Death in Epilepsy:
A Retrospective Study
Lear-Kaul KC, Coughlin L, Dobersen MJ
Sudden unexpected death in epilepsy: a retrospective study.
Am J Forensic Med Pathol, Mar 2005, 26(1) p11-17.
I've posted this
American Journal of Forensic Medicine and Pathology
article in PDF file format.
If you don't have an Adobe Acrobat PDF file program, you can download a FREE version HERE.
I really wish that researchers performing reviews of potential "SUDEP" deaths would finally begin to include investigation of the possibility that positional asphyxia forms of death are occasionally misidentified as SUDEP deaths especially since the forensic requirements for determining a SUDEP death are so similar to the forensic requirements for determining any form of positional asphyxia death. According to this Retrospective study's article;
"The term sudden unexpected death in epilepsy, or SUDEP, encompasses sudden unexpected, witnessed or unwitnessed, nontraumatic and nondrowning deaths in epileptic patients where postmortem examination does not reveal a toxicologic or anatomic cause of death, with or without evidence of a seizure and excluding documented status epilepticus."
- Their Definition Reference:
Nashef L, Brown S. Epilepsy and sudden death. Lancet. 1996;348: 1324-1325.
Since a full-body seizure entirely exhausts the victim's body, if the victim's position after the seizure stops interferes with his breathing even only "minimally" and he is unable to move OUT of the asphyxiating position prior to entering respiratory arrest, there is a high potential for a positional asphyxia death occurring post seizure.
AND, since a full-body seizure can cause an altered level of consciousness productive of involuntarily violent and aggressive behavior ("EXCITED DELIRIUM"), there is a very high potential for a restraint asphyxia death following a seizure. If bystanders or emergency responders restrain the total-body-exhausted seizure victim in a manner that interferes with breathing, he will rapidly enter respiratory arrest. Since the victim will continue to struggle even after respiratory arrest, cardiac arrest will ensue.
Of the 67 "SUDEP" deaths reported in this article, 38 victims "were found on a bed or a couch. In a majority of cases, the body was found in the prone position (37 cases, 67%)."
Was the prone position that each of these individuals was found in one that could have interfered with their airway or their mechanical ability to breathe? This study's authors provided NO indication of them having considered or investigated this possibility.
Unfortunately, the failure of this study's authors to consider or investigate the possibility of a positional form of asphyxia causing any alleged "SUDEP" death is NOT at all unusual.
To date, I've NEVER read a SUDEP article that clearly considers the possibility of a positional form of asphyxia causing any alleged "SUDEP" death.
However, the most OUTRAGEOUS example (to my knowledge) of this failure involves one of the victims included in THIS 2005 March SUDEP retrospective study.
Victim #13, a 27 y/o male, had a "witnessed" seizure while in JAIL on his "day of death," and was "found" PRONE in bed by the paramedics.
Did his jailers simply allow him to remain prone in bed after his "witnessed" seizure? Or, were they preventing him from getting up and about after his seizure by employing forceful-prone-restraint?
The 2005 March SUDEP retrospective study authors entirely failed to indicate whether or not they bothered to explore the possibility that Victim #13 was being forcefully-prone-restrained at the time of his death.
And, IF forceful-prone-restraint was being employed at the time of his death, Victim #13 was a restraint asphyxia victim NOT a SUDEP victim.
Another factor that SUDEP researchers have universally failed to explore:
When victims of a "witnessed" seizure enter cardiopulmonary arrest and receive resuscitation efforts, what is their pH when they arrive at the hospital?
Granted; you cannot entirely "fault" SUDEP researchers for not identifying and exploring this factor on a regular basis. A pH measurement is NOT routinely obtained during cardiopulmonary resuscitation efforts performed in the emergency department! (Something that is entirely the incredibly ridiculous "fault" of emergency department physicians and the American Heart Association.)
But, ANYTIME a sudden death victim's emergency department pH is determined, it is important to both SUDEP and restraint asphyxia research that these pH measurements are collected, documented, and compared to "common" cardiac arrest pH levels.
IN SUMMARY (aka "The Bottom Line!"):
The authors of this study complain that, "A major difficulty with incidence studies is the continued reluctance in using the term SUDEP as a cause of death, making reliance solely on death certificates inconsistent and incomplete."
I agree with them! Firstly, I believe that "SUDEP" is, indeed, a specific cause of death (similar to SIDS). And, I agree with these authors' complaint about the terminology of SUDEP needing to become universally recognized in order to more accurately identify cases of SUDEP. (We've had this same damn problem getting Medical Examiners to use the terms "restraint asphyxia" when identifying deaths due to RESTRAINT causing a positional asphyxia form of death thus, clearly identifying the "manner of death" being "homicide" in restraint asphyxia cases, whereas the "manner of death" is most often "accidental" in positional asphyxia cases.)
However, if these authors wish to see the term "SUDEP" become more frequently employed as a cause of death, they (and other SUDEP researchers) will have to better substantiate SUDEP as a specific cause of death, entirely independent from OTHER causes of death such as positional asphyxia or restraint asphyxia!
Thus, it would be terrifically beneficial to SUDEP researchers if the forensic medical definition of SUDEP were AMENDED as follows:
"The term sudden unexpected death in epilepsy, or SUDEP, encompasses sudden unexpected, witnessed or unwitnessed, nontraumatic and nondrowning deaths in epileptic patients where postmortem examination does not reveal a toxicologic or anatomic cause of death, with or without evidence of a seizure and excluding documented status epilepticus, and when PERIMORTEM investigation reveals that all forms of positional asphyxia causes of death can be ruled-out to a reasonable degree of medical certainty."
Clearly; if sudden unexpected, witnessed or unwitnessed, nontraumatic and nondrowning deaths in epileptic patients, where postmortem examination does not reveal a toxicologic or anatomic cause of death (with or without evidence of a seizure, but excluding documented status epilepticus) are NOT EVALUATED for the potential of positional asphyxia or restraint asphyxia as having caused the death ...
"SUDEP" will NEVER be accurately understood or identified.
Nor is SUDEP likely to EVER be universally accepted as a specific cause of death,
entirely independent from OTHER causes of death.
Sudden Unexpected Death in Epilepsy:
Is Death by Seizures a Cardiac Disease?