On January 31, 2017, K. A., a resident of Albuquerque, NM went to the office of Curtis Boyd, MD for an abortion procedure around 24 weeks of pregnancy. This procedure typically takes between 3 and 4 days to complete. On the first day Mrs. A would have received an injection of the medication digoxin into her uterus to cause the fetal demise of her unborn baby. During this visit she would have also undergone the first insertion of laminaria cervical dilators into her cervix to prepare her body for labor in 3 to 4 days as determined by the physician performing the procedure, in this case Curtis Boyd MD. Laminaria cervical dilators are replaced each day leading up the induction of labor and delivery of a stillborn. On Friday, February 3, 2017, Ms. A returned to Curtis Boyd’s office to complete her procedure. However, while at his office she complained of shortness of breath and her oxygen saturation dropped below her baseline. Curtis Boyd’s staff made a call to 911 at 12:04 p.m. to have Ms. A transferred to UNM Hospital but that transport request was later cancelled. Ms. A was pronounced dead at UNM Hospital on February 4, 2017 at 12:10 a.m.
On January 31, 2017, K. A., a resident of Albuquerque, NM went to the office of Curtis Boyd, MD for an abortion procedure around 24 weeks of pregnancy. This procedure typically takes between 3 and 4 days to complete. On the first day Mrs. A would have received an injection of the medication digoxin into her uterus to cause the fetal demise of her unborn baby. During this visit she would have also undergone the first insertion of laminaria cervical dilators into her cervix to prepare her body for labor in 3 to 4 days as determined by the physician performing the procedure, in this case Curtis Boyd MD. Laminaria cervical dilators are replaced each day leading up the induction of labor and delivery of a stillborn. On Friday, February 3, 2017, Ms. A returned to Curtis Boyd’s office to complete her procedure. However, while at his office she complained of shortness of breath and her oxygen saturation dropped below her baseline. Curtis Boyd’s staff made a call to 911 at 12:04 p.m. to have Ms. A transferred to UNM Hospital but that transport request was later cancelled. Ms. A was pronounced dead at UNM Hospital on February 4, 2017 at 12:10 a.m.
On January 31, 2017, K. A., a resident of Albuquerque, NM went to the office of Curtis Boyd, MD for an abortion procedure around 24 weeks of pregnancy. This procedure typically takes between 3 and 4 days to complete. On the first day Mrs. A would have received an injection of the medication digoxin into her uterus to cause the fetal demise of her unborn baby. During this visit she would have also undergone the first insertion of laminaria cervical dilators into her cervix to prepare her body for labor in 3 to 4 days as determined by the physician performing the procedure, in this case Curtis Boyd MD. Laminaria cervical dilators are replaced each day leading up the induction of labor and delivery of a stillborn. On Friday, February 3, 2017, Ms. A returned to Curtis Boyd’s office to complete her procedure. However, while at his office she complained of shortness of breath and her oxygen saturation dropped below her baseline. Curtis Boyd’s staff made a call to 911 at 12:04 p.m. to have Ms. A transferred to UNM Hospital but that transport request was later cancelled. Ms. A was pronounced dead at UNM Hospital on February 4, 2017 at 12:10 a.m.
4QUNM |
neattisciencrs | OFFICE of the MEDICAL INVESTIGATOR
CENTER
Report of Findings
Case Number: 2017-00704
AZ
County Pronounced: Beso
aw Enforcement
Agent:
Date of Birth:
Pronounced Date: 2472017 {2:10.00 aM
Central Ofc Investigator Cot Kaien
Deputy Field Investigator: Coit Kaicich CO!
