Toxicological findings in 889 fatally injured obese pilots involved in aviation accidents

Prevalence of drugs in fatally injured obese pilots involved in aviation accidents has not been evaluated. Therefore, toxicological findings in such pilots (body mass index ≥30 kg/m(2) ) were examined in a data set derived from the Civil Aerospace Medical Institute's (CAMI's) Scientific Information System for 1990-2005. Aeromedical histories of these aviators were retrieved from the CAMI medical certification and toxicology databases, and the cause/factors in the related accidents from the National Transportation Safety Board's database. In 311 of the 889 pilots, carbon monoxide, cyanide, ethanol, and drugs were found, and glucose and hemoglobin A(1c) were elevated. Of the 889 pilots, 107 had an obesity-related medical history. The health and/or medical condition(s) of, and/or the use of ethanol and/or drugs by, pilots were the cause/factors in 55 (18%) of the 311 accidents. Drugs found were primarily for treating obesity-related medical conditions such as depression, hypertension, and coronary heart disease.     

Quantitation of atenolol, metoprolol, and propranolol in postmortem human fluid and tissue specimens via LC/APCI-MS

Hypertension is a growing medical concern in the United States. With the number of Americans suffering from hypertension increasing, the use of antihypertensives such as beta-blockers is increasing as well. In fact, three beta-blockers - atenolol, metoprolol and propranolol - were among the 200 most prescribed medications in the United States in 2003. Pilots that successfully manage their hypertension can remain certified to fly. The Federal Aviation Administration currently designates approximately 8% of active pilots as "hypertensive with medication". The Civil Aerospace Medical Institute (CAMI) performs toxicological evaluation on victims of fatal aviation accidents. At CAMI beta-blockers are analyzed using gas chromatography with mass spectrometric detection. We have, however, recently developed a liquid chromatography with mass spectrometric detection (LC/MS) method for the simultaneous quantitation of three commonly prescribed beta-blockers, atenolol, metoprolol and propranolol. One advantage of our LC/MS method is the specificity provided by an ion trap MS. Utilizing an ion trap MS, we were able to conduct MS/MS and MS/MS/MS on each analyte. This method also eliminates the time-consuming and costly derivitization step necessary during GC/MS analysis. Additionally, by utilizing this novel method, any concerns about beta-blocker metabolite and/or sample matrix interference are eliminated. The limits of detection for this method ranged from 0.39 to 0.78 ng/mL and the linear dynamic range was generally 1.6-3200 ng/mL. The extraction efficiencies for each analyte ranged from 58% to 82%. This method was successfully applied to postmortem fluid and tissue specimens obtained from victims of three separate aviation accidents.     

Fatal aviation accidents in Lower Saxony from 1979 to 1996

So far no national or regional studies have been published in Germany regarding the number of fatal aviation accidents and results of autopsy findings. Therefore, we evaluated all fatal aviation accidents occurring in Lower Saxony from 1979 to 1996. A total of 96 aviation accidents occurred in this period involving 73 aeroplanes. The crashes resulted in the death of 154 people ranging in age from 19 to 68 years. The greatest number of victims in a single crash of an aircraft was (n=7). Other types of fatal accidents were crashes of aircraft and helicopter while on the ground (n=5), hot-air balloons (n=2), parachutes (n=10), hang glider accidents (n=5) and the striking of a bystander by a model airplane. Autopsies were performed on 68 of the 154 victims (44.2%), including 39 of the 73 pilots (53.4%). Some of the autopsies yielded findings relevant to the cause of the accident: gunshot wounds, the presence of alcohol or drugs in blood and preexisting diseases. Our findings emphasize the need for autopsy on all aviation accident victims, especially pilots, as this is the only reliable method to uncover all factors contributing to an accident.     

