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in Epilepsy Is Death by Seizures a Cardiac Disease? |
CITATION:
P-Codrea Tigaran S, Dalager-Pedersen S, Baandrup U, et al.
Sudden unexpected death in epilepsy: is death by seizures a cardiac disease?
Am J Forensic Med Pathol, Jun 2005, 26(2) p99-105.
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.
CHAS' REVIEW
(Updated July, 2005):
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 very similar to the forensic requirements for determining any form of positional asphyxia death.
"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."
- The ABOVE definition QUOTE is from a MARCH 2005 SUDEP article:
Lear-Kaul KC, Coughlin L, Dobersen MJ.
Sudden unexpected death in epilepsy: a retrospective study.
Am J Forensic Med Pathol, Mar 2005, 26(1) p11-7.
[MY use of boldface text.]
- Lear-Kaul/Coughlin/Dobersen's Definition Reference:
Nashef L, Brown S. Epilepsy and sudden death.
Lancet. 1996;348:1324-1325.
A full-body seizure entirely exhausts the victim's body. Thus, 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, a positional asphyxia death will occur post seizure.
Additionally, since a full-body seizure causes an altered level of consciousness that may be productive of involuntarily violent and aggressive behavior ("EXCITED DELIRIUM"), there is a very high potential for a restraint asphyxia death to occur following a seizure if the victim involuntarily acts-out in a violent and aggressive behavior. If bystanders – or emergency responders – restrain the total-body-exhausted seizure victim in a manner that interferes with his breathing, he will rapidly enter respiratory arrest. Since the victim will continue to struggle even after respiratory arrest, cardiac arrest will rapidly ensue.
Of the 23 death case studies reported in the JUNE 2005 SUDEP article, 7 victims were found in a prone position.
4 victims were found in a "sitting position." However, being unconscious (or already dead) when "found," they certainly couldn't have been sitting in an UPRIGHT position. Thus, they had to have been "slumped over" in some fashion.
Was the prone or "sitting" 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, although this study's authors provided significantly important POSITION information, it is NOT at all "unusual" they didn't indicate having considered or investigated the possibility that a positional form of asphyxia caused any of the alleged "SUDEP" deaths they reported. In fact, to date, I've NEVER read a SUDEP article that indicated the authors having considered the possibility of a positional form of asphyxia having caused any alleged "SUDEP" death.
The most OUTRAGEOUS example (to my knowledge) of this failure to consider a positional form of asphyxia having caused a "SUDEP" death is demonstrated by one of the 67 death case studies discussed in the MARCH 2005 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 Victim #13's 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 until the paramedics arrived? The MARCH 2005 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.
The reason this exploration failure is so significant: IF forceful-prone-restraint was being employed at the time of his death, Victim #13 was a restraint asphyxia victim – NOT a SUDEP victim. Thus, to include this case study in a "retrospective" of deaths allegedly attributed to "SUDEP" is not only inaccurate, it undermines the authors' argument that SUDEP is a legitimate ("sole") "cause of death."
Another factor that all SUDEP researchers have universally failed to explore to date:
When victims of a "witnessed" seizure enter cardiopulmonary arrest and receive resuscitation efforts, what is their pH when they arrive at the hospital? This question is especially important to the JUNE 2005 SUDEP authors, because the purpose of their article was to examine the question, "Is Death by Seizures a Cardiac Disease?"
It has already been established that there is a significant difference between the pH of a victim of "simple" or "common" or "acute" Cardiac Arrest, and the pH of a restraint asphyxia victim.
[SEE Restraint Asphyxia Deaths vs. "Common Cardiopulmonary Arrest" Deaths]
Consequently, if SUDEP exists apart from positional asphyxia deaths (whether or not the positional asphyxia involved restraint), there likely would be a significant difference between the pH of a SUDEP victim (in the absence of a restraint asphyxia mechanism) and the pH of a restraint asphyxia victim – AND a significant difference between the pH of a SUDEP victim (in the absence of a restraint asphyxia mechanism) and the pH of a cardiac arrest victim.
However, potential SUDEP case study researchers cannot be "faulted" for not identifying and exploring this factor on a regular basis. Why? Because, a pH measurement is NOT routinely obtained during cardiopulmonary resuscitation efforts performed in ANY emergency department! Thus, the pH measurement is rarely ever available to SUDEP or restraint asphyxia researchers.
Clearly, the failure to routinely obtain a blood sample and ABG analysis prior to pronouncing ANY victim DEAD, is entirely the "fault" of those responsible for developing and establishing emergency department resuscitation protocols and those responsible for developing and establishing ACLS guidelines for emergency department physicians.
Still, ANYTIME a sudden death victim's emergency department pH IS determined, it is vitally important to both SUDEP research and restraint asphyxia research that these pH measurements are collected, documented, and compared to those of "common" cardiac arrest victims' pH levels.
IN SUMMARY (aka "The Bottom Line!"):
The authors of the JUNE 2005 SUDEP provided substantially more specific POSITION information than did authors of previous SUDEP studies. Yet, MORE information than that provided by these authors needs to be collected, considered, and described if SUDEP is ever going to be accepted as a legitimate "cause of death."
The authors of the MARCH 2005 SUDEP retrospective study complained 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!
I believe that "SUDEP" is, indeed, a specific cause of death (similar to SIDS), and is often entirely separate from restraint asphyxia deaths.
I also agree with many SUDEP researchers' complaint about the terminology of SUDEP needing to become universally recognized in order to more accurately identify cases of deaths due to 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, as I've previously identified, if SUDEP researchers wish to see the term "SUDEP" become more frequently employed as a legitimate "cause of death," they have to better substantiate SUDEP as a cause of death that is entirely independent from OTHER causes of death – such as positional asphyxia or restraint asphyxia!
Thus, it would be terrifically beneficial to SUDEP researchers (and restraint asphyxia 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 ...
YOURS, CHAS
BTW: Here is a LINK to the MARCH 2005 SUDEP article
I referred to in the above review:
Sudden Unexpected Death in Epilepsy:
A Retrospective Study
Email Charly at: c-d-miller@neb.rr.com