CAUSE OF DEATH
Pulmonary thromboembolism
Duete
Pregnancy
MANNER OF DEATH
‘Natural
Rebecca Asch-Kendrick, MD. Lauren E Dvorscak, MD
Forensic Pathology Flow ecial investigator, Asistant Professor of
Pathology
‘lsignatures authenticated eectonicaly
Date: 57252017 1:31:28 PM
inte 528201713128 PM Report Name Death Ivesiaton Repti Too!Case Number: 2017-00704 ‘Summary Opinion —
Medical Investigator Medical Investigator Trainee
Lauren E Dvorscak, MD Rebecca Asch Kendrick, MD
‘SUMMARY AND OPINION
PATHOLOGIC DIAGNOSES:
1. Pulmonary thromboembolism
A. Extensive organizing thromboemboli, bilateral pulmonary arterial vasculature
B Pulmonary edema
C. Clinical echocardiogram demonstrated reduced ventricular funtion
I. Clinical evidence of septic abortion, per medical records
~ A. Status post fetal abortion by dilatation and evacuation
1. Catheter placement, uterus
2. Complete products of conception and intact placenta with trivascular umbilical cord
B. Antemortem blood culture positive for Aerococcus species (per medicel records)
C. Postmortem uterine swabsitissue cultures grew rare to few colony growth of Aerococcus species
Uterine endometritis
1. Microscopic neutrophilic exudates, uterine endometrium and maternal surface of placenta
MI Pleural effusions
1 Left chest cavity, 600 mL serous fluid
2. Right chest cavity, 600 mL serous fluid
IV, Clinical evidence of acute coagulopathy, per medical records
A. Bloody fluid, 100 mL, peritoneal cavity
B Fibrin microthrombi, glomerclar
C. Parenchymal hemorrhage, eft adrenal gland
/D. Status post multiple blood product transfusions
'. Status post extensive resuscitation attempts,
A. Contusions, chest
B. Rib fractures, anterolateral
VI Probe patent foramen ovale
VIL. Contusions, minor, extremities
SUMMARY AND OPINION:
‘This 23 year old woman, KINI ANIM, died of pulmonary thromboembolism due to pregnancy.
7 According to reports, Ms, AMINE vas at a clinic preparing forthe final portion ofa termination of pregnancy. She
presented tothe clinic with complaints of cramping pain as expected and was resting preparing for labor. While at the
clinic, she noted that she was feeling short of breath, and her oxygen saturation dropped below her baseline. She was
placed on oxygen with some improvement of her symptoms, Due to the conceming symptoms, she transferred to
University of New Mexico Hospitals, where she continued to have cramping abdominal pain, elevated heart rate and
difficulty maintaining normal blood oxygen levels despite supplemental oxygen therapy.
‘At the hospital, inital testing revealed fluid buildup in the lungs (pulmonary edema), without evidence of significant
bload clots, and evaluation of er heart revealed reduced ventricular (pumping chamber) function. Due to rapid
decompensation inher clinical status (requiring the placement of a breathing tube) and the concer for a significant
infection, she was taken emergently tothe operating room to complete the abortion procedure. During the operatios
sustained a cardiac arrest. Extensive resuscitation efforts were ultimately unsuccessful
she
Bacterial cultures taken during her hospital admission ultimately grew Aerococcus species in the blood and mixed
organisms (including Aerococcus species) inthe placental tissue
Autopsy examination revealed a well-developed, well-nourished young woman with extensive medical intervention.
Internal and mieroscopic examination revealed large, organizing, bilateral pulmonary thromloemboli (large blood clots
inthe arteries ofthe lungs). Additional autopsy findings included pulmonary edema with large pleural effusions (Aid in
‘and around the lungs), and a boggy, intact uterus, consistent with recent pregnancy. The lining of the uterus, as well as
coe OF Dest: Paget Printed S017 13129 7Mcase Number: 2047-00704 ‘Summary Opinion —,
the maternal surface of the placenta showed acute inflammation, consistent with the clinical picture ofa septic abortion
The placenta and products of conception were otherwise unremarkable. Incidental findings included a patent foramen
ovale (opening between two chambers in the heat). Injuries including bruising on the chest and ri fractures were most
consistent with resuscitation attempts. The only other injuries detected were minor scattered bruises on the arms and.
legs.
Toxicology analysis of the antemortem blood revealed a therapeutic level of oxycodone and its breakdown product,
oxymorphone,
Postmortem microbiological cultures ofthe uterus were positive for rare to few colony growth of Aerovoccus species.
Postmortem bacterial cultures ofthe heart blood and lungs grew many types of organisms, most consistent with
postmortem bacterial overgrowth and/or contamination
Pulmonary thromboembolism, or blood clots that occlude the arteries of the lungs, may be rapidly fatal, causing death by
blocking normal blood flow to the lungs and preventing the normal oxygenation of tissues.