Alcohol,illicit drugs and medicinal drugs in fatally injured drivers in Spain between 1991 and 2000

The aim of this study was to assess the presence of alcohol, illicit drugs and medicinal drugs among Spanish drivers involved in fatal road accidents between 1991 and 2000. Samples were obtained for 5745 drivers killed in road accidents from January 1991 to December 2000. Of the samples, 91.7% represented males and 8.3% females; 40.7% were under 30 years of age, 31.9% were under 31-50 years of age, 19.5% were over 51 years of age, and for 7.9% the age was unknown. Between 1991 and 2000, some type of psychoactive substance was detected among 50.1% of those drivers killed in road accidents, this being mainly alcohol (43.8%) and, less frequently, illicit drugs (8.8%) and medicinal drugs (4.7%). In all the cases, in which alcohol was detected, combined use with other substances accounted for only 12.5%, whilst in the case of illicit and medicinal drugs, figures representing combined use with other substances were 75.6% for the former and 65.8% for the latter. For one in every three cases (32.0%), a blood alcohol level over 0.8 g/l was recorded; cocaine (5.2%), opiates (3.2%) and cannabis (2.2%) were the three illicit drugs most frequently detected. Among medicinal drugs, were benzodiazepines (3.4%), anti-depressant drugs (0.6%) and analgesics (0.4%). The results show the frequent presence of psychoactive substances, particularly alcohol, among Spanish motor vehicle users involved in fatal road accidents. It should be pointed out that illicit and medicinal drugs in combination with other substances were a common feature.     

Toxicological findings in Federal Aviation Administration general aviation accidents

Blood, urine, and tissue specimens were received from 377 Federal Aviation Administration (FAA) aviation fatalities during fiscal year 1989. Carbon monoxide at less than 10% saturation was found in 94% of the cases, and cyanide at less than 0.5 mg/L was found in 96% of the cases. Ethanol at greater than 10 mg/dL was found in 14.8% of the cases, but only 4.5% were determined to be due to ethanol ingestion from toxicological findings. Excluding nicotine and ethanol, 12.6% of the cases were positive for one or more drugs. Acetaminophen and salicylate were the most frequently found drugs. Cannabinoids were found in 1.3% of the cases and benzoylecgonine in 1.6%. There was minimal use of therapeutic drugs that cause central nervous system depression or stimulation. These results show no consistent pattern of drug involvement in civilian aviation fatalities.     

涉及死亡非医疗过失纠纷的类型,死因和发生原因——27年医疗纠纷法医尸检回?

对1992～1998年间206例非医疗过失尸检资料进行回顾性研究,表明涉及死亡的非医疗纠纷中各类疾病死亡占53.88%,难以避免的并发症占39.81%,医疗意外占6.31%.发生原因中对死因怀疑占44.66%,怀疑输液(血)错误占15.05%,怀疑治疗出问题占9.71%,怀疑用药错误或诊治延误各占8.74%,其它13.11%与医护人员态度不好、医院管理有关.     

Ethanol formation in unadulterated postmortem tissues

During the investigation of aviation accidents, postmortem samples obtained from fatal accident victims are submitted to the FAA's Civil Aerospace Medical Institute (CAMI) for toxicological analysis. During toxicological evaluations, ethanol analysis is performed on all cases. Many species of bacteria, yeast, and fungi have the ability to produce ethanol and other volatile organic compounds in postmortem specimens. The potential for postmortem ethanol formation complicates the interpretation of ethanol-positive results from accident victims. Therefore, the prevention of ethanol formation at all steps following specimen collection is a priority. Sodium fluoride is the most commonly used preservative for postmortem specimens. Several studies have been published detailing the effectiveness of sodium fluoride for the prevention of ethanol formation in blood and urine specimens; however, our laboratory receives blood or urine in approximately 70% of cases. Thus, we frequently rely on tissue specimens for ethanol analysis. The postmortem tissue specimens received by our laboratory have generally been subjected to severe trauma and may have been exposed to numerous microbial species capable of ethanol production. With this in mind, we designed an experiment utilizing unadulterated tissue specimens obtained from aviation accident victims to determine the effectiveness of sodium fluoride at various storage temperatures for the prevention of microbial ethanol formation. We found that without preservative, specimens stored at 4 degrees C for 96 h showed an increase in ethanol concentration ranging from 22 to 75 mg/hg (average 42 +/- 15 mg/hg). At 25 degrees C, these same specimens showed an increase ranging from 19 to 84 mg/hg (average 45 +/- 22 mg/hg). With the addition of 1.00% sodium fluoride, there was no significant increase in ethanol concentration at either temperature.     

