A Symbiotic Relationship Between the Toxicologist and … · A Symbiotic Relationship Between the...
Transcript of A Symbiotic Relationship Between the Toxicologist and … · A Symbiotic Relationship Between the...
A Symbiotic Relationship Between theToxicologist
and the World of Numerology
D. AndersonLos Angeles County Dept. of Coroner
CAT/SAT May, 2003
Toxicologist
! Postmortem & Antemortem• Analysis of Biological specimens for the
presence of drugs and/or poisons.– Specimens
• Postmortem: Many possibilities• Antemortem: Blood, Urine or other
! Interpretation• Attempt of an assignment of behavior• Cause/effect relationship
What is Numerology?! The study of the symbolism of numbers! History
• Some 10,000 years ago– Egypt and Babylonia used numbers for calculations– Foundation of modern mathematics
! Modern Day• Provides significant information on people’s
personalities and character. ! Toxicologist
• Assignment of a meaning to the quantitation performed
Merging of the Two!Numerology and Toxicology
• Heart Blood vs Femoral Blood Levels– Obviously there’s a difference!– Redistribution going on!
!Comparison to already established values– Literature
• Journals: JAT, JFS, etc.• Winek• Baselt
– Laboratory• Establish your own values!
Merging of the Two!Liver Levels
• Acute vs Chronic• Agrees or disagrees with the “supposed”
blood sample
!Gastric Levels• Suicide or Accident• More Information needed!• Will the pathologist believe you?
Life as a Toxicologist !(Theoretically Speaking)
Knowledge is Bliss!
020406080
100120
0 1 2 3 4 5 6 7 8 9 10
Years Experience
Kno
wle
dge
Confidence
Life as a Toxicologist !(Actually)
And You Thought you Knew Something?
0
20
40
60
80
100
0 1 2 3 4 5 6 7 8 9 10
Years Experience
Kno
wle
dge
Confidence
Fentanyl
! Short duration of action! Synthetic Phenylpiperidine derivative related
to meperidine! 50-100 x more potent than morphine! Administration
• Sublimaze– Injectable form
• Duragesic– Transdermal Patch
Fentanyl-Duragesic! Distributed by Janssen Pharmaceuticals! Doses per every 72 hours:
• 25 ug/hr 2.5 mg fentanyl• 50 ug/hr 5.0 mg fentanyl• 75 ug/hr 7.5 mg fentanyl• 100 ug/hr 10 mg fentanyl
C22H28N2OMW=336.5
Fentanyl-Duragesic
! Symptoms• CNS: Analgesia and Sedation• Severe respiratory depression
– Muscle rigidity, seizures, coma and hypotension
! Serum concentrations undetectable for 2 hrs, rise gradually for 12-14 hrs. • Steady state reached within 24 hours
– 25 ug/hr 0.30 - 1.2 ug/L– 50 ug/hr 0.60 - 1.8 ug/L– 75 ug/hr 1.1 - 2.6 ug/L– 100 ug/hr 1.9 - 3.8 ug/L
Fentanyl-Duragesic
! Pharmacodynamics• Loss of consciousness: 34 + 7 ug/L
• Respiratory depression: 1-5 ug/L
• Minimal effective concentration to produce an analgesic effect: 0.63 + 0.25 ug/L
Twenty-five Postmortem Cases involving Duragesic®
! Three Year Study- Fentanyl Patch Application! Demographics
• 18 males, 7 females • Ages 19-84, average age 46 years
! Modes of Death• 15 Accidental• 5 Naturals• 3 Suicides• 2 Undetermined
Duragesic®-Summary by modeTwenty-five Postmortem Cases
! Accidents: 15 cases• Heart Blood Range 35-139 ug/L (14)• Femoral Blood Range 4.5-43 ug/L (10)
• 9 cases: Fentanyl directly related to cause of death – Heart Blood Range 6.4-139 ug/L (8)– Femoral Blood Range 4.5-43 ug/L (6)
• 6 cases: Fentanyl was considered a non-factor– Heart Blood Range 3.7-22 ug/L (6)– Femoral Blood Range 6.8-19 ug/L (4)
Duragesic®-Summary by mode Twenty-five Postmortem Cases
! Naturals: 5 cases• Heart Blood Range 1.8-81 ug/L (5)• Femoral Blood Range 3.1-24 ug/L (2)
! Suicides: 3 cases• Heart Blood Range 6.3-29 ug/L (2)• Femoral Blood Range 6.5 ug/L (1)
! Undetermined: 2 cases• Heart Blood Range <2.0-2.6 ug/L (2)
Duragesic®-Recovered PatchesTwenty-five Postmortem Cases
! 18 cases! Recovered Patches Heart Bld Fem. Bld (ug/L)
• 1 patch (10) 1.8 - 139 7.9 - 43• 2 patches (6) 3.5 - 81 3.1 - 19• 6 patches (1) 34 19• 11 patches (1) 29 -----
! Conclusion ?????
