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)

a. All previously asymptomatic or symptomatic* 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

• verdose, etc.).

* Symptoms = syncope, exercise-related pre-syncope, palpitations, seizure of unknown origin especially with familial pattern of seizures

• b. Previously asymptomatic or undiagnosed

symptomatic individuals, who drown while swimming without phenomena such as poor swimming skills, fatigue, boating accident, intoxication, etc.

Coroner’s Framework (cont’d)

The Coroner Should

• i. In 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

• n 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

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 - . . .)

Challenging Cases: Clinician – Coroner Collaboration & Cooperation in the Evaluation of Sudden Cardiac Death