Clinically, Ms. AIIINE's evaluation (by CT angiography) for pulmonary thromboembolism (blood clot in the lungs) was
negative at her presentation to the hospital. A review of the literature reveal that falsely negative results for this test are
typically rare, but such rates have been reported tobe as high as 10.7% in one study (1). Essentially, even though the
clinical test for a blood clot was negative, Ms, AIIM did have a significant blood clot in her lungs atthe time of autopsy
that caused her sudden and unexpected death
‘When the arteries in the lungs are significantly oochuded (blocked) by thromboemboli (blood clots) symptoms and signs
such as shortness of breath, increased heart rate, decreased oxygenation of the blood, and chest pain may occur. Ms.
AMINE experienced many of these symptoms, along with a rapid deterioration in her respiratory function, reduced heart
‘function, and fluid buildup in her lungs. These clinical findings are all consistent with the postmortem findings of large
blood clots in her lungs.
Most often, a blood clot in the lungs actually originates from another source such as the deep leg veins. Risk factors for
the development of blood clots include hypercoagulable states, such as pregnancy, among other factors such as high
blood pressure, smoking, obesity, and immobility. Ms. AlMNNI's pregnancy ultimately placed her at increased probability
of developing blood clots, which occur at approximately #4 fold higher rate in pregnant women when compared tothe
general poptlation (2-4), Pulmonary embolism is the th leading cause of maternal mortality in the United States (2-4)
‘To further complicate her clinical picture, Ms. ANH also had a high white blood cell count and other clinical features
concerning for sepsis (or widespread inflammation and infection) upon her hospital admission. At autopsy, Ms. A
{id have some evidence of acute inflammation aad a positive postmortem bacterial culture for Aerococeus species.
However, her overall condition in the hospital was remarkable for significant respiratory distress that decompensated
rapidly. While she likely did have an infection from the abortion process, the blockage of her pulmonary arteries by
blood clots would have caused the rapid clinical symptoms leading to death, even without infectious or inflammatory
complications. The cause of death, therefore, is best certified as pulmonary thromboembolism due to pregnancy. The
‘manner of death is natural
REFERENCES:
1, Hogg K, Brown G, Dunning J, Wright H, Carley S, Foex B, and Mackway-Jones K. Diagnosis of pulmonary
‘embolism with CT pulmonary angiography’ a systematic review. Emerg Med J. 2006,23:172-178,
2, Marik PE, Plante LA. Venous thromboembolic disease and pregnancy. N Engl J Med. 2008;359(19):2025.
3, Creanga AA, Berg Cl, Syverson C, Seed K, Bruce C, Callaghan WM. Pregnancy-Related Mortality in the United
States, 2006-2010, Obstetries & Gynecology. 2015;125(1):5-12.
4, Schwartz DR, Malhotra A, Weinberger SE. Pulmonary embolism in pregnancy: Epidemiology, pathogenesis, and
diagnosis In: UpToDate, Leung LLK, Mandel J, Lockwood CI (SEds); Finlay G (Ed), UpToDate, Waltham, MA
(accessed April 2017)
Caste OfDeam: Page 2 ito 57252017 131:28 PI\UNM
HEALTH SciENCrS | OFFICE of the MEDICAL INVESTIGATOR
CENTER
DEATH INVESTIGATION SUMMARY
Case Number: 2017-00704
—, {i
County Pronounced: Benalla
law Enforcement:
‘Agent
Date of Ei:
Pronounced DateTime: 24/2017 121000 AM
Central Ofc Investigator: Ct Kalcch
Deputy Feld Investigator: Cot Kakicn CO!
CAUSE OF DEATH
Pulmonary thromboembolism
Deb
Pregnancy
‘MANNER OF DEATH
‘Natural
Rebecca Asch-Kendrick, MD Lauren E Dvorscak, MD
Forensic Pathology Fellow Mica investigator, Assstnt Professor of
Pathology
‘sites auencates cetoricaly
Dae: 5252017 13128 Pa
Pir 2097 131:204 apo hae De estan Repay Ts
Death Investigation Report page 1 of 26DECLARATION
The death of AMIN, KEEN was investigated by the Office of the Medical Investigator under the
statutory authority of the Office of the Medical Investigator.
|, Lauren E Dvorscak, MD, a board certified anatomic, clinical, and forensic pathologist licensed to
practice pathology in the State of New Mexico, do declare that | personally performed or supervised
the tasks described within this Death Investigation Summary document. Itis only after careful
Consideration of all data available to me atthe time that this report was finalized that | attest tothe
diagnoses and opinions stated herein
Numerous photographs were obtained along the course of the examination. | have personally
reviewed those photographs and attest that they are representative of findings reported in this
document.