Duragesic®-Conclusions Twenty-five Postmortem Cases
! Non-fentanyl related deaths: 10 cases • Heart Blood Range <2.0-7.0 ug/L (9)• Femoral Blood Range 3.1-7.9 ug/L (4)
NOTE: Apparent minimal redistribution! Multiple-drug related deaths-Fentanyl contributing
factor: 11 cases • Heart Blood Range 12-139 ug/L (9)• Femoral Blood Range 12-43 ug/L (5)
NOTE: Apparent redistribution occurs as heart blood concentrations increase
Duragesic®-Conclusions Twenty-five Postmortem Cases
! Four Interesting Cases that did not fit the Retrospective analysis• 2 Cases involving Cancer Patients
– Heart blood levels 22 & 47 ug/L– Femoral blood levels 19 & 24 ug/L
Tolerance to fentanyl?• 2 Other Cases
– Heart blood levels 6.4 & 81 ug/L– Femoral blood level 4.5 ug/L – COD: Acute Fentanyl Intoxication-Accident ?
Atherosclerotic cardiovascular disease-Natural ?
Duragesic® Published Literature
! Edinboro, et al., 1997• 83 year old cancer patient• Heart Blood 25 ug/L 3- 100 ug/hr patches• COD: Fentanyl Overdose MOD: Undetermined
! Flannagan, et al., 1996• 31 year old funeral home worker• Heart Blood 15 ug/L 1- 75 ug/hr patch
1- 100 ug/hr patch• COD: Fentanyl poisoning
Duragesic®
!Discussion• Better investigations and complete histories are
necessary to interpret any postmortem levels.
• Postmortem fentanyl levels following therapeutic use ranges to 7.0 ug/L in Heart blood.
• Postmortem redistribution is minimal
Case Study
! 47 year-old female (66 inches, 139 lbs)• Unresponsive in motel room
• History of chronic back pain
• Reportedly with suicidal ideation
Fentanyl Case Study
!Autopsy• No fatal trauma
• Pulmonary edema and congestion
• 18 “Duragesic” patches on chest and back
Patch Lady
!Toxicology Results
! Interpretation?
Heart Blood Femoral Blood LiverFentanyl 85 ng/ml 70 ng/ml 540 ng/g
Methamphetamine 1.5 ug/ml --- ---Amphetamine ND --- ---
Another Fentanyl Case
! 56 year old male (130 lbs, 69 inches)
! Slumped in drivers seat of his car-parked in driveway
!Duragesic patch on upper right arm
Another Fentanyl Case
!Toxicology
! Interpretation?
Central Blood (ng/ml) Femoral Blood (ng/ml)Fentanyl 15 8.5
Cocaine! 31 year-old Male (66 inches, 211 lbs)
• 0000 hrs: drinking heavily and throwing up• Unresponsive in residence living room at 0230
hrs• Long history of cocaine abuse• History of suicidal ideations• Recently lost job as armed security guard
Mr. Coke Head
!White powdery substance • Wrapped in a paper envelope on windowsill of
living room!¾ Empty bottle of brandy seen on kitchen
counter! Suicide note NOT present
Mr. Coke Head
!Toxicology Results
! Interpretation?
Heart Bld (ug/ml) Femoral Bld (ug/ml)Cocaine 0.33 1.2Benzoylecgonine 13 14
Other Cocaine CasesCase #2
! 42 year old male! Found unresponsive on Apartment Floor!No drug paraphernalia recovered!No trauma noted!No history available
Toxicology
! Interpretation?
Heart Bld (ug/ml) Femoral Bld (ug/ml)Cocaine 81 15Benzoylecgonine 30 19Cocaethylene 0.83 0.37
Case #3
! 36 year old male!Apparent Natural Death!Died at hospital and transported to Mortuary!Attending Physician refused to sign DC!Coroner Jurisdiction
Case #3
!Toxicology
! Interpretation?
Heart Bld (ug/ml) Femoral Bld (ug/ml)Cocaine ND NDBenzoylecgonine 8.8 8.5Cocaethylene ND ND
Last Coke Case
! 57 year old male!Unspecified heart problems!Respiratory concerns and diabetes!Handicapped
• Obese (370 lbs)• Uses electric cart for mobility• Unresponsive in house
Case #4
!Toxicology
! Interpretation?
