Clinical effects and lethal and forensic aspects of propofol

Propofol is a potent intravenous anesthetic agent that rapidly induces sedation and unconsciousness. The potential for propofol dependency, recreational use, and abuse has only recently been recognized, and several cases of accidental overdose and suicide have emerged. In addition, the first documented case of murder using propofol was reported a few months ago, and a high profile case of suspected homicide with propofol is currently under investigation. A number of analytical methods have been employed to detect and quantify propofol concentrations in biological specimens. The reported propofol-related deaths and postmortem blood and tissue levels are reviewed. Importantly, limitations of propofol detection are discussed, and future considerations are presented. Because propofol has the potential for diversion with lethal consequences, the forensic scientist must have a basic understanding of its clinical indications and uses, pharmacologic properties, and detection methods. In addition, medical institutions should develop systems to prevent and detect diversion of this potential drug of abuse.     

Planned and unplanned complex suicides: a 5-year retrospective study

The notion of planned and unplanned complex suicides first appeared in 1974 by Marcinkowski and, since then, no systematic study of complex suicides has been published in the English forensic literature. Here, the authors present a 5-year retrospective study of complex suicides. Nineteen complex suicides were reviewed: five unplanned and 14 planned, including the first case of an unplanned complex suicide in a woman. All cases were analyzed in terms of gender, age, methods of suicide, the presence of a suicide note, and past suicide attempts, and statistically compared with a 50-case sample of simple suicides. A further comparison was established with compiled data from the literature. Similarities were revealed regarding incidence of complex suicides, male gender predominance, and types of methods used. In contrast, results showed a higher average age for planned complex suicide victims. Finally, the authors discuss the application of the complex suicide definition.     

Suicide by cop among female subjects in officer-involved shooting cases

An analysis of suicide by cop (SBC) among female subjects in a large sample (n = 707) of officer-involved shootings (OIS) is reported. Women represented 3% of the total sample (n = 21) and 5% (n = 12) of the 256 SBC cases. Therefore, 57% of the women (n = 12) were classified as SBC, and 81% of the women (n = 17) behaviorally evidenced some suicidal motivation. The results underscore that when a female subject becomes involved in a situation leading to an OIS, there is a very high likelihood that she is motivated to be intentionally killed. She is almost guaranteed to have a diagnosed mental disorder, has been prescribed psychiatric medications, and is abusing a substance at the time, most likely alcohol. Nevertheless, she also poses a serious risk of injury to both police officers and civilians during the encounter and will possess a firearm half the time. The wish for suicide is often precipitated by serious relationship issues. Comparisons are made to the male subjects in our previous study.     

Suicidal electrocution in Sydney: a 10-year case review

A retrospective study was undertaken of all cases of death due to suicidal electrocution in Sydney, Australia between 1996 and 2005. A total of 25 cases were identified with 20 cases (80%) as a result of direct attachment to an electrical outlet and five cases (20%) as a result of immersion in a body of water with an electrical appliance. Twenty of the 25 individuals were men (mean age = 57 years, range 22-90) and five were women (mean age 67, range 53-88). At least 35% of decedents were either currently working or had worked as electricians. Electrical timers had been used in eight (32%) cases, the fuse blown in one case, but the remaining 16 (64%) bodies were "live" on arrival of witnesses or electricity personnel. This study demonstrates the phenomenon of electrical suicide as a regular occurrence in Sydney. We highlight the need for investigators and emergency workers to remain vigilant upon discovery of electrical suicides, due to the fact that most bodies remain electrically active after death.     

Different Mechanisms of Decapitation: Three Classic and One Unique Case History

Abstract: Three classic cases and one exceptional case are reported. The unique case of decapitation took place in a traffic accident, while the others were seen after homicide, vehicle‐assisted suicide, and after long‐jump hanging. Thorough scene examinations were performed, and photographs from the scene were available in all cases. Through the autopsy of each case, the mechanism for the decapitation in each case was revealed. The severance lines were through the neck and the cervical vertebral column, except for in the motor vehicle accident case, where the base of skull was fractured. This case was also unusual as the mechanism was blunt force. In the homicide case, the mechanism was the use of a knife combined with a saw, while in the two last cases, a ligature made the cut through the neck. The different mechanisms in these decapitations are suggested.     

A distant-range, suicidal shotgun wound of the back

The case being reported is one of a shotgun fatality with a thoracic back wound. A 23-year-old man was shot from a distance with trajectories going from back to front and on a nearly horizontal level. These findings observed in the autopsy could represent homicide, but scene investigation and police records were interpreted and it became clear that the case was suicide. Thus, this case shows that the determination of the manner of death requires a careful forensic investigation including autopsy findings, scene investigation, and reconstruction of the events.     