Incidence of cannabinoids in medical examiner urine specimens

Cannabinoid use was studied in a nonspecific population of postmortem urine specimens in the State of Maryland. Of 500 sequential specimens screened for cannabinoids by enzyme multiplied immunoassay EMIT, 63 (13%) were initially positive and 58 (12%) were confirmed positive (92%). It was observed that geographic location and race did not correlate with cannabinoid prevalence. Cannabinoid use was observed to be strongly age related, with peak use by the 21- to 25-year-old age group where 22% of the cases were positive. Use of cannabinoids was also closely linked to homicides, which represented nearly half of the positive cases but only 13% of the total cases. When comparing manner of death, the greatest percent of confirmed positives was seen in homicide (26%) and drug-related (17%) deaths. The incidence of cannabinoid use was found to be more than 3 times as great in drug-related (17%) as compared to natural deaths (5%). The percent of cannabinoid-positive cases from vehicle-related accidents was low (6%) and that from nonvehicle-related accidents somewhat higher (10%). Other drugs appeared in cannabinoid-positive cases. Most prevalent was ethanol N = 18, followed by morphine (from heroin, N = 11), quinine N = 11, and cocaine N = 11. Phencyclidine (PCP) occurred twice and several other drugs were reported only once. Of the 25 homicide cases screened for drugs, 64% were positive for some drug including ethyl alcohol. Thus it appears that a high percentage of homicide cases are drug related. Males greatly outnumbered females (56:2) in positive cases, but the number of female specimens received was small.     

交通肇事眼损伤鉴定及其VEP检查特征分析

对 30例交通肇事眼损伤鉴定及其VEP检查结果进行回顾性分析 ,旨在探讨交通肇事眼损伤鉴定的特征 ;结果表明 :与普通伤害案件相比 ,(1)交通肇事眼损伤鉴定时合并颅脑损伤 (83% )及多颅神经损伤 (53% )的比例较高 ;导致复视及眼球运动受限 (30 % )的情况较多 ;视神经损伤 (2 0 % )及眶壁骨折 (2 0 % )的发生率较高 ;鉴定时应注重这些方面的检查。 (2 )交通肇事眼损伤鉴定当事人主诉双眼视力下降 (53% )的比例较高 ,雾视法进行伪盲试验受到限制 ,VEP检查显得更为主要。VEP检查是确证视神经损伤的良好方法 ,不同程度的视功能障碍其VEP表现为波形熄灭、波形离散、波幅降低、潜伏期延长不等。另一方面 ,交通肇事后弥漫性脑组织损伤也在眼底及VEP上有一定表现。     

Vitreous Fluid and/or Urine Glucose Concentrations in 1335 Civil Aviation Accident Pilot Fatalities*

Abstract: During aviation accident investigations, vitreous fluid and urine samples from pilot fatalities are analyzed for glucose and blood for hemoglobin A_1c (HbA_1c) to monitor diabetic pilots and to discover other pilots with undiagnosed/unreported diabetes. The prevalence of elevated glucose concentrations in fatally injured pilots was evaluated by searching the Civil Aerospace Medical Institute’s Toxicology Database for the period 1998–2005. Out of 1335 pilots involving 363 vitreous fluid, 365 urine, and 607 vitreous fluid and urine analyses, 43 pilots had elevated glucose in vitreous fluid (>125 mg/dL) and/or in urine (>100 mg/dL). Of the 20 pilots whose blood samples were analyzed, nine had >6% HbA_1c—four were known diabetics, and five were unknown diabetics. Urinary glucose levels were elevated in all 13 known hyperglycemic pilots. A considerable number of pilots (30 of 43) had elevated glucose and HbA_1c (5 of 20), suggesting undiagnosed/unreported diabetic conditions.     

