Fatal intravenous injection of potassium in hospitalized patients

We describe 4 cases of fatal intravenous injection of potassium in the hospital setting. These cases illustrate the subtlety of findings in such deaths and remind the forensic pathologist to consider this type of event in sudden, unexpected death of hospitalized patients.     

Fatal accidental intrathecal injection of vindesine

ABSTRACT: A 25-year-old woman being treated for non-Hodgkin's lymphoma was accidentally given vindesine intrathecally. The error was recognized immediately and a spinal cord washing was performed through syringing with isotonic saline. However, the patient died 6 weeks later with increasing paralysis, which was followed by neurologic failure. The deceased was autopsied and the central nervous system was removed for a microscopic examination. The results showed microscopic lesions extending from the lumbar to the thoracic portion of the spinal cord, which included pseudocystic transformation of the cells, degeneration of myelin, and microhemorrhages. The brain was edematous and, in the cerebellum, the vermis showed a loss of granule and Purkinje cells. The authors compare this report on vindesine toxicity with cases in the literature involving vincristine. The treating physician admitted responsibility and was sentenced to both a fine and imprisonment.     

Fatal intravenous drug abuse secondary to streptomycin overdose

A fatal case of chronic intravenous drug abuse involving the injection of a nonpsychoactive veterinary combination of penicillin G and streptomycin is reported. The circumstances surrounding the death indicate that the decedent died as a result of streptomycin induced paralytic neuromuscular blockade.     

Homicide by intravenous injection of naphtha

A case of homicide by the intravenous injection of Energine, a petroleum distillate spot remover, is presented. This case is the only known homicide committed with naphtha. This elderly man had severe natural disease in addition to chest trauma sustained in the assault leading to death; however, the rapid injection of approximately 25 mL of Energine was the overwhelming cause of death.     

Suicide by intravenous injection of sublimate solution

A 19-year-old drug-dependent man tried to commit suicide by intravenous self-injection of 5 ml concentrated mercury II chloride solution. He arrived at an intensive-care unit 2 h later with predominantly gastrointestinal symptoms and died 70 h later, despite hemodialysis and antidote therapy. The pathologic-anatomical picture was dominated by severe acute sublimate nephrosis and a coagulation disorder. The highest Hg content was found in the kidneys (5.69 mg%); in the gastrointestinal tract the Hg concentration lay between 1.12 and 3.26 mg%.     

Four deaths due to intravenous injection of cocaine

Cocaine is a potent psychotropic drug that alters mood and behavior by stimulating the central nervous system. Deaths from abuse of cocaine are relatively rare. Most such deaths appear to be related to the intravenous injection of the drug. Acute fatal cocaine intoxication is characterized by headache, cold sweats, rapid pulse, tremors and nausea, followed by convulsions, unconsciousness and death. The prime mode of death appears to be respiratory paralysis, secondary to the effects of cocaine on the medullary portion of the brain. This paper presents four deaths due to acute cocaine intoxication following intravenous injection. Blood concentrations of cocaine were 0.11, 0.37, 0.36 and 0.75 mg/dl.     

Homicide due to intravenous metallic mercury injection followed by sodium cyanide injection

We report a case of homicide due to intravenous mercury injection followed by meperidine and sodium cyanide injection. A 35-year-old woman was found dead in bed at home by her husband. Reportedly, she had been sick for more than 5 months. Initial death investigation revealed no evidence of foul play. Her death was believed to be natural. Therefore, her body was buried without an autopsy. Two months after death, her family requested an autopsy because they suspected her physician husband killed her. Her body was exhumed, and an autopsy was performed. Postmortem examination revealed numerous metallic mercury globules in the pulmonary arteries. Toxicological analysis revealed a high concentration of mercury in the tissue samples of the lungs, liver, heart, and kidney. In addition, cyanide and meperidine were also found in the heart and liver. The detailed case history and postmortem examination findings are described.     

Fatal intravenous fentanyl abuse: four cases involving extraction of fentanyl from transdermal patches

The transdermal fentanyl system delivers a specific dose at a constant rate. Even after the prescribed application time has elapsed, enough fentanyl remains within a patch to provide a potentially lethal dose. Death due to the intravenous injection of fentanyl extracted from transdermal patches has not been previously reported. We present 4 cases in which the source of fentanyl was transdermal patches and was injected. In all of these cases, the victim was a white male who died at home. Case 1 was a 35-year-old with no known history of drug use, who was found by his wife on the floor of his workshop. Police recovered a fentanyl patch, needle, and syringe at the scene. Case 2 was a 38-year-old with a known history of drug use whose family claimed that he was in a treatment program that used fentanyl patches for unknown reasons. His brother found him dead in bed, and law enforcement officers found a hypodermic needle beside the body; a ligature around his left hand, and apparent needle marks between his first and second digits were also noted. Case 3 was a 42-year-old with a recent attempted suicide via overdose who was found dead at his home. An empty box of fentanyl patches, Valium, Ritalin, and 2 syringes were found at the scene. Case 4 was a 39-year-old found by his mother, who admitted to removing a needle with attached syringe from the decedent's arm. Medications at the scene included hydrocodone, alprazolam, zolpidem, and fentanyl patches. All reported deaths were attributed to fentanyl intoxication, with blood concentrations ranging from 5 to 27 microg/L.     