This document is divided into 8 sections with a final Procedural Notes section:
Summary and Opinion
External Examination
Medical Intervention
Postmortem Changes
Evidence of Injuries
Internal Examination
Microscopy
Ancillary Lab Studies
Should you have questions after review of this material, please feel free to contact me at the Office of
the Medical Investigator (Albuquerque, New Mexico) - 505-272-3063.
Pn Sasz017 19.20 7 Repost Nave Dea Inesigaon Summary
Death investigation Repert page 2 of 26Case Number: 2017-00704 ‘Summary Opinion —,
Medical Investigator Medical Investigator Trainee
Lauren E Dvorscak, MD Rebecca Asch- Kendrick, MD
‘SUMMARY AND OPINION
PATHOLOGIC DIAGNOSES:
|. Pulmonary thromboembolism
A. Extensive organizing thromboemboli bilateral pulmonary arterial vasculature
B. Pulmonary edema
C. Clinical echocardiogram demonstrated reduced ventricular function
IL Clinical evidence of septic abortion, per medical records
‘A. Status post fetal sbortion by dilatation and evacuation
1. Catheter placement, uterus
2. Complete products of conception and intact placenta with trivascular umbilical cord
'B. Antemortem blood culture positive for Aerococcus species (per medical records)
. Postmortem uterine swabsitssue cultures grew rare to few colony growth of Aerocoecus species
D. Uterine endometritis
I, Microscopic neutrophilic exudates, uterine endometrium and maternal surface of placenta
TIL, Pleural effusions
1. Left chest cavity, 600 mL serous fluid
2. Right chest cavity, 600 mL serous fluid
IV. Clinical evidence of acute coagulopathy, per medical records
‘A. Bloody fuid, 100 mL, peritoneal cavity
BB. Fibrin microthrombi, glomerular
. Parenchymal hemorthage, let adrenal gland
DD, Status post multiple blood product transfusions
YV. Status post extensive resuscitation attempts
‘A. Contusions, chest
B. Rib fractures, anterolateral
VIL. Probe patent foramen ovale
Vil, Contusions, minor, extremities
‘SUMMARY AND OPINION:
‘This 23 year old woman, KEN AMINIL, died of pulmonary thromboembolism due to pregnancy.
According to reports, Ms. ANNIE was ata clinic preparing for the final portion ofa termination of pregnancy. She
presented to the clinic with complaints of cramping pain as expected and was resting preparing for labor. While atthe
clinic, she noted that she was feeling short of breath, and her oxy'gen saturation dropped below her baseline. She was
placed on oxygen with some improvement of her symptoms, Due to the concerning symptoms, she transferred to
University of New Mexico Hospitals, where she continued to have cramping abdominal pain elevated heart rate and
difficulty maintaining normal blood oxygen levels despite supplemental oxygen therapy.
{At the hospital, initial testing revealed fluid buildup in the lungs (pulmonary edema), without evidence of significant
‘blood clots, and evaluation of her heart revealed reduced ventricular (pumping chamber) function, Due to rapid
‘decompensation in her clinial status (requiring the placement of a breathing tube) and the concem fora significant
infection, she was taken emergently to the operating room to complete the abortion procedure. During the operation, she
sustained a cardiac arrest. Extensive resuscitation efforts were ultimately unsuccessful
Bacterial cultures taken during her hospital admission ultimately grew Aerococcus species in the blood and mixed
organisms (including Aerococcus species) in the placental tissue.
Autopsy examination revealed a well-developed, well-nourished young woman with extensive medical intervention,
Internal and microscopic examination revealed large, organizing, bilateral pulmonary thromoemboli (large blood clots
in the arteries ofthe lungs), Additional autopsy findings included pulmonary edema with large pleural effusions (fluid in
‘and around the lungs), and a boggy, intact uterus, consistent with recent pregnancy. The lining of the uterus, as well as
caso 01 Det Page 1 Pied: $2017 13131 PAL
Death investigation Report page 3of 26Case Number: 2017-00704 ‘Summary Opinion ——
the maternal surface of the placenta showed acute inflammation, consistent with the clinical picture ofa septic abortion.