Fatal hunting injuries in North Rhine-Westphalia

The investigation covers 14 fatal hunting accidents which occurred in North Rhine-Westphalia in the last 23 years, among them 13 firearm fatalities. All the accidents happened during the statutory hunting season reaching a peak in the main small game season. 86% of the persons causing the accidents and 73% of the victims were over 41 years and experienced hunters. 36% of the accidents were caused by the victims themselves. The fatal gunshot injuries were inflicted by rifle bullets in 7 cases (54%) and shotgun pellets in six cases (46%). No accidents were due to shotgun slugs or handgun ammunition. The main factors responsible for the fatalities were: covering the victim while swinging on the game (31%), failure to discharge the firearm while descending from the raised hide or transporting the weapon in vehicles (31%), mistaking the victim for game (15%), failure to discharge the weapon during a hunting break or while pressing down obstacles or careless handling of the weapon (23%). In no case was the accident caused by a defective weapon or ammunition. In conclusion aspects of preventing fatal hunting accidents are discussed.     

The Grand Canyon midair collision. A stimulus for change

Commercial aviation in the United States developed rapidly from a nucleus of pilots who returned from World War I, barnstormed and flew primitive airmail routes, and were hired by the new commerical airlines of the 1930s. The death of U.S. Senator Bronson Cutting in a 1935 crash was an important stimulus to improved governmental regulation of civil aviation. The air traffic control system, primitive until and throughout World War II, was soon proven to be inadequate for postwar demands. The midair collision of two large airliners over the Grand Canyon in June 1956 that killed the 128 persons on board was itself a strong stimulus for serious efforts, particularly in improving air traffic control systems. This and many other difficult problems in aviation safety have been addressed in the subsequent 33 years, some with success, although it has not always been immediate, and with major accidents still occurring. Commercial air travel is safe and widely accepted, however, and there is promise for additional important advances here.     

Causes of unexpected death in patients with multiple sclerosis: a forensic study of 50 cases

To determine the cause of death (as a result of neurologic or nonneurologic complications or accidents) in patients with multiple sclerosis (MS), we reviewed the autopsies of 50 subjects with MS from the Office of the Chief Medical Examiner of Maryland (OCME) between 1982 and 2004. The series included 32 females and 18 males (mean age, 45.8 years; range, 25-69 years) and the causes of death were classified into 3 categories: (A) neurologic complication directly related to MS; (B) nonneurologic complications or other medical causes; and (C) accidents, etc. Of the 50 cases, in 43 there was a history of MS, but in 7 subjects there was not, and the diagnosis was established by neuropathologic examination. In Group A, 21 (42%) cases, deaths were directly related to a neurologic complication; in Group B, 14 (28%) cases were related to the following nonneurologic and medical causes: ASCVD 9 (18%), metabolic disorder 1 (2%), pulmonary embolism 3 (6%), and bronchopneumonia 1 (2%); and in Group C, 15 (30%) cases, deaths were due to trauma, 9 (18%); intoxication, 5 (10%); and thermal injury, 1 (2%). Thus, among the 50 subjects, in 26, deaths occurred naturally; and in 24, from accidents, homicides, suicides, or undetermined causes. Pathologically, the majority of cases showed either chronic inactive (66.7%) or chronic active (15.6%) demyelinating lesions, mainly in the cerebral hemispheres. In some cases, it appears that demyelinating lesions, involving brain regions that regulate cardiorespiratory activity, could be considered as the immediate cause of death, but a large proportion appears to be due to other causes such as accidents and trauma. Thus, it seems likely that taking specific precautions could prevent some deaths in MS.     

