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Sudden

Death

in Adolescence

Gordon K. Murphy, M.D.

From The Miami Valky Hospital and the Office of Coroner, Montgomery County, Dayton, Ohio

ABSTRACT. The majority of adolescent deaths are sudden and unexpected; of these, the great majority result from violence. These violent deaths largely accounted for the 25%

increase in total adolescent mortality during the 1960s. Yet, sudden death in adolescence is not a distinct entity and

receives little study from either pediatricians or

pathol-ogists.

Some cases of sudden death in adolescence are puzzling

and difficult to classify. The pathologist must in each case

obtain a detailed history, usually perform a complete autopsy, and obtain consultation when necessary. Only then

will each case be adequately studied, and related medical

questions and other problems be properly resolved. Pediat-rics 61:206-210, 1978, adolescence, autopsy, sudden death.

Sudden death in adolescence is a topic that has received ‘little or no formal study in the general medical, pediatric, or forensic pathology litera-ture.’ In contrast, many aspects of sudden death in infancy and in adulthood have been extensively studied.

While sudden unexpected death in infancy has been recognized as a syndrome (sudden infant death syndrome or SIDS), i.e., a repetitively found constellation of historical, scene, and phys-ical findings or lack of findings,’ sudden death in adolescence certainly is not a syndrome. Unlike SIDS, sudden unexpected deaths of adolescents are due to a number of well-defined causes or

types of causes. SIDS and adult sudden unexpected death are generally understood to

denote only natural causes of death,2 for in these age groups sudden natural deaths far outnumber unnatural. In infants, congenital anomalies and infectious diseases are other leading causes sudden unexpected natural death, while in adults cardiovascular disease is the most common cause. In contrast, sudden death in adolescence must

include unnatural and traumatic causes as well, for, as we shall see, these are far more common

among adolescents than are natural causes.

NATURE OF THE PROBLEM

Adolescence is defined as being the span of

years from 12 or 15 to 19 or 20, corresponding roughly to the age of puberty and young

adult-hood. “Sudden unexpected natural death” has been defined (as similarly we now define its unnatural counterpart) as death occurring

instan-taneously or within 24 hours of onset of acute symptoms or signs in a previously ambulatory,

apparently healthy, and nonhospitalized per-son.3

Sudden unexpected death in an adolescent or

young adult is certainly a tragic event,4 whether it is due to natural causes or, as it so often is, to

unnatural causes-accident, suicide, or homicide. Because of the sudden unexpected nature of these

deaths and the frequent involvement of trauma,

most of these deaths fall under the jurisdiction of the coroner’s or medical examiner’s office. Although the adolescent may have been under the care of a physician, perhaps a pediatrician, prior to death, and perhaps for the very condition resulting in his death, the postmortem investiga-tion now becomes the responsibility of the coroner or a forensic pathologist.

The sudden unexpected death of a previously healthy adolescent invariably raises emotional

issues and often has legal ramifications as well.

Parents and friends of the adolescent, physicians,

and attorneys are thus frequently and intensely

Received April 27; revision accepted for publication July 25,

1977.

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interested and involved in deaths of this age

group. They often want or even demand to know, and in general have a right to know, the cause and

manner of death and the answers to associated questions if such can be determined by the

postmortem investigation.

METHOD OF STUDY

The coroner, pathologist, or forensic

patholo-gist must not merely perform an autopsy when

indicated, but must carefully and thoroughly document the autopsy and other pertinent

find-ings and provide intelligible and meaningful answers to questions that may be raised regarding them. In this work he can often use, and may

require the assistance of the adolescent’s parents, friends, teachers, or physician, as well as that of

other persons.