‘The placenta and products of conception were otherwise unremarkable. Incidental findings included a patent foramen
‘ovale (opening between two chambers in the heart). Injuries including bruising on the chest and rib fractures were most
Consistent with resuscitation attempts. The only other injuries detected were minor scattered bruises on the arms and
legs.
Toxicology analysis of the antemortem blood revealed a therapeutic level of oxycodone and its breakdown product,
oxymorphone.
Postmortem microbiological cultures ofthe uterus were positive for rare to few colony growth of Acrococeus species
Postmortem bacterial cultures ofthe heart blood and lungs grew many types of organisms, most consistent with
postmortem bacterial overgrowth and/or contamination,
Pulmonary thromboembolism, or blood clots that occlude the arteries of the lungs, may be rapidly fatal, causing death by
blocking normal blood flow to the lungs and preventing the normal oxygenation of tissues
Clinically, Ms. AIINIF's evaluation (by CT angiography) for pulmonary thromboembolism (blood clot inthe lungs) was
negative at her presentation to the hospital. A review of the literature reveals that falsely negative results for this test are
typically rare, but such rates have been reported to be as high as 10.7% in one study (1). Essentially, even though the
clinical test fora blood clot was negative, Ms. Atkins did have a significant blood clot in her lungs atthe time of autopsy
that caused her sudden and unexpected death
‘When the arteries in the lungs are significantly occluded (blocked) by thromboembol (blood clots), symptoms and signs
such as shortness of breath, increased heart rate, decreased oxygenation of the blood, and chest pain may occur. Ms
experienced many of these symptoms, along with a rapid deterioration in her respiratory function, reduced heart
function, and luid buildup in her lungs. These clinical findings are all consistent with the postmortem findings of large
blood clots in her lungs.
Most often, a blood clot in the lungs actually originates from another source such asthe deep leg veins. Risk factors for
the development of blood clots include hypercoagulable states, such as pregnancy, among other factors such as high
blood pressure, smoking, obesity, and immobility. Ms pregnancy ultimately placed her at increased probability,
of developing blood clots, which occur at approximately a4 fold higher rate in pregnant women when compared to the
general population (2-4), Pulmonary embolism is the 6th leading cause of maternal mortality in the United States (2-4).
To further complicate her clinical picture, Ms. Alllilalso had a high white blood cell count and other clinical features
concerning for sepsis (or widespread inflammation and infection) upon her hospital admission. At autopsy, Ms. A
id have some evidence of acute inflammation and a positive postmortem bacterial culture for Aerococcus species.
However, her overall condition in the hospital was remarkable for significant respiratory distress that decompensated
rapidly. While she likely did have an infection from the abortion process, the blockage of her pulmonary arteries by
blood clots would have caused the rapid clinical symptoms leading to death, even without infectious or inflammatory
complications, The cause of death, therefore, is best certified as pulmonary thromboembolism due to pregnancy. The
manner of death is natural
REFERENCES:
1. Hoge K, Brown G, Dunning J, Wright H, Carley 8, Foex B, and Mackway-Jones K, Diagnosis of pulmonary
embolism with CT pulmonary angiography: a systematic review. Emerg Med J. 2006;23:172-178
2. Matik PE, Plante LA. Venous thromboembolic discase and pregnancy. N Engl J Med. 2008;359(19):2025.
43, Creanga AA, Berg CJ, Syverson C, Seed K, Bruce C, Callaghan WM, Pregnancy-Related Mortality inthe United
States, 2006-2010. Opstetries & Gynecology. 2015;125(1}:5-12.