Formation of an interfering substance, 3,4-dimethyl-5-phenyl-1,3-oxazolidine, during a pseudoephedrine urinalysis

During fatal aviation accident investigations, biosamples from the victims are submitted to the FAA Civil Aeromedical Institute (CAMI) for drug analysis. In the process of one such analysis by CAMI, an unknown substance was found in a urine sample. Simultaneous screening by thin layer chromatography (TLC) and gas chromatography/FID (GC/FID) suggested the presence of pseudoephedrine. A subsequent routine confirmation analysis of a separate urine aliquot by GC Fourier transform infrared (GC/FTIR) and GC mass spectrometry (GC/MS) indicated that the retention times of the unknown substance matched with those of pseudoephedrine. However, its infrared and mass spectra were different--the -OH and -NH groups were missing, a C-O-C group was present, and the molar mass was 12 atomic mass units (amu) more than that of pseudoephedrine. A subsequent literature search suggested that ephedrine-like amines react with aldehydes to form oxazolidines. Therefore, the 12-amu increase could be accounted for by condensation of pseudoephedrine with formaldehyde. Since this aldehyde is present in various grades of methanol and ethyl acetate, and these solvents were used during the solid-phase extraction, 3,4-dimethyl-5-phenyl-1,3-oxazolidine was synthesized by using (+)-pseudoephedrine HCl and formaldehyde. The analytical findings of the synthesized compound were consistent with those of the unknown interfering substance, confirming that it was the oxazolidine. Aldehyde contaminants in solvents or specimens can transform drugs of interest and may result in misidentification of a compound originally present in specimens. Therefore, chemicals used in analyses should be of the highest available purity, and a multi-analytical approach should be adopted to maintain a high degree of quality assurance.     

Changing patterns of drug and alcohol use in fatally injured drivers in Washington State

We have previously reported on patterns of drug and alcohol use in fatally injured drivers in Washington State. Here we revisit that population to examine how drug use patterns have changed in the intervening 9 years. Blood and serum specimens from drivers who died within 4 h of a traffic accident between February 1, 2001, and January 31, 2002, were analyzed for illicit and therapeutic drugs and alcohol. Drugs when present were quantitated. Samples suitable for testing were obtained from 370 fatally injured drivers. Alcohol was detected above 0.01 g/100 mL in 41% of cases. The mean alcohol concentration for those cases was 0.17 g/100 mL (range 0.02-0.39 g/100 mL). Central nervous system (CNS) active drugs were detected in 144 (39%) cases. CNS depressants including carisoprodol, diazepam, hydrocodone, diphenhydramine, amitriptyline, and others were detected in 52 cases (14.1%), cannabinoids were detected in 47 cases (12.7%), CNS stimulants (cocaine and amphetamines) were detected in 36 cases (9.7%), and narcotic analgesics (excluding morphine which is often administered iatrogenically in trauma cases) were detected in 12 cases (3.2%). For those cases which tested positive for alcohol c. 40% had other drugs present which have the potential to cause or contribute to the driver's impairment. Our report also considers the blood drug concentrations in the context of their interpretability with respect to driving impairment. The data reveal that over the past decade, while alcohol use has declined, some drug use, notably methamphetamine, has increased significantly (from 1.89% to 4.86% of fatally injured drivers) between 1992 and 2002. Combined drug and alcohol use is a very significant pattern in this population and is probably overlooked in DUI enforcement programs.     

医疗事故的原因分析和相关技术鉴定的建议

目的分析医疗事故的发生原因,及医疗纠纷技术鉴定的现状。方法32例医疗纠纷技术鉴定按一般情况(性别、年龄、主要疾病、后果)和鉴定结果(有无失误、因果关系、责任程度等)进行统计分析。结果死亡鉴定17例,活体鉴定15例。32例中医疗事故13例,非医疗事故19例,医疗事故的原因多为医疗责任心不强。结论加强医务人员综合素质培养可以减少医疗事故的发生。为了使医疗纠纷技术鉴定取得积极的效果,建议国家进一步完善有关尸体解剖的立法;事故等级中宜增加医疗差错的鉴定;有必要进一步提高医疗纠纷鉴定的公正性。     

Distribution of ∆9‐Tetrahydrocannabinol and 11‐Nor‐9‐Carboxy‐∆9‐Tetrahydrocannabinol Acid in Postmortem Biological Fluids and Tissues From Pilots Fatally Injured in Aviation Accidents