Accidental boric acid poisoning following the ingestion of household pesticide

Borate-containing compounds were formerly used as topical antiseptics and were components of many medicinal preparations including skin powders and ointments used for the treatment of burns and diaper rash. These compounds were also used as irrigants for body cavities, including the pleural, vaginal, and rectal cavities. These applications were subsequently discontinued by the medical community when the toxicity and potential lethality of borates were recognized. Although documented cases of borate poisoning are now rare, the chemical is still an active component commonly used in high concentrations in household disinfectants/cleaners, pesticides, and wood preservatives. While the majority of documented borate-related deaths have occurred in infants, the toddler population is currently at risk due to possible exposure to these household products. We present the case of an 18-month-old child who died following the accidental ingestion of a boric acid-containing, commercially available roach pesticide product.     

Schizophrenia and suicide: a 10-year review of Kentucky medical examiner cases

The risk of suicide is significantly increased in schizophrenics; it is estimated that 10-13% of individuals suffering from schizophrenia commit suicide. Schizophrenia is marked by psychotic exacerbations and remissions, with persistent deterioration in baseline functioning with each relapse. We present a 10-year (1993-2002) retrospective review of Medical Examiners' cases of suicide of schizophrenic victims. Twenty-nine cases were between the ages of 20 and 75 (mean age of 41.6 years). The majority of victims were male (62.1%) and Caucasian (86.2%). The leading method of suicide for both males and females was firearm injury (48.3%) mostly of the head, followed by overdose (20.7%), and hanging (13.8%). A comprehensive investigation of the biopsychosocial factors is warranted in cases of schizophrenics who commit suicide. This study offers an insightful analysis pertaining to the determination of intent in formulating the manner of death in this unique population.     

Suicides in the young people of Geneva, Switzerland, from 1993 to 2002

Suicides in Geneva in those less than 25 years old, from 1993 to 2002, were reviewed. Scenes investigations, autopsy findings, toxicology results, and psychiatric history (when available) were examined. There were 65 cases. The average annual suicide rate was 11/100,000. Seventy-seven percent were male, and 23% were female. The youngest was 12 years old and most of the victims were 18 years old and over (89%). For men, the use of firearms was the most common method (38%), followed by fall from height (16%) and drowning (10%). For women, fall from height was the most frequent (40%), followed by firearms and medication overdoses (20% each), hanging (13%), and drowning (7%). Toxicological analysis was performed in 41% of the cases and showed that alcohol was present in 26% and other drugs in 67% of these cases. The most common drugs present were benzodiazepines, cannabis, and cocaine.     

Youth suicide in New Mexico: a 26-year retrospective review

Although suicidal behavior in children and adolescents is a major public health problem, large-scale research on suicide in this population is uncommon. In this study, we reviewed autopsy and field reports for all pediatric suicide cases referred to the New Mexico Office of the Medical Investigator from 1979 to 2005. The age-adjusted suicide rate was 4.8 per 100,000. Psychologic stressors and parasuicidal behavior were identified in some cases. Seventy-six percent of suicides occurred in the victim's home or yard, and 25% left a suicide note. In 26% of cases, alcohol or other drugs were detected in postmortem. Gunshot wound was the most common method overall (58%), followed by hanging (30%). Although the age-adjusted suicide rate is higher in New Mexico than nationally, the trends in the population are similar. With a solid understanding of the circumstances, it may be possible to predict, and hopefully prevent, future cases of child and adolescent death.     

Antidepressants at Autopsy in Hispanic Suicidal Youth in Miami‐Dade County,Florida*

Abstract: Controversy has surrounded the use of antidepressants and suicidal behaviors in youth. This study reviewed the Medical Examiner’s Office records of 253 persons aged 24 years or younger classified as suicides in Miami‐Dade County, Florida, from 1990 to 2007. Information was collected regarding demographic information, suicidal characteristics, psychiatric and psychosocial factors, and toxicology results. Eighty‐five percent of the sample was men, and 53.4% of the subjects were Hispanic. Consistent with previous literature, the existence of antidepressants at autopsy was rare; present in only 6% (n = 15) of the victims. The occurrence of antidepressants was not significantly different between Hispanics (n = 7) and non‐Hispanics (n = 8). The incidence of antidepressants was weakly correlated with a tendency to be men and no history of psychiatric illness. The presence of antidepressants in Hispanic youth suicide victims was similar to non‐Hispanics.     

Suicidal decapitation using a tractor loader: a case report and review of the literature

In forensic practice, decapitated bodies are predominantly associated with decapitation by wheels of trains or with postmortem dismemberment following homicide. In the suicidal context, decapitation accounts for less than 1% of total suicide. Apart from decapitation by trains, other encountered methods involve suicidal hanging and vehicle-assisted ligature suicide. Reported here is a unique case of suicidal decapitation in a 45-year-old man using a tractor loader at the foot of a silo, on his farm. The head was recovered in the loader and there were several impact spots from the loader as well as blood on the silo wall. The autopsy revealed a complete decapitation wound with the severance plane located between the third and fourth cervical vertebra. A 1.5 cm wide abrasion on the anterior part of the neck and abrasions under the chin were noted. This very unique case of intentional suicidal decapitation is the first reported case of a planned system intended to create decapitation outside the unique case of homemade guillotine and the more common decapitation by train.     