Heart Bld (ug/ml) Femoral Bld (ug/ml)Cocaine 1.1 1.1Benzoylecgonine 9.4 11Cocaethylene ND ND
A Very Interesting Case Study
!Early December, 2000!Decedent
• 34 year old male found unresponsive in hallway of his home
• Exclusive Pasadena area • Blunt force trauma to the head• Bruises and Abrasions to the arms
Who Dun-it Case Study?
!History of Decedent• Ex-Jockey
– Winner of the 1991 & 1999 Kentucky Derby
– Christopher W. Antley• Heavily into drugs and alcohol• Living as a recluse
– Friends constantly checking in – Bringing meals
Jockey-Boy! Scene Description
• Single family residence• Decedent found in hallway between kitchen and
bedrooms• Blood spatter on the floor and walls throughout the
hallway– Appears that the decedent was crawling around
• Bedroom in a disarray– Door ripped off hinges– Does not appear to be a robbery
• Drawers, closets and cabinets are closed
Jockey-Boy
!Clothing• Shirt covered in blood splotches• Pants covered in blood
!Toilet paper (bloody) resting by his head• As if he attempted to blot his head injury
Jockey-Boy
! Obvious struggle throughout the home per investigation.
! Moded as Homicide per responding Officers, Investigating Detectives, and Coroner’s Investigator
! Ex-employee/roommate named as prime suspect
Jockey-Boy!Autopsy
• Forehead: Large hematoma• Small puncture to the top of the scalp• Arms
– Elbow• Large round abrasion and bruising
– Forearm• Bruises • Defensive wounds from “warding off blows”
! NO OBVIOUS Anatomical Cause of Death
Jockey-Boy! Pathologist re-visits the scene with the
Coroner Investigator
!Collects multiple pills and medication throughout bedroom
Jockey-Boy
! Pended for Toxicological Studies• Blood
– Heart and Femoral
• Liver• Gastric Contents• Liver• Vitreous• Urine• Bile
Jockey-Boy! Toxicology
• Heart Blood – Ethanol– Cocaine & Metabolites– Opiates– Barbiturates Not Detected– Phencyclidine– Marijuana– Methamphetamines– Bases Positive– Acid/Neutral Drugs
Jockey-Boy! Toxicology
! Cause of Death established??
Heart Blood Femoral Blood Liver Gastric (mg total) UrineAmphetamine 3.1 1.3 15 0.22 2.0Methamphetamine 0.84 0.50 2.6 0.12 4.8Pharmaceutical (Bases)
Paroxetine 1.0 0.32Propranolol 1.7 0.73
Acid/NeutralsCarbamazepine 20 21
Drug Concentrations (ug/ml or ug/g)
Jockey-Boy
! Paroxetine-Antidepressant• Redistribution
– Heart 1.0 ug/ml vs Femoral 0.32 ug/ml
! Propranolol-Heart Medication• Redistribution
– Heart 1.7 ug/ml vs Femoral 0.73 ug/ml
!Carbamazepine– Therapeutic concentrations
• Heart 20 ug/ml vs Femoral 21 ug/ml
Jockey-Boy
!Amphetamine and Methamphetamine• Interpretation
– Ingestion of Amphetamine?– Ingestion of Methamphetamine?– Ingestion of Amp. and Methamp.?– Ingestion of a drug breaking down to Amp.? – Ingestion of drug breaking down to Amp. and
ingestion of Methamp.?
Heart Blood Femoral Blood Liver Gastric (mg total) UrineAmphetamine 3.1 1.3 15 0.22 2Methamphetamine 0.84 0.5 2.6 0.12 4.8
Drug Concentrations (ug/ml or ug/g)
Clobenzorex
! Clobenzorex Hydrochloride• C16H18ClN-HCl
– Formula weight 296.2– Molecular weight 259.5
• Manufactured by Hoechst Marion Roussel– 30 mg Capsule– Dark/light green in color– Marked with HMR– Distributed in Mexico
• Metabolizes to d-amphetamine
Jockey-BoyClobenzorex
! Symptoms• 20 times less potent than Amphetamine• Similar to other sympathomimetic amines
– Drug mouth– Excitation– Increase alertness/difficulty in sleeping
Jockey-Boy
!Toxicology
! Final Interpretation
Heart Blood Femoral Blood Liver Gastric (mg total) Urine BilePharmaceutical (Bases)
Clobenzorex 1.9 QNS 174 4.9 1.3 14
Drug Concentrations (ug/ml or ug/g)