Challenging Cases: Clinician Coroner Collaboration & - PowerPoint PPT Presentation

Challenging Cases: Clinician – Coroner Collaboration & Cooperation in the Evaluation of Sudden Cardiac Death Joel A. Kirsh, MD, MHCM, FRCPC Cardiology and Critical Care, Hospital for Sick Children Professor of Pediatrics, University of Toronto

Coroners & Medical Examiners

Coroners in Ontario • Medical model – must be licensed physician • Legally bound to determine:  Identity of the deceased  Cause of death  Time and place of death  By what means: Natural, accident, homicide, suicide, undetermined • Recommendations to prevent similar deaths “We Speak for the Dead, to Protect the Living”

Case 1: Playing in the pool

14 minutes later . . .

5 minutes after that . . .

Courtesy of Dr. Glenn Taylor, HSC Pathology

Courtesy of Dr. Glenn Taylor, HSC Pathology

RV RV Endo Endo Epi Epi

2 years prior to death • Palpitations reported by patient • Irregular heartbeat noted by family MD • Referred to pediatrician; ECGs obtained

Junctional rhythm, RBBB/RVH, LAD, PVC ’ s

2 years prior to death: Red Flags • Palpitations reported by patient • Irregular heartbeat noted by family MD • ECG: RBBB/RVH, LAD with PVC ’ s • Echo: RV at “ upper limit of normal ”  Adult normal values used for 12yo boy  Well above normal value for age/gender Case closure: Natural death, likely preventable.

Case 2: Syncope in the backyard • 14 yo boy brought to ER - running, fainted

Case 2: Syncope in the backyard • 14 yo boy brought to ER - running, fainted • ECG initially interpreted as normal  Uncertain followup of abnormal reading • Seizure workup: EEG, CT head normal

Cases of exercise-induced seizures • Ogunyemi AO, Neurology 1988 3 children • Simpson RK, NEJM 1989 3 adults* • Schmitt B, Neuropediatrics 1994 2 children • Sturm JW, Neurol 2002;59:1246 2 adults • Werz MA, Epi&Behav 2005;6:98 1 adult * All 3 had structural CNS pathology

3 months later: Collapsed while playing on the schoolyard Could not be resuscitated, despite multiple drugs/defibrillations

Postmortem Examination

Case 2: Red flags for SCD • 14 yo boy brought to ER - running, fainted • Abnormal ECG, but managed as normal • Seizure workup (EEG, CT) normal  No alternative cause sought

Coroner’s Warrant • Murmur heard 2 years prior:  Echocardiogram performed

Family history • Father has severe HOCM • Followed by specialist at a teaching hospital • Children were never referred for evaluation  One of two siblings subsequent Dx w HOCM Case closure: Natural death, likely preventable MD referred to medical regulator for investigation - echo report replaced by a “corrected” report after the death

Challenging cases • Exertional syncope, “screening” echo –ve, SCD ARVC • Father with HCM, no family screening, eldest son SCD • VF, late death in ICU, no PM, no organs/DNA retained • SCD with -ve PM, FDRs to geneticist, genotyping only  Referred to cardiology 3 months later, still awaiting genotyping  Obvious LQTS on ECG

• Retrospective review of 162 SCDs • Antemortem symptoms 92 (57%)  Pre/syncope 42 (46%) • Sought medical advice 74 (80%) • ECG performed 32 (43%) • Abnormal ECGs 24 (75%)  Most not recognized as abnormal

Tim Chan & Chris Sun, U of T Centre for Healthcare Engineering

2000: Different funding, different aims • Clinical & genetic testing: MOHLTC  Health and Long-Term Care  Health of citizens and residents • Death Investigations: MOCSCS  Community Safety & Correctional Services  Public Safety, Death Prevention • Minimal formal interaction re SUD/SCD

Diversity in Death Investigations Schraeder et al, Am J Forensic Med Pathol 2009;30 • SUDEP cases in U.S. • National survey of coroners and MEs • Specialization is the exception  ~1/3 of coroners medical, most not pathologists  58% of ME’s pathologists, 8% of ME’s non-medical • Significant variation in neuropathology consultn • Cost barrier to PM’s (40% rural, 15% urban)

Real world practices Michaud et al, Int J Legal Med 2010;125:359-366 • Survey of 97 forensic pathologists • Predominantly EU but some NA/Africa/Asia • “25 year old man dies while playing tennis” • 10% of respondents: “No autopsy performed”  29%: “No suspicion of third-party intervention”  11%: “Insufficient resources” • 38% of respondents do not retain EDTA blood • 60% of respondents cannot access DNA testing • 80% do not collaborate with cardiologist(s)

CAREFUL study Van der Werf et al, Europace 2015 • Intervention to improve autopsy rates and cardiogenetic referral after SCD < 45yo • Regional interventions:  Website & telephone “hotline”  Coroners/GP/paramedic education • No change in measured rates:  Autopsy performed 43%  Cardiogenetic clinic 8.4%

The Ontario approach • Consensus across specialties and centres  Cardiology (adult & pediatric)  Genetics/Genetic counselors  Pathologists & Coroners • Initial in-person meeting • Teleconferences/emails • Six month to produce statement

Coroner’s Framework (Ontario, Canada – orig. 2006, under revision) All previously asymptomatic or symptomatic * a. but undiagnosed individuals under the age of forty years who suffer a sudden witnessed collapse followed by death and where the scene and circumstantial evaluation are negative for obvious causes of death e.g. drug overdose, etc.). * Symptoms = syncope, exercise-related pre-syncope, palpitations, seizure of unknown origin especially with familial pattern of seizures

Coroner’s Framework (cont’d) b. Previously asymptomatic or undiagnosed symptomatic individuals, who drown while swimming without phenomena such as poor swimming skills, fatigue, boating accident, intoxication, etc.

The Coroner Should i. I n cases of likely or actual SCD, establish contact with next of kin and provide information regarding avenues for clinical follow-up as per prior regional arrangement. ii. Advise the family that tissues have been retained, and will be made available on authorized request to the appropriate genetic testing facility. iii. Establish regional referral patterns for cardiogenetic assessment, and provide information on these to the next of kin.

Investigating Relatives Tan et al, Circulation 2005;112:207 • 17/43 (40%) had an established diagnosis Average of 8.9 presymptomatic relatives per family

Summary • Room to improve detection of IHRD • Medical model for death investigation  Alignment and collaboration with clinical medicine • Early recognition of “red flags” for SCD • Familial assessment after index case(s) • Better understanding of epidemiology of SCD • New strategies for prevention of SCD

Challenging Cases: Clinician – Coroner Collaboration & Cooperation in the Evaluation of Sudden Cardiac Death Joel A. Kirsh, MD, MHCM, FRCPC Cardiology and Critical Care, Hospital for Sick Children Professor of Pediatrics, University of Toronto (July 2000 – December 2017)

Challenging Cases: Clinician – Coroner Collaboration & Cooperation in the Evaluation of Sudden Cardiac Death Joel A. Kirsh, MD, MHCM, FRCPC Regional Supervising Coroner Office of the Chief Coroner for Ontario (September 2007 - . . .)