Little is known of the postmortem distribution of ?⁹‐tetrahydrocannabinol (THC) and its major metabolite, 11‐nor‐9‐carboxy‐?⁹‐tetrahydrocannabinol (THCCOOH). Data from 55 pilots involved in fatal aviation accidents are presented in this study. Gas chromatography/mass spectrometry analysis obtained mean THC concentrations in blood from multiple sites, liver, lung, and kidney of 15.6 ng/mL, 92.4 ng/g, 766.0 ng/g, 44.1 ng/g and mean THCCOOH concentrations of 35.9 ng/mL, 322.4 ng/g, 42.6 ng/g, 138.5 ng/g, respectively. Heart THC concentrations (two cases) were 184.4 and 759.3 ng/g, and corresponding THCCOOH measured 11.0 and 95.9 ng/g, respectively. Muscle concentrations for THC (two cases) were 16.6 and 2.5 ng/g; corresponding THCCOOH, “confirmed positive” and 1.4 ng/g. The only brain tested in this study showed no THC detected and 2.9 ng/g THCCOOH, low concentrations that correlated with low values in other specimens from this case. This research emphasizes the need for postmortem cannabinoid testing and demonstrates the usefulness of a number of tissues, most notably lung, for these analyses.     

Dental identification problems in the Abu Dhabi air accident

The forensic odontological examination of 112 victims in the 1983 air accident near Abu Dhabi is described with particular reference to the problems encountered in the age assessment of the 26 children, and serves to illustrate that dental identification in aviation accidents may be of only limited application in Asian victims. Following this accident, other means of identification had misguidedly been removed by the recovery teams. Of those identified, half were by dental means alone, but this amounted to only 6.24% of the total number of victims.     

Drugs and alcohol consumption amongst Spanish drivers.

We have analysed patterns of alcohol and regular drug consumption by Spanish drivers. Six hundred and seventy five properly completed questionnaires were received from drivers attending three medical traffic centres in Valladolid (Spain) for medical examination prior to obtaining or renewing their driving licence in 1990. Among those surveyed, 24% were 'daily' drinkers and 56.7% were 'weekly' drinkers, the majority (55.5%) being 'light' drinkers (1-39 g/day of pure alcohol). Of those surveyed 28.9% took drugs. The most commonly consumed drugs were analgesics (6.5%), anti-allergic drugs (5.2%) and oral contraceptives (4.6%). Of those drivers taking drugs 28.2% were 'daily' drinkers and 53.8% were 'weekly' drinkers. The study indicates widespread consumption of alcohol and drugs by Spanish drivers.     

The prevalence of drugs in carbon monoxide-related deaths: a retrospective study, 2000-2003

The objective of this study was to review demographic characteristics and drugs detected in carbon monoxide (CO)-related deaths from cases received by the Office of the Cuyahoga County Coroner in Cleveland, Ohio, from 2000-2003. Postmortem reports were reviewed, and decedents for which CO was listed as the cause of death were included. The data were compiled into 3 groups according to the official coroner's verdict as to the manner of death: accident, suicide, and homicide. Included in this study were 122 cases: 84 (69%) accidental, 31 (25%) suicide, and 7 (6%) homicide. Accident decedents were typically white males, aged 40-59 years, residing in Cleveland. Suicide decedents were also middle-aged, white males but residing in the suburbs. Homicide decedents under the age of 6 were characteristically black (N=2), while decedents over the age of 39 were predominately white (N=3). Carboxyhemoglobin (COHb) levels in suicide cases were higher than concentrations measured in accidental deaths. The highest percentage of suicide decedents (36%) had a COHb level>70% saturation, accident decedents (36%) between 50% and 69% saturation, and homicide decedents (71%) below 50% saturation. Ethanol (N=34) was detected in 28% of deaths, and therapeutic and/or abused drugs (N=50) were detected in 41% of deaths. Illicit drugs were detected in 11% of cases (cocaine/metabolites; THC/metabolites), other drug positives were therapeutic medications. The most common drugs detected were antidepressants and antihistamines in suicides and pain medications and antihistamines in accidents.