the cause of death was cardiopulmonary failure resulting from cardiac arrhythmia, and the head injury was a result of an unconscious fall down the stairs.

Keywords


sudden cardiac death; ICD; fall trauma; diagnostic difficulties; autopsy

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References


Soar J, Böttiger BW, Carli P, Couper K, Deakin CD, Djärv T, et al. European Resuscitation Council Guidelines 2021: Adult advanced life support. Resuscitation 2021;161:115-51.

Mirowski M. The automatic implantable cardioverter-defibrillator: an overview. J Am Coll Cardiol 1985;6(2):461-6.

Mauf S, Jentzsch T, Laberke PJ, Thali MJ, Bartsch C. Why we need postmortem analysis of cardiac implantable electronic devices. J Forensic Sci 2016;61(4):988-92.

Hampton JR, Adlam D. The ECG in practice. 5th ed. Edinburgh: Elsevier/Churchill Livingstone; 2008. p. 310-2.

Mazurek M, Lenarczyk R, Kowalski O, Kalarus Z. Co lekarz praktyk powinien wiedzieć o automatycznym kardiowerterze-defibrylatorze? Chor Serca Naczyń 2014;11(3):128-37.

Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, et al. Wytyczne ESC dotyczące diagnostyki i leczenia ostrej i przewlekłej niewydolności serca w 2016 roku. Kardiol Pol 2016;74(10):1037-147.

Biton Y, Rosero S, Moss AJ, Goldenberg I, Kutyifa V, McNitt S, et al. Primary prevention with the implantable cardioverter-defibrillator in high-risk long-QT syndrome patients. Europace 2019;21(2):339-46.

Teresiński G, editor. Medycyna sądowa. Vol. 1. Warszawa: Wydawnictwo Lekarskie PZWL; 2019. p. 355-568.

Raszeja S, Nasiłowski W, Markiewicz J. Medycyna sądowa: podręcznik dla studentów. Warszawa: Państwowy Zakład Wydawnictw Lekarskich; 1993. p. 93-9.

Teresinski G. O ustalaniu okoliczności urazu głowy. Arch Med Sąd Krym 2002;LII(2):65-83.

Black CJ, Busuttil A, Robertson C. Chest wall injuries following cardiopulmonary resuscitation. Resuscitation 2004;63(3):339-43.

Kralj E, Podbregar M, Kejžar N, Balažic J. Frequency and number of resuscitation related rib and sternum fractures are higher than generally considered. Resuscitation 2015;93:136-41.

Goyal D, Nadar SK, Wrigley B, Koganti S, Banerjee P. Skuteczne leczenie komorowych zaburzeń rytmu serca za pomocą kontrapulsacji wewnątrzaortalnej u pacjenta z ciężką dysfunkcją skurczową lewej komory i angiograficznie prawidłowymi tętnicami wieńcowymi. Folia Cardiol 2010;5(6):371-4.

Carvajal-Zarrabal O, Hayward-Jones PM, Nolasco-Hipolito C, Barradas--Dermitz DM, Calderón-Garcidueñas AL, López-Amador N. Use of cardiac injury markers in the postmortem diagnosis of sudden cardiac death. J Forensic Sci 2017;62(5):1332-5.

Basso C, Burke M, Fornes P, Gallagher PJ, de Gouveia RH, Sheppard M, et al. Guidelines for autopsy investigation of sudden cardiac death. Virchows Arch 2008;452(1):11-8.

Kauferstein S, Kiehne N, Peigneur S, Tytgat J, Bratzke H. Cardiac channelopathy causing sudden death as revealed by molecular autopsy. Int J Legal Med 2013;127(1):145-51.

Bartsch C, Irnich W, Risse M, Junge M, Weiler G. Postmortem in situ diagnosis of pacemakers and electrodes to detect dysfunction. Leg Med (Tokyo) 2003;5 Suppl 1:S397-400.

Raasch FO. Pacemaker postmortem. West J Med 1978;128(1):48-9.

Kirkpatrick JN, Ghani SN, Burke MC, Knight BP. Postmortem interrogation and retrieval of implantable pacemakers and defibrillators: a survey of morticians and patients. J Cardiovasc Electrophysiol 2007;18(5):478-82.

Sinha SK, Crain B, Flickinger K, Calkins H, Rickard J, Cheng A, et al. Clinical inferences of cardiovascular implantable electronic device analysis at autopsy. J Am Coll Cardiol 2016;68(12):1255-64.

Kaliszan M, Daniłowicz-Szymanowicz L, Kempa M, Tomczak E, Krzyżanowska M, Jankowski Z, et al. Postmortem analysis of electrogram records from an implantable cardioverter-defibrillator (ICD) in the reconstruction of a road traffic accident. J Forensic Sci 2019;64(5):1551-4.

Bartsch C, Irnich W, Junge M, Stertmann WA, Risse M, Weiler G. Post--mortem evaluation of 415 pacemakers: in situ measurements and bench tests. Europace 2005;7(2):175-80.

Saint-Martin P, Rogers C, Muto J, Boyle NG, Rieders D, Sathyavagiswaran L. Pacemaker/defibrillator evaluation at Los Angeles County Department of Coroner. J Forensic Sci 2008;53(5):1160-5.

Makinae H, Numata N, Kitaoka H, Daimon M, Yamamoto T, Amano A. Use of pacemaker programmers for disaster victim identification. Forensic Sci Med Pathol 2013;9(4):551-3.




DOI: https://doi.org/10.21164/pomjlifesci.921

Copyright (c) 2023 Szymon Rzepczyk, Paweł Świderski, Bartosz Bijata, Damian Rusek, Beata Bożek, Czesław Żaba

License URL: https://creativecommons.org/licenses/by-nc-nd/3.0/pl/