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 mustinclude 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.
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
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
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
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