4, Schwartz DR, Mathotra A, Weinberger SE. Pulmonary embolism in pregnancy: Epidemiology, pathogenesis, and
diagnosis In: UpToDate, Leung LLK, Mandel J, Lockwood CJ (SEds); Finlay G (Ed), UpToDate, Waltham, MA
(aceessed April 2017)
CatseofDeate Page 2 Piss 257201713131 PL
Death Investigation Report page 4 of 26Cave Number: 2017-00704
External Examination
Medical Investigator
[Lauren E Dvorscak, MD
Exteral exam dat time:
‘Authority for examination:
1D confirmed at time of exam:
Means used to confm identity:
fication means:
Name on orange bracelet:
Other name on orange bracelet:
Location of green bracelet:
Name on green bracelet:
Cte name on green bracelet
Hospital 10 tags or bracelets?
yes specty stated name and
location:
Boy length (rm
Body weight (has):
BM:
Development:
Development comments:
Statue:
Age:
Anasarca
Edema localized
Dehydration:
‘Scalp hair color:
‘Scalp hair color comments:
Medical Investigator Trainee
Rebecea Asch-Kendrick, MD
2/4/2017 9:13:00 AM
oMr
Yes
Visual
Left wrist
Decedent name
Left wrist,
Decedent name
Yes
Right ankle decedent name
162.00
67.40
25.68
Well-developed
Well-nourished
Appears to be stated age
No
No
No
Brown
‘The roots are dark with blonde ends,
‘Scalp hair length:
Eyes:
rides:
Eyes corneas:
Eyes sclerae:
Eyes conjunctvae:
Eyes petechiae:
Palpebral petechiz:
‘Bulbar ptechise:
Facial petechiae
Estamal Exinaton
Long
Both eyes present
Brown
‘Translucent
White
‘Translucent
No
No
No
No
Paget
Death investigation Report page 5 of 26
Pied 5282087 13:1 PMCase Number: 2017-00704
External Examination
(ral mucosal peteciae:
Nose:
Ears
Ups:
Facial hair:
Facial har color
Maxllary dentition:
Mandibular detion
Condition of dentition:
Neck
Trachea midline:
(Chest development:
‘Chest symmetrical:
(Chest diameter
‘Abdomen:
Ars:
Back:
Spine
External genitalia
Breast development
Breast masses:
Right hand digits complete:
Lett hand cits complete:
Right fot agit complete:
Let fot digits complet:
Extromiies:
‘Muscle group atrophy:
Senile purpr
Piting edema:
Muscle other:
Tattoos preset:
Tattoo anterior chest:
Tattoo back:
Tattoo right forearm:
Tattoo left shoulder:
Tatoo left arm:
Tatoo lef forearm:
Tattoo right lower leg:
Tatoo lef thigh
Tattoo let lower leg:
tem Eatin
No
Normally formed
Normally formed
Normally formed
None
Does not apply
Natural
Natural
Adequate
‘Unremarkable
Yes
Normal
Yes
“Appropriate
Protuberant
Unremarkable
‘Unremarkable
Normal
Female
‘Symmetric
None
Yes
‘Well-developed and symmetrical
No
No
No
No
Tattojs)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Page 2
Death Investigation Report page 6 of 25
Pena S25 2087 13131 PALCase Number: 2017-00704
Cosmetic piercing present
‘Cosmetic piercing right ear:
(Cosmetic piercing let er:
Cosmetic piercing lower ip:
Cosmetic piercing umbilicus:
Scarfs) present:
Scar right knee:
Scar left knee:
Reported by:
Verified by:
Reviewed and approved by:
ama! Examiaton
External Examination
Cosmetic Piercings)
Yes
Yes
Yes
Yes
Yes
Searls)
Yes
Yes
Yes
Reporting Tracking
Rebecca Asch-Kendrick, MD
Lauren E Dvorscak, MD on 5/25/2017 9:58:26 AM
Lauren E Dvorscak, MD on 5/25/2017 1:31:28 PM
Page 3
DDoath investigation Report page 7 of 26
Pina $252017 13131 PUCase Number: 2017-00704
Medical Intervention A
Moscal Investigator
‘Lauren E Dvorscak, MD
Evidence of meical intervention:
nasogastric tube present, specify
course and posit
endotracheal tube present,
speci course and poston:
Endotrachesl tube:
Endotrachel tube comment:
Tracheostomy steube:
Mediastial tube():
Chest tube(s)
If Foley catheter present, specify
course and poston
Foley catheter:
Foley catheter commont:
Medical Investigator T
Rebecca Asch-Kendtick, MD
Yes
Indweling Tubes
Yes
Passes through the mouth and oropharynx, between the vocal folds and terminates in
the trachea proximal tothe carina
Other
A catheter passes through the cervix and terminates inthe uterus.