Pattern and Trend of Deliberate Self-Harm in Western Nepal

Abstract:  Acts of deliberate self-harm (DSH) not only affect the people directly involved, but also have grave psychological and social impact on the family and community. In the present study, a cohort of 173 cases of DSH reported from April 2002 to March 2005 was retrospectively analyzed, by perusing the medicolegal register maintained by the Emergency Department at the Western Regional Hospital, Pokhara in the Western Development Region of Nepal. The data were entered and analyzed using SPSS Version 10.1. More than two-thirds of total cases were females. About 60% of cases were observed in the age group of 15–24 years. Poisoning (89.6%) was the most preferred method of deliberate self-harm. Organophosphate pesticides were consumed in nearly two-thirds of the poisoning cases. The majority of cases were reported during the months of May to July and had occurred during the last quarter of the day. More than a twofold increase was observed in the frequency of cases during the 3-year study period. The said observations were compared and contrasted with the available literature across the globe. The presentation is concluded by highlighting the limitations encountered in Nepal and the scope to overcome the same.     

Self-inflicted burns: the value of collaboration between medicine and law

Self-inflicted burns are rare in France, but they lead to major, often life-threatening complications. The authors reviewed medical data for patients hospitalized in a burn center from January 2004 to December 2008. Thirty-eight cases of self-inflicted burns were compared with 220 accidental burns. Women were predominantly affected (57.9%, n = 22). A psychiatric history (71%, n = 27) was more frequent in this population. The mean age of the victims was 38 years. The leading method of suicide was flame (94%, n = 36) associated with gasoline used as an accelerant (77.7%, n = 28). Mean total burn surface area (41.5%) and mortality (36.9%) were higher in the self-inflicted burn population. By recognizing epidemiological characteristics and patients at risk, we can better classify lesions related to self-immolation. It is important for the forensic physician to consult survival details to correlate these data with the results of autopsy.     

An Unusual Suicide Inside a Grave with Two Gunshot Wounds to the Head—The Psychological Approach

Abstract: In this report, the authors present a case of suicide committed by a 66-year-old man, inside a grave at the local cemetery, with two gunshot wounds to the head. A multiple-paged, handwritten suicide note was found in an army type bag inside the victim’s car, while a second one was found in his house. Medicolegal examination of the body revealed two typical contact gunshot entrance wounds and one exit wound to the head. Toxicological analysis of the femoral blood was negative for alcohol and drugs. The history, scene and autopsy findings, along with further police investigation, indicated an obvious case of suicide. The literature is reviewed and discussed. We report this case as the place of suicide is extremely uncommon and as there is no mention of a gunshot suicide inside a grave in the current literature.     

Alcohol-Related Mortality Risk in Natural and Non-Natural Death Cases

Abstract:  Determination of the associations between alcohol influence and sudden natural death represents challenges for medicolegal investigations. The aim of this study was to investigate the prevalence of alcohol influence in medicolegal autopsies. In our study of natural and non-natural deaths cases (5496 total: 4045 males, 1451 females) were examined. Blood alcohol concentrations (BACs) were detected by headspace gas chromatographic method. We investigated the alcohol-related mortality using hierarchical log-linear statistical models. Severe BACs were detected among suicidal victims in the oldest age group (>65 years) (In F  = 0.442) and among the homicide victims between the age of 40–65 years (In F  = 0.234). Correlations we found between manner-of-death and sex suggested that the rate of males in accidents (ln F  = 0.140) and the rate of females in homicides (ln F  = 0.193) were higher. It was concluded that the accurate statistical mortality database may provide a huge support for the determination of alcohol effects on human health and mortality.     

Suicide behind bars: trends, inconsistencies, and practical implications

The results of two comprehensive approaches are compared: the nationwide surveys of suicides in U.S. jails by Hayes and the international meta-analyses of suicides in jails and prisons by Fazel et al. Factors are classified as demographic, situational, clinical, and methodical. More than 50% of U.S. jail suicide victims were men, white, unmarried, under 28 years of age, charged with minor or drug-related offenses, and intoxicated with drugs or alcohol. Suicides significantly occurred in isolation. Suicide victims in the international study were significantly (p < 0.001) men, white, married, pretrial, and charged with or convicted of violent offenses. Psychiatric diagnosis, alcohol abuse, taking psychotropic medication, and suicidal ideation were also positively correlated in the international study, but suicide victims were distributed more evenly over age-groups. Results of other studies illustrate the near universality of some findings. Three theories of suicide are briefly discussed.