Based on my experience as a forensic

patholo-gist, I believe that a complete autopsy should be

performed in all cases of sudden death in adoles-cence with but a few, well-defined exceptions. Most of the latter are cases in which an adolescent

dies suddenly and perhaps unexpectedly but, in

the opinion of the attending physician and

coroner, without question from a natural disease

process that has been closely watched by the physician. My primary reasons for insisting on an

autopsy in all other cases are as follows:

The autopsy may help to demonstrate the cause and manner of death. “Cause of death” is

under-stood in forensic practice to be the primary disease, injury, or physiologic disturbance that

brings about a person’s death. “Manner of death”

is ruled “natural” when death results solely from a disease process. When injury causes or con-tributes to a death, the manner of death is termed “unnatural” and is ruled, according to the circumstances of the injury, “accident,” “homi-cide,” or “suicide.” Cause and manner of death

are not always obvious from the history, or even after the gross autopsy. It may then be necessary to collect body specimens for toxicology or

chem-ical analyses or tissue for microscopic

examina-tion. The coroner or forensic pathologist may not be able to determine the cause or manner of death, or both, even after all indicated

examina-tions have been performed. In these cases he must

then sign the death certificate as “manner of

death” or “cause and manner of death”

“undeter-niined.”

In cases of sudden death in adolescence that are due to natural disease, specifically cases of congenital defects, the parents frequently ask the pathologist, “Is this something hereditary?” They are concerned that this same lesion may prove

lethal in other children that they either now have or may be planning to have. The pathologist should be able to supply a reasonable answer to this question either of his own knowledge or with the help of a geneticist or pediatrician.

An autopsy should be performed to provide

documentation of postmortem findings for legal

purposes. This may seem obvious in cases of accidental death where life insurance benefits may be in question, or in homicidal death where the results of the autopsy will be utilized during criminal prosecution. Many do not realize, however, that in unnatural deaths, even when the deceased adolescent was legally responsible for or

contributed to his own death, his estate or parents

may still bring civil suit against others involved in

the incident, seeking redress for “wrongful death,” “pain and suffering” experienced by the decedent, and the like. A complete autopsy must be performed in these cases.

RESULTS

The Table lists the leading causes of death

among teenagers 15 to 19 years of age in the

United States for the years 1966, 1969,6 1972, and 1974!’

It must be noted that in compiling these data, government sources have listed as “causes of death” three that are in fact “manner(s)” of death (“accidents,” “homicide,” and “suicide”; for

clar-ification, see “Method of Study”). In order to

minimize confusion while discussing these data, accidents, homicides, and suicides will be referred to as “causes of death,” bearing in mind that for each there are numerous true “causes.”

While virtually all of the causes of death listed here may present as sudden unexpected death, accidents, homicide, and suicide almost invar-iably present as such.

Not only are the majority of all adolescent

deaths sudden and unexpected, but cases of

sudden death in adolescence due to violence, with

those resulting from motor vehicle accidents predominating, have constituted the majority of all adolescent deaths during the four one-year periods shown in the Table. Of the four leading causes of death during the nine-year period, three are unnatural and only one, malignant neoplasms,

is a natural cause.

“The [25%] rise in teenage mortality during the 60’s was due primarily to deaths from violent

causes-accident, homicide and suicide. Death

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TEN LEADING CAUSES OF DEATH AMONG TEENAGERS 15 TO 19 YEARS OF AGE IN THE UNITED STATES

1966 1969 1972 1974

r---

---

---

----% of Rank % of Rank % of Rank % of Rank

Total Total Total Total

Accidents 62 1 59 1 59 1 57 1

Motor vehicle (%) 72 70 70 68

Other (%) 28 30 30 32

Homicide 5 3 7 2 8 2 9 2

Malignant neoplasms 8 2 6 3 6 4 6 4

Suicide 4 4 5 4 6 3 7 3

Diseases of heart 2 7 2 5 2 5 2 5

Influenza & pneumonia 2 6 2 6 2 6 1 7

Congenital anomalies 2 5 2 7 2 7 2 6

Cerebrovascular diseases 0 8 1 8 1 8

Nephritis & nephrosis 1 8 0.7 9 0.3 10 0.25 10

Coniplications of pregnancy, 0.5 9 0.5 10 0.4 9 0.30 9

childbirth, & puerperium

All others NC 14 14 14.5

Total deaths 18,171 21,141 22,318 21,982

#{176}Notclassified as per 1969 tabulation.’