Medical intervention other:
Injuries associated with cardiopulmonary resuscitation attempts include multiple, bilateral, anterolateral rib fractures and
scattered contusions on the central chest.
A pulse oximeter monitor is on left hand
ECG Monitoring Pads Present?:
ECG Chest Pade:
ECG abdomen pads:
Other pads comments:
Defirilator pads present:
Left Lower outer chest:
Back:
Vascular eatheters):
Right internal jugular von
Right femoral vein
Posterior aspect fright hand:
Let antecubitl fossa:
Posterior aspect of left hand:
Mest nterventon
Electrocatdiogram (ECG) Monitoring Pads
Yes
Yes
Defibrtator Pads
Yes
Yes
Vascular Catheter(s)
Paget Pinot Sz017 13131 PA
Death investigation Report page 8 of 26,Case Number: 2017-00704 Medical Intervention
Vascular catheters) comments
‘An additional vascular eatheter is in the right arm.
Recent Surgical Intervention
Evidence of recent surgical No
Intervention
Roport Tracking
Reported by: Rebecea Asch-Kendrick, MD
Veriied by: Lauren E Dvorscak, MD on 5/25/2017 9:49:21 AM
Reviewed and approved by: Lauren E Dvorscak, MD on 5/25/2017 1:31:28 PM
ec nevenion Page 2
Death investigation Report page 9 of 26
rine 8252017 13132Case Number: 2017-00704
Medical Investigator
Lauren E Dvorscak, MD
External exam date:
Body temperature:
Lvor ments = atlon
(applicable
Liver mots
(applicable)
Livor ments blanching and
patterns
(i applicable):
Postmortem Changes
Medical Investigator Trainee
Rebecca Asch Kendrick, MD
2/4/2017 9:13:00 AM
Cool subsequent to reftigeration
Fully fixed
Purple
Fully Fixed.
Both anterior and posterior
‘The head, neck, and upper chest are congested
State of preservation:
Reported by:
Verified by:
Reviewed and approved by:
Postma Change
No decomposition
Report Tracking
Rebecea Asch-Kendrick, MD
Lauren E Dvorscak, MD on 25/2017 9:59:24 AM
Lauren E Dvorak, MD on 5/28/2017 1:31:28 PM
Page 1
Death Investigation Report page 10 of 28
Pinte 862017 12432 PMCase Number: 2017-00704 Evidence of Inury ——.
Maia ovessgtr Medical investor Tee
Lawen€Dvowcak MD Rebeca Asch Kendik, MD
Avatar ay jt Yes
iden nig
Atopy cate: 24/2017 9:13:00 AM
uy Lecaon inury Description
1 Blunt injury Eaeaiies Scattered 0.1 -0.4 em, purple contusions ae on the upper and
lower extremities.
Report Tracking
Reported by: Rebecca Asch-Kendrick, MD
Verified by: Lauren E Dvorscak, MD on 5/25/2017 9:59:56 AM
Reviowed and approved by: Lauren E Dvorscak, MD on 5/25/2017 1:31:28 PM
idee jury Page1 Pinas 5250047 13132
Death Investigation Report page 11 of 26Case Number: 2017-00704 Internal Examination —
Medical Investigator Medical investigator Trainee
Lauren E Dvorscak, MD Rebecea Asch-Kendrick, MD.