Death by potassium chloride intravenous injection: evaluation of analytical detectability

Potassium chloride intravenous injection is used in suicide attempts and lethal procedures for state-sanctioned punishment. Owing to its relatively high concentrations in hemolyzed blood (25-80 mM) compared to serum (about 4 mM), it is difficult to conclude potassium poisoning by postmortem analysis of biologic samples. A 41-year-man was found dead with an injection sign on his foot and a syringe close to the corpse. No particular signs were noted during the autopsy. Blood, bile, and urine were submitted to xenobiotic screening procedures used in the laboratory. Syringe content was found positive to potassium ions. Blood potassium concentration was determined by ion-selective electrode measurement (range 3.0-150 mM). Blood was found positive for diazepam at therapeutic level. Potassium concentration was 160.0 (cardiac) and 87.3 mM (femoral blood). Our results show that potassium concentration was significantly higher in heart blood in a suicide case. Hence, the general issue of considering potassium poisoning hardly demonstrable by toxicology needs to be questioned and thoroughly studied.     

Suicide by intravenous injection of cocaine. A report of three cases

Death as a consequence of cocaine abuse is continuing to increase in all parts of the United States. Cocaine use may cause the development of psychosis, with subsequent expression of suicidal ideations, and potentially even successful suicide. Cocaine dependence may also cause depression in the individual who is unable to control his or her craving for the drug, and suicide may be perceived as the only solution to a desperate problem. Despite the dramatic escalation of cocaine abuse and the potential toxicity of this drug, there have been no reports within the United States of cocaine being used as the agent to accomplish a suicide. Herewith are reported three cases in which depression and desperation over cocaine dependence were the motivations for successful suicide, which was accomplished through the intravenous injection of cocaine to the point of death. True cocaine suicide is probably only identified through the presence of objective scene information that unequivocally proves suicidal intent, such as notes or letters which contain information to this effect. A careful search of the scene of death in cocaine fatalities is mandatory, and diligent application of routine scene investigation principles may reveal that suicide through the use of cocaine is more widespread than first appearances would suggest.     

Toxicological study on intravenous thiopental anesthesia--interrelation between rate of injection and distribution of thiopental

A simple, rapid and accurate method to extract and clean thiopental in biological materials rich in fat was developed by using a separation column packed with Extrelut and Florisil. A Quantitative determination of thiopental by means of a gas chromatograph equipped with a flame photometric sulfur detector was attempted. The calibration curve was linear over the range of 5-200 micrograms/ml. Extraction of replicate tissues involving 3 micrograms of thiopental resulted in a recovery of the 99.7-101.8% range and a coefficient of deviation of the 0.3-1.9% range. Replicate extraction of five tissues from rats treated with thiopental resulted in a coefficient of deviation of below 6%. In rats given 40 mg/kg of thiopental and sacrificed after 5 min, the thiopental levels in fat were found to be higher after a slow intravenous injection than after a quick injection. The same tendency, however, was not observed in other tissues. It seems that the rate of intravenous thiopental injections might be estimated by comparison with thiopental levels in fat tissues.     

Fatal assumption

This article questions the assumption that mentally disabled individuals are regularly afforded competent counsel. It finds that such counsel is frequently not available and that our failure to challenge this assumption threatens to make illusory reform efforts by lawyers and mental health professionals alike. The presence of vigorous, independent counsel is critical, especially since legal rights are not self-executing. Such counsel serves an educative function in the entire process, seeks to assure the implementation of collateral legal rights, and avoids the “underidentification” of mental disability cases. These functions have become more important as the political and social climate has changed and as the subject matter has become more complex. A series of reform recommendations is offered to litigators, policy makers, judges, and legislators.     

Fatal verapamil poisoning

A case of fatal verapamil poisoning is reported. The pathologic and toxicologic findings are discussed.     

Fatal cocaine poisoning

A case of lethal cocaine poisoning after parenteral application is described. The results of the quantitative gas chromatographic determination in blood, liver, urine, stomach contents and muscle are reported.     

Fatal bromethalin poisoning

Bromethalin is a neurotoxin found in some rodenticides. A delusional 21-year-old male presented to a hospital with altered mental status the day after ingesting a bromethalin-based rodenticide. He died 7 days after his self-reported exposure to c. 17 mg bromethalin (equivalent to 0.33 mg bromethalin/kg). His clinicopathologic course was characterized by altered mental status, obtundation, increased cerebrospinal fluid pressure, cerebral edema, death, and diffuse histologic vacuolization of the white matter in the central nervous system seen on microscopic examination at autopsy. The presence of a demethylated form of bromethalin in the patient's liver and brain was confirmed by gas chromatography with mass spectrometry. Clinical signs and lesions observed in this patient are similar to those seen in animals poisoned with bromethalin. This case illustrates the potential for bromethalin ingestion to result in fatal human poisoning.