A study of death rates for selected causes of death among teenagers for the years 1960 through 1969 reveals that accidents were the leading cause of death among adolescents. As recently, however, as 1965, “malignant neoplasms” and

“major cardiovascular-renal diseases” ranked as

second- and third-leading causes of death,

respec-tively. In 1968, suicide first supplanted major

cardiovascular-renal diseases as third-leading

cause of death, and in 1969 homicide first

supplanted malignant neoplasms as the second-leading cause.’

Accidental deaths due to “poisoning” were categorized only as resulting from “solid and liquid substances” and “gases and vapors” prior to 1968, with a total of 246 such deaths being recorded in 1966 and 268 in 1967.’ With the inclusion in 1968 of the category “drugs and medicaments,” the number of reported deaths due to “poisoning” rose to 384 that year,’#{176}524 in

1969, and 580 in 1972. The inclusion of “drugs” in 1968 was appropriate and in keeping with the marked increase in the illicit use of drugs by adolescents and adults around, and certainly since, that time. ‘ ‘ The reported and recorded

number of accidental deaths due to drugs, as well

as the number of deaths due to suicide, are both undoubtedly lower than the actual numbers of

such deaths. These discrepancies are in part the result of, respectively, the recognized difficulties in ruling some drug-related deaths and the

reluc-tance of some examiners to certify as suicides any

cases other than the most obvious.’2

The steady increase in deaths of adolescents due to homicide is most disturbing and tragic.

There has been a 1 1 1% increase in the number of homicidal deaths of adolescents in the nine-year

period under consideration, and from 1960 to#{149} 1969 the homicide rate among teenagers almost doubled. About one of every 1 1 adolescent deaths

is now a result of homicidal violence. Suicides

have shown a similar steady, 95% increase during

the same period.

Meanwhile, the total numbers of deaths due to most natural causes listed in the Table have declined. Deaths due to malignant neoplasnis

have remained nearly constant, thus falling from second-leading cause of death in 1966 to fourth in

1972 as total deaths from all causes continued to

increase.6 This relative decrease in deaths due to

malignant disease is at least in part a reflection of the advances made during this period in the

treatment of some malignant neoplasms common

to children and adolescents.”

CASE REPORTS

Three example cases will serve to illustrate both types of sudden death in adolescence and problems and considerations faced by the

pathol-ogist and family that are peculiar to each of these,

and similar, cases. In each case, a complete

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Case I

A 14-year-old boy who had a history of good health and

who had apparently been asymptomatic immediately preceding his death, was running laps on an outdoor track at

school when he complained of dizziness and shortness of breath. After being excused to go to the locker room and shower, he suddenly collapsed and died. Attempts at resus-citation by a physician at the scene were unsuccessful.

At autopsy, the positive findings were limited to the cardiovascular system. The heart was enlarged, weighing 360

gm. The left coronary artery took anomalous origin from the right half of the right coronary sinus, then passing to the left to near the usual point of bifurcation of this vessel. There the

left coronary artery bifurcated into hypoplastic circumflex

and anterior descending branches. Each branch initially had a lumen less than 1 mm in diameter, and each was shortly thereafter lost to gross dissection in the subepicardial fat. There was extensive subendocardial fibrosis in the right ventricle. The left ventricle showed borderline hypertrophy.

In all anterior papillary muscles of that chamber there were

areas of milky appearing fibrosis and of hyperemia. Micro-scopic sections here revealed resolving ischemic changes. The aorta was of smaller-than-average caliber throughout.

The sudden death was attributed to cardiac arrhythmia with anomalous origin of a left coronary artery with hypo-plastic branches, and evidence of previous ischemic damage to myocardium. The autopsy findings were discussed by the pathologist with the decedent’s mother on two occasions.