Date of Autopsy: 2182017 9:13:00 AM
Date of ternal Exam: 2/4/2017 9:13:00 AM
‘BODY CAVITIES
Chest cavities examined: Yes
‘See evidence of injury section No
(Organs in normal anatomic Yes
postion
Other organ position comments
Diaphragm: Intact
Serosal surfaces: ‘Smooth and glistening
Body cavity adhesions present No
Fiuld accumulation present: Yes
Fluid accumulation ight chest Yes
avi:
Fluid accumulation left chesteavity Yes
Fluid accumulation pericardial sac: No
Fluid accumulation abdominal Yes
caviy:
Fluid accumulation pelvis: Yes
Fluid accumulation comments:
Left chest - 600 mL. serous uid
Right chest - 600 mL serous fluid
‘Abdomen and pelvis - 100 mL bloody fluid
HEAD
Brain examined: Yes
‘See separate forensic No
neuropathology consultation report
See evidence of injury section: No
See evidence of medial No
Intervention section:
See postmortem changes section: No
Brain fresh (gh: 11ss
Brain xed (g):
Facial skeleton: No palpable fractures
Calvatum: No fractures
‘Skul base: No fractures
‘Skull comments
Dura mater: Unremarkable and without masses
Dural venous singuses: Patent
Leptomeninges: ‘Thin and transparent
nema Examination Paget
‘Death investigation Report page 12 of 26
PMcase Number: 2047-00704
Internal Examination
Epidural hemorrhages
hematomas:
‘Subdural hemorrhages
hematomas:
Subarachnoid hemorrhag
Cereal hemispheres:
(Gyral and sucal pattems:
{yal convolutions and sul:
Uncal process:
‘cerebellar tosis:
Cranial nerves:
Basilar arterial vasculature:
(cerebral cortex:
White matter:
(Corpus callosum:
Deep gray matter structures:
Brainstem:
‘cerebellum:
‘Spinal cord examined:
Mile ears examined:
Neck examined:
‘See Evidence of Inury section:
‘See Evidence of Medical
Intervention section
‘See Postmortem Changes section:
‘Subcutaneous soft tissues:
‘Strap muscles:
Jugular vein:
‘Carotid artres:
Tongue:
Epiglottis:
Hyoid bone:
Lary
Platine tonsils:
Heart examined:
See separate Cardiovascular
Pathology report:
See Evidence of Injury section:
See Evidence of Medical
Interveation section:
Ina Exsmiston
Absent
Absent
Absent
Symmetrical
Unremarkable
No widening or flattening of gyri and no narrowing of sulci
Unremarkable
‘Unremarkable
Unremarkable
Unremarkable
‘Unremarkable
‘Unremarkable
Unremarkable
‘Unremarkable
‘Unremarkable
‘Unremarkable
Spinal Cord
No
Middle Ears
No
Yes
No
No
No
Unremarkable
Unremarkable
Unremarkable
Unremarkable
Unremarkable
Unremarkable
Unremarkable
Unremarkable
Not examined
‘CARDIOVASCULAR SYSTEM
Yes
No
Pag
Death Investigation Roport page 19 of 26
ina 9252017 13133 4Case Number: 2017-00704 Internal Examination —
See Postmortem Changes section: No
Hoar
Rightcoronaryoatum postion: Normal
Ltt coronary otum position: Normal
Supply ofthe posteioe Right coronary artery
myocardium:
Heart rsh (g 2900
Heart ed (gh
Coronary ater stenosis by atherosclerosis (perce)
Right coronary ostium: 0
Proximal thd ight coronary 0
rey:
Wide thid ight coronary atey: 0
Distal thd ght coronary atary: 0
Left coronary ostium: °
Lat main coronary ater: °
Proximal third et anterior °
descending coronary artery
ide thied et anterior °
descending coronary artery:
Distal third left anterior descending — 0
coronary artary:
Proximal third ot lecuflex o
coronary artery
Middle tid left circumflex o
coronary artery:
Distal third leftcrcumflex coronary 0
artery:
‘Cardiac Chambers and Valves:
cardiac chambers: Unremarkable
‘Tricuspid valve: Unremarkable
Pulmonie valve: ‘Unremarkable
Mitral valve: Unremarkable
Aortic valve: Unremarkable
Other valve comments:
Circumferential valvular measurements ere as follows:
Tricuspid valve = 11 em
Pulmonic valve = 5 em.
Mitral valve = 8.5 em
Aone valve = 6m
Right ventricular myocardium: No fibrosis, erythema, pathologic infiltration of adipose tissue or areas of accentuated
softening oF induration
Left ventricular myocardium: No fibrosis, erythema, or areas of accentuated softening or induration
Ail sptum: Other - See comments
Ventricular septum: Unremarkable
‘ther septal comments
Inara Examination ges Pinta S017 #389 FAL
Death investigation Report page 14 of 26,Case Number, 2017-00704 Internal Examination —
‘The foramen ovale is probe-patent.
Right ventricular fre wall 0.2m
thickness:
Left ventricular free wallthickness: 0.8m
Intervetricuar septum thickness: 0,8 cm
ota
‘ora examined: Yes
Orices ofthe major vascular Patent
branches:
Coaretation No
‘Vascular dissection: No
‘Aneurysm formation: No
Complex atherosclerosis: No
