“Autopsies: Essential for Accurate Cause of Death and Medical Insight”

Need for Autopsy in every death –

Autopsy meaning “to see for oneself” usually is a thorough examination of a corpse by dissection to determine the cause, mode, and manner of death; or the exam may be performed to evaluate any disease or injury that may be present for research or educational purposes.

Autopsies are performed for either legal or medical purposes. Autopsies can be performed when any of the following information is desired:

• Manner of death needs to be ascertained:
  • Determine if death was natural or unnatural.
  • Injury, its source and extent on the corpse.
• Postmortem interval
• Determining the deceased’s identity
• Retain relevant organs
• If it is an infant, determine live birth and viability

Usually, a forensic autopsy is carried out when the cause of death is pertinent to any criminal conspiracy, while a clinical or academic autopsy is performed to find the medical cause of death and is used in cases of unknown or uncertain death, or for research purposes.

Although all bodies, on which autopsies are carried out should be considered to be potentially infective, however, all pathogens are not equally dangerous. Hence, as per the international standards, the pathogens those which are dangerous to health and have been separated into four categories:

• Hazard Group 1: includes all environmental pathogens those which pose no real threat to the individual or community;

• Hazard Group 2: includes all pathogens those which usually do not pose a threat to individuals but occasional hazard is possible from such organisms. A good example of this is diarrhoeal disease, in particular Escherichia coli (E-Coli) infection. With general care the risk from performing an examination on such a case should be minimal, without a need for any special containment. This bacterium, however, is highly infective, spreading via faeces, and contamination of hands with spread to the mouth is possible, if the safeguards for routine examination outlined earlier are not adhered to. This includes wearing intact gloves and being thorough about hand washing;

• Hazard Group 3: pathogens are more hazardous, and these organisms may cause severe human disease, may spread to the community, and may present a serious hazard to mortuary workers. However, effective treatment and prophylaxis are usually available. Examples include Mycobacterium Tuberculosis and HIV. It is recommended that post mortems should not be performed as a matter of routine in these circumstances, but if a post mortem is considered necessary on such patients, then high- risk procedures should be followed as described below;

• Hazard Group 4: pathogens are extremely dangerous and include smallpox and the viral haemorrhagic fevers. Usually, no effective treatment or prophylaxis is available. Patients with these diseases are admitted to isolation wards of dedicated hospitals and post mortems should be avoided if possible. If they are absolutely essential, ultra-high-risk precautions are taken in specified units with high-security rooms and cabinets.

With cognizance to the above Hazard Group 3 & Hazard Group 4, it is mention-worthy that in different instances substantial errors have been demonstrated while adhering to the said guidelines; hence the need for clinical autopsy becomes inevitable. Clinical autopsies serve two major purposes:

• They are performed to gain more insight into pathological processes and determine what factors contributed to a patient’s death.
• To ensure the standard of care at hospitals. Autopsies can yield insight into how patient deaths can be prevented in the future

A systematic review of studies of the autopsy has confirmed that in about 25% of autopsies, a major diagnostic error was revealed.

A large meta-analysis suggested that approximately one-third of death certificates are incorrect and that half of the autopsies performed produced findings that were not suspected before the person died. Also, it is found that over one-fifth of unexpected findings can only be diagnosed histologically, i.e., by biopsy or autopsy, and that approximately one-quarter of unexpected findings, or 5% of all findings, are major and can similarly only be diagnosed from the tissues preserved.

One study found that out of 694 diagnoses, “Autopsies revealed 171 missed diagnoses, including 21 cancers, 12 strokes, 11 myocardial infarctions, 10 pulmonary emboli, and 9 endocarditis, among others”.

Focusing on intubated patients, one study found “abdominal pathologic conditions – abscesses, bowel perforations, or infarction – were as frequent as pulmonary emboli as a cause of class I errors. While patients with abdominal pathologic conditions generally complained of abdominal pain, results of an examination of the abdomen were considered unremarkable in most patients, and the symptom was not pursued”

In India, an autopsy is generally carried out under Sections 174; or, 176 of the Criminal Procedure Code (CrPC). Both the sections having its own legal jurisprudence, and is restricted to reported unnatural deaths. An identified venomous snakebite & instant death due to venomisation is considered to be an accidental unnatural death, investigated by an Investigating Police Officer – who prepares an Inquest Report (Panchanama), following which the deceased is taken to any Government Hospital where a Post-Mortem (Autopsy) is performed.

But, in our country dawdles a silent assassin – “Indian Common Krait – Kalach”. The snake being nocturnal mostly bites during night time. The Risk Assessment, following the bite which mostly remains asymptomatic, becomes arduous as:

• There is no pain at the bite site; puncture wounds may not be apparently visible.
• No ecchymosis (leaking of blood from blood vessels into the subcutaneous tissue that underlies the skin), swelling, or any other local sign. At times, the bite is misquoted as mosquito bite.
• Non-specific symptoms include numbness, paresthesias (the feeling of tingling, numbness or “pins and needles), extreme aching of head, and abdomen.
• It is vital to recognise the patients of Krait bites early before the onset of significant neurotoxicity when the antivenom is more effective. Neurotoxicity is slow in onset (usually within 2 hours) and progresses over time. The early features include ptosis (drooping of the upper eyelid), blurred vision, diplopia (double vision) and difficulty in swallowing.

After neurotoxic envenomation caused by a common Krait bite, the patient requires a very large dose of polyvalent anti-snake venom (ASV) to overcome the neurological manifestations. The neurotoxic envenomation is primarily composed of a highly strong presynaptic neurotoxin that prevents impulses from nerve terminals from being transferred to muscle receptors. Although the venom contains a few additional neurotoxic ingredients, it has no cytotoxic, haematotoxic, or other components. Case fatality rates can be higher when patients do not have immediate access to life-saving anti-snake venom serum (ASVS).

Krait envenomation can be associated with rhabdomyolysis contributing towards renal damage. Possible ischemic effect causing tubular degeneration is also significant. This can be clearly inferred from the findings of histology. Plausible immunological mechanism is adequate in explaining the changes in the end organs in fatal krait bite.

‘Rhabdomyolysis’ is the breakdown of muscle tissue that releases a damaging protein into the blood.

This muscle tissue breakdown results in the release of a protein (myoglobin) into the blood. Myoglobin can damage the kidneys. Symptoms include dark, reddish urine, a decreased amount of urine, weakness and muscle aches. Early treatment with aggressive fluid replacement reduces the risk of kidney damage.

The cited symptoms and eventualities create a confusion with regards to the cause of the ailments, and mostly the probable cause of death is cited as Respiratory Failure, which disallows the kin of the victim to pursue any police complaints, and in the process gets deprived of Accidental Death Benefits.

Hence it is quintessential to perform an autopsy in the eventuality of a death arising out of the bite of an Indian Common Krait – Kalach.

To be continued………………

Writer Suvro Sanyal

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