Sudden death in adolescence may be due to a variety of congenital cardiac anomalies, with

various congenital syndromes and valvular anom-alies the most common, and coronary artery anomalies less common.3 Fenoglio et al. reported

that, “The incidence of sudden unexpected death (SUD) in anomalous origin of the left coronary

artery from the right SV (sinus of Valsalva)

together with the right coronary artery is 27%

It is not likely that the possibility, let alone the probability, of this coronary artery anomaly would be considered before death in such an apparently asymptomatic young man. The pros-pect for surgical correction of such a coronary

artery anomaly when it is diagnosed before death is dependent on its exact nature.’3

Case 2

A 14-year-old youth, previously in good health, had severe

epistaxis while playing in an informal basketball game at school. Shortly afterward he became comatose, and was hospitalized with a diagnosis of “intracranial hemorrhage.”

He died several hours later. A history was subsequently

obtained from his family showing that he had been struck on the head by a thrown basketball several days previously. He

did not lose consciousness at that time, nor apparently did he complain of any related symptoms or disability between the time of that incident and his later, rather sudden collapse.

At autopsy, there was no evidence of trauma to the scalp, skull, or meninges. Examination of the fresh brain revealed brain swelling and a deep-seated hematoma in the right temporal-parietal area. The fixed brain was further examined

by a neuropathologist. The 5-cm hematoma was situated in

the white matter close to the right lateral ventricle, but there

was no evidence of intraventricular hemorrhage. No other

discrete lesion was seen in the brain.

This case raises the question of spontaneous vs.

traumatic cause of the cerebral hemorrhage. Such

hemorrhage may arise from spontaneous rupture of a congenital arteriovenous malformation or

angioma. The failure, as in this case, to find

histologic evidence of such a lesion does not rule out its presence, for it is known that such lesions

may destroy themselves in the process of acute

lethal rupture. On the other hand, it might be postulated that the present case is one of delayed hemorrhage in such a lesion secondary to the reported head trauma.’6

It was the final opinion of both pathologists involved in this case that the lethal hemorrhage was spontaneous in nature. Their opinion was

based on the lack of symptoms referable with certainty to the reported head trauma; the lack of demonstrable injury to the scalp, skull, and brain; and the deep-seated location of the hemorrhage. The autopsy findings and this opinion were communicated to both the decedent’s physician and his parents.

Case 3

A 13-year-old boy frequented a public swimming pool where, after closing time, he would dive to the bottom to retrieve coins. He had reportedly been cautioned by the pool

operator against diving too deeply. One afternoon the youth

dove into the pool but did not regain the surface.

No evidence of injury was seen on external examination of

the body prior to autopsy. Reflection of the scalp, however, revealed an area of fresh subgaleal hemorrhage at the

anterior vertex, with an underlying, slightly depressed frac-ture of the left parietal bone and cerebral contusions.

It was concluded that the youth had probably been

stunned or knocked unconscious on diving into the pool and

striking his head on the bottom, and that he subsequently

drowned.

Sixteen months after the boy’s death, a parent filed a civil

suit in six figures, alleging negligence on the part of the swimming pool operator.

Even though the cause and manner of death may seem “obvious” in a case such as this one, the coroner or forensic pathologist must both obtain an accurate history at the time and thoroughly

and completely document the findings at autopsy in case he is called on to testify to them in court months or even years later.

These three cases all illustrate the need for the pathologist to obtain in every case as accurate and detailed a history as possible. The history may be obtained from witnesses to the decedent’s injury or collapse, his family, medical and hospital records, and any other pertinent sources of infor-mation. The history must include the decedent’s

medical and social history, including family and

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injury or collapse; and any medical-surgical treat-ment rendered prior to death. By obtaining such a

history prior to performing the autopsy the

pathologist will be aware of specific questions or problems that must be dealt with during the examination, and will be able to more accurately interpret the autopsy findings. The pathologist

must also avail himself of expert consultation

when evaluating autopsy or laboratory findings, particularly in unusual cases such as case 2.

COMMENT

Sudden unexpected death in adolescence is an increasingly common and a profoundly disturbing occurrence that must be dealt with by families, pediatricians, and pathologists. It is a spectrum of

causes rather than a distinct entity, with

trau-matic and unnatural causes of death far more common than natural.

