Concentrations of lidocaine and monoethylglycylxylidide (MEGX) in lidocaine associated deaths

Concentrations of lidocaine and MEGX were determined in a variety of tissues and other samples collected at autopsy. In 13 of the cases examined in which lidocaine was associated with death, tissue concentrations were greater than 15 mg/kg. Tissue concentrations in other patients treated with lidocaine were significantly lower.     

Ten years of "body packers" in New York City: 50 deaths

We reviewed all 50 body packer deaths in New York City from 1990 to 2001. The majority (37/50) of deaths were caused by acute intoxications due to open or leaking drug packets in the gastrointestinal tract. The number of packets recovered ranged from 1 to 111 (average 46). The weight of the combined packets ranged from 9.4 to 1,200 g (average of 377). The age ranged from 19 to 57 years (mean 37.1). The decedents were: 82% male, 66% Hispanic, 24% Black, and 10% White. The manners of death were 47 accidents, 1 homicide, 1 natural, and 1 undetermined. The causes of death included 42 acute intoxications, 5 intestinal obstructions/bowel perforations, 1 gunshot wound, 1 intracerebral hemorrhage due to hypertensive disease, and 1 undetermined. Of the 50 decedents, 42 were transporting opiates, 4 cocaine, and 4 both opiates and cocaine. There were 9 deaths from 1990-1995 and 41 from 1996-2001. Of the 41 deaths between 1996 and 2001, only 6 involved cocaine. In New York City there has been an increase in body packer deaths from the early 1990s to the late 1990s. Along with this increase is a marked predominance of opiate body packer deaths with few cocaine deaths.     

"Permanent discharge": deaths of people under 50 years of age in residential aged care in Victoria

In June 2007 there were 210 people under 50 years of age living in residential aged care in Victoria, Australia, most of whom had acquired brain injuries. There are an average of 21 deaths per year in this group yet very little is known about the causes of such deaths. While the Coroners Act 2008 (Vic) requires mandatory reporting of "unexpected" and "accidental" deaths, anecdotal evidence and data from the Coroner's Office suggest that most deaths of people under 50 years of age in residential aged care are not reported. This research presents the cases of three "preventable" deaths, none of which was reported to the coroner and all of which have implications for systemic reform. It concludes that cross-sectoral solutions to meet the complex needs of people under 50 years of age with disabilities in residential aged care are urgently needed as well as monitoring to help us to understand better the needs of young people in residential aged care.     

The use of the term "obesity" in deaths reported to coroners in Australia

There is growing government awareness of the increasing incidence of obesity in the Australian community and its potential impact on health policy issues. This column considers the appropriateness of the WHO definition of the term "obesity" and analyses its use by Australian forensic pathologists and coroners as a cause of death in "medical cause of death" statements. While families may have concerns about the use of this term in reference to a deceased family member, the use of "obesity" in medical cause of death statements could have considerable influence on coroners' recommendations with regard to health policy in this area.     

Multiple deaths resulting from shipboard exposure to trichlorotrifluoroethane

During the course of dockside ship maintenance, a compartment was partially flooded with tricholotrifluoroethane gas. One sailor entered the compartment, collapsed, and was then rescued by two other men. All three victims then climbed a 11-m (36-ft) ladder and collapsed. They all experienced a rapid development of cardiac arrest. We report on the pathologic, toxicologic, and pathophysiologic aspects of the incident.     

中暑死与冻死的法医学鉴定

中暑死与冻死在法医学鉴定实际工作中并不常见,但由于其病理学表现往往不够明显,在法医实际鉴定时易被漏诊。本文作者查阅了国内外相关文献资料,并结合作者实际法医学鉴定经验将中暑死与冻死的法医学鉴定要点作出初步的总结。     

Suicide by cyanide: 17 deaths

We reviewed 17 intentional ingestions of cyanide that occurred in New York City over a ten-year interval. The toxicologic and postmortem findings were reviewed. Certain occupations and nationalities of the decedents predominated among this group of suicides. Scientists, jewelers. and metal workers were common occupations among the decedents. In addition, 8 of 17 fatalities were West Indian/Caribbean Island and South American decedents, including three decedents from Guyana. Fourteen of the 17 fatalities were male. Pink lividity, a "bitter-almond" smell. and a hemorrhagic gastric mucosa were not prevailing findings in these decedents. A color test was used for screening for cyanide with confirmation and quantitation using gas chromatography.     

Toxicologic aspects of deaths due to falls from height

A prospective study of 161 victims of falls from height is reported. The aim was to determine the interest of systematic qualitative and quantitative toxicological analysis in such fatalities. The primary cause of death was suicide (84.5%), followed by accidents (7%) and homicide (1%). In the remaining 7.5%, cause of death was undetermined. In the suicides, there was evidence of psychotropic medicines in 57% of the observations, with a much higher proportion of benzodiazepines and antidepressants in women than in men. Quantitative toxicologic analysis showed overdosing on medication in 16 suicide victims, with toxic levels in 11 of these. Systematic qualitative and quantitative toxicologic analysis made a significant contribution to the diagnosis of suicide by revealing either an unknown psychiatric treatment or a toxic level.     

Multiple deaths from argon contamination of hospital oxygen supply

During the course of routine hospital surgical procedures, three patients lapsed into hypoxic cyanosis. Two expired immediately, another after four days of coma. Investigation of the hospital's central liquid oxygen tank revealed that it had been refilled recently and was labelled both "oxygen" and "argon." Mass spectrometric analysis of gas sampled from the questioned tank revealed a predominance of argon. A discussion of the sampling technique, method of analysis, role of the criminalist, and causes of this accident is presented.     

Dragging deaths: a case in point

A 16-year-old boy was riding his bicycle when he was struck by a truck. He was dragged over 2 1/2 miles (4 km) before he was deposited on the side of the road. The injuries evident at autopsy revealed the boy died from dragging and not from the initial impact. The scene, and the autopsy findings, will be discussed.     

Police custody: deaths and medical attention

Information was obtained from all the county constabularies regarding deaths and medical attention given to those in police custody. It was presumed that this information covered all deaths in custody in Denmark during the period 1981 through 1985. There is no apparent increase in the absolute number of deaths during detention during the period 1969 through 1985. The number of deaths occurring in custody in relation to the annual number of persons incarcerated has fallen during the period 1955 through 1985. Simultaneously, a marked rise has occurred in the number of persons held in police custody. During the period 1981 through 1985, 7.9 persons were incarcerated per 1000 population per year. One homicide and nineteen other deaths occurred. The most frequent cause of death was asphyxiation as a result of aspiration of gastric contents during alcohol intoxication, drug poisoning, and intracranial hemorrhage. A physician had been consulted but had not diagnosed the seriousness of the condition in 42% of the deaths. All the deceased were men, and all suffered from the effects of social, psychiatric, and physical diseases. The lethality evaluated from hospitalized clients with the same type of life-threatening conditions was found to be 25%. A discussion is presented of the costs which will be incurred if a large group of those kept in police custody were admitted to hospital. Similarly, changes in the present arrangements are suggested that could ensure a greater certainty of avoiding deaths in detention.     

Asphyxial deaths and petechiae: a review

Conjunctival and facial petechiae, although nonspecific findings, are considered hallmarks of asphyxial deaths. Consensus in the literature suggests that their pathogenesis is related to the combined effects of increased cephalic venous pressure and hypoxic damage to endothelial cells. Despite the common knowledge that they are neither predictable findings in all asphyxial deaths nor rare in natural, nonasphyxial deaths, the belief persists that petechiae are corroborative evidence of asphyxia. We suggest that a clear, physiologically based understanding of the pathogenesis of petechiae of the head is critical for their appropriate interpretation. We present a review of the literature and the basis of our conclusion that conjunctival and facial petechiae are the product of purely mechanical vascular phenomena, unrelated to asphyxia or hypoxia.     

Deaths associated with liposuction: case reports and review of the literature

Tumescent liposuction is a common cosmetic procedure that is performed as an outpatient service in physician's offices and is largely believed to be safe. The protuberant areas of the body containing the undesirable fat deposits are injected with normal saline containing lidocaine and epinephrine for pain control and hemostasis, and the waterlogged cells are suctioned out via cannula through a small incision. We recently encountered three cases in which deaths were attributed to this procedure. Two showed fat embolization in the lung and one died from fluid overload. The osmium tetroxide post-fixed lung sections showed fat emboli in the interstitial capillaries and arterioles. We reviewed the recent literature and found that pulmonary thromboemboli, fat embolization, fluid overload, and lidocaine and epinephrine intoxication are found at autopsy in many cases. Forensic pathologists responsible for determining the cause and manner of death should become familiar with the postmortem findings and risks of liposuction therapy and communicate them to their clinical colleagues and communities.     

Asphyxial deaths from the recreational use of nitrous oxide.

The recreational use of nitrous oxide is widespread. Nitrous oxide for recreational use is usually obtained from anesthesia tanks or whipped-cream machine chargers or cans. Twenty previously described deaths associated with recreational nitrous-oxide use describe anesthesia tanks and whipped-cream machine dispensors as a source. Five deaths associated with nitrous oxide use are presented; two involving whipped-cream cannisters as the source, two involving anesthesia tanks, and one involving a racing fuel tank as a source of nitrous oxide. Autopsy findings in our cases were subtle or negative, but usually suggestive of asphyxia. Through a laboratory simulation, we have confirmed that nitrous oxide displaces oxygen in a closed space, which probably leads to asphyxia. A review of the literature, neuropharmacology, and pathophysiology of nitrous oxide use is also presented.     

Computer-assisted interpretation in forensic toxicology: morphine-involved deaths

Case data from 200 morphine-involved deaths (Spiehler, V. and Brown, R., Journal of Forensic Sciences, Vol. 32, No. 4, July 1987, pp. 906-916) were analyzed for patterns and relationships using artificial intelligence (AI) computer software. Case parameters were blood unconjugated morphine, blood, brain, and liver total morphine, sex, age, frequency of use, time of death after injection, cause of death, and presence of other drugs. The programs used were Expert 4 (Biosoft-Cambridge), BEAGLE (Warm Boot, Ltd.), and KnowledgeMaker (Knowledge Garden Inc.). Interpretation was defined as estimating the dose, response, and time after drug dosing. The AI programs were used to advise on time and response outcomes for cases, to calculate the probability of the estimate being true, to develop rules for interpretation of morphine-involved cases, and to diagram a decision tree. On known cases the AI programs were successful 70 to 90% of the time in classifying the cases as to response and time. No data on dose were available in this database. The success rate in individual cases was proportional to the program-estimated probability. All three programs found the case parameters of most value in predicting response to be blood unconjugated morphine, blood total morphine, and liver total morphine. The case data most useful in estimating time of death since drug injection were blood unconjugated morphine, percent unconjugated morphine in blood, and brain total morphine. The rule induction programs found that morphine overdoses were characterized by blood unconjugated morphine greater than 0.24 micrograms/mL, liver morphine greater than 0.50 to 0.75 micrograms/g, brain morphine greater than 0.08 micrograms/g or greater than blood unconjugated morphine, and percent blood unconjugated morphine greater than 37%. Rapid deaths were characterized by percent unconjugated morphine greater than 44 to 50%; blood unconjugated morphine, as a function of other drugs present, greater than 0.09 to 0.21 micrograms/mL; and brain total morphine greater than 0.16 to 0.22 micrograms/g. This work demonstrates that inexpensive AI programs commercially available for personal computers can be useful in interpretation in forensic toxicology.     

Malaria deaths in the United States: case report and review of deaths, 1979-1998

Malaria is the world's most important parasitic disease, accounting for an estimated 300 to 500 million new cases and between 1.5 and 2.7 deaths annually. The majority of these deaths occur in sub-Saharan Africa where malaria is endemic and are the result of infection with Plasmodium falciparum. The number of deaths in the United States due to malaria is comparably much lower and involves so-called "imported" cases in which U.S. travelers acquire the infection upon travel to endemic areas and subsequently return to the United States or in which infected foreign citizens travel to the United States. There were a total of 118 deaths due to malaria in the United States between 1979 and 1998 with an average of 5.9 deaths per year. Specific epidemiological data provided by the CDC regarding the 40 deaths that occurred between 1992 and 1998 yielded the following results. Deaths occurred in patients ranging from 9 months to 89 years of age (median, 53 years). Thirty-eight (95%) of these were due to P. falciparum and two (5%) due to P. vivax. Anti-malarial chemoprophylaxis was taken in 40% of cases, not taken in 45% of cases, and unknown in 15% of cases. Twenty-four (60%) of the cases involved U.S. travelers to endemic areas, of whom 59% traveled to Africa, 25% to South America, 8% to India, 4% to Haiti, and 4% to unspecified areas. The remaining cases included eleven foreign travelers to the U.S. (27.5%), three induced cases (7.5%), and two undetermined cases (5%). Thirty-nine (98%) of the cases were diagnosed antemortem and only one case was known to have come to the attention of the medical examiner/coroner. An illustrative case report demonstrates many of the features associated with fatal malaria infections in the United States. The case involves a U.S. student who was studying in Africa and who, by report, had not taken antimalarial chemoprophylaxis. Despite seeking medical attention, the patient was not diagnosed with P. falciparum infection and cerebral malaria until the time of medico-legal autopsy, where the classic gross and microscopic features of cerebral malaria were identified. This case represents one of the few cases of P. falciparum infection in the United States not diagnosed antemortem. Given the worldwide prevalence of the disease, increasing international travel, and rapidly developing drug resistance, malaria will continue to be an important disease and should be considered in cases of sudden, unexplained deaths. By reviewing the major epidemiological features of malaria-related deaths in the United States and by presenting the major gross and microscopic features of cerebral malaria, an attempt is made at raising the awareness of the forensic community to the potential of malaria-related deaths.     

Cocaine-related deaths: an enigma still under investigation

In recent years there has been an increase interest in cocaine-related death reflecting the rising trend in cocaine use in Europe. Nevertheless it is still now very difficult to attribute a death to cocaine. We can affirm that cocaine can be responsible for the cause of death only when there is a reasonably complete understanding of the circumstances or facts surrounding the death. Isolated blood cocaine levels are not enough to assess lethality, and should be always considered and evaluated in relation to concentrations of cocaine and benzoylecgonine concentrations in body tissue compartments, especially in brain and blood. We have reanalyzed all of our cocaine-related cases from 1990 to 2005, applying the methodology used by Spielher and Reed over 30 years ago. Our aim was to try to validate this model and verify its applicability and effectiveness after 20 years.