The majority of all adolescent deaths are sudden and unexpected, and in 1972 and 1974

sudden unnatural adolescent deaths resulting

primarily from violence, those due to accident, suicide, and homicide, alone constituted 73% of

all adolescent deaths in the United States.

The increase in total adolescent deaths during the past decade was due primarily to these sudden unexpected deaths resulting from violence, while death rates for other, nonviolent causes declined.”

The steady increase in adolescent deaths, particularly those due to homicidal violence and

suicide, is taking place in a period and a climate

marked by an increasing amount of violent behavior at all levels of our society. Adolescents are with increasing frequency both the perpetra-tors and the victims of homicide (Time, July 11,

1977, pp 18-28). Factors such as the prevailing

climate of violence, chronic family problems, and

reactive depression are all in part responsible for the steady increase in adolescent suicides.

IMPLICATIONS

Sudden death in adolescence has nonetheless received little or no attention in the medical or forensic literature. It, however, must be given increased attention, particularly by pediatricians and pathologists because of its increasing frequency, the violent nature of many adolescent deaths and the attendant problems in properly

certifying them, and the frequent interest shown

in these cases by families and the public.

Those who investigate and report sudden adolescent deaths must in each case insist on a meticulous history and thorough autopsy

exami-nation, then communicate their findings to others

in an understanding and compassionate fashion.

But equally as important, they must if at all possible use the information thus gained to educate those involved and the public concerning the greater problem of violence in society and

means by which it may be combatted.

REFERENCES

1. Beckwith JB: The sudden infant death syndrome. Curr Probl Pediatr 3:6, 1973.

2. Paul 0, Schatz M: On sudden death. Circulation 43:7, 1961.

3. Lambert EC, Menon VA, Wagner HR. Vlad P: Sudden unexpected death from cardiovascular disease in children. Am I Cardiol 34:89, 1974.

4. Luke JL, Helpern M: Sudden unexpected death from natural causes in young adults. Arch Pathol 85:10, 1968.

5. Vital StatLctics of the United States.-1966: II. Mortality.

National Center for Health Statistics, Dept of Health, Education, and Welfare, Public Health

Service, 1968, part A, pp 1-100-1-161.

6. Teenagers, marriages, divorces, parenthood and mortal-ity. Vital Health Stat series 21-23, 1973, pp 25-27,

33-36.

7. Vital Statistics of the United States-1972: II. Mortality.

Rockville, Md, National Center for Health Statis-tics, 1976, part A, pp 1-186-1-251.

8. Vital Statistics of the United States-1974: II. Mortality.

Rockville, Md, National Center for Health Statis-tics, 1976, part B, pp 7-150-7-167.

9. Vital Statistics of the United States-1967: 11. Mortality.

National Center for Health Statistics, 1969, part A, p 1-154.

10. Vital Statistics of the United States-1968: II. Mortality.

Rockville, Md, National Center for Health Statis-tics, 1972, part A, p 1-198.

11. MacKenzie RG: A practical approach to the drug-using adolescent and young adult. Pediatr Clin North Am

20:1035, 1973.

12. Spelman JW: Suicide: A medical examiners viewpoint, in Wecht CH (ed): Legal Medicine Annual. New

York, Appleton-Century-Crofts, 1969, pp 165-184. 13. Holleb Al: Children and cancer. GA 26:128, 1976. 14. Fenoglio J, Cheitlin MD, deCastro CM, McAllister H:

Sudden unexpected death associated with anonia-bits origin of the left cnronary artely. Read before the American Society of Clinical Pathologists, Chicago, Sept 19-26, 1975.

15. Koops B, Kerber RE, Wexler L, Greene RA: Congenital coronary artery anomalies. JAMA 226: 1425, 1973.

16. Courville C: Intracerebral hemorrhage, in Forensic Neuropathology. Mundelein, Ill, Callaghan & Go,

1964, pp 81-91.

17. McAnarney ER: Suicidal l)ehaVior of children and

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1978;61;206

Pediatrics

Gordon K. Murphy

Sudden Death in Adolescence

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1978;61;206

Pediatrics

Gordon K. Murphy

Sudden Death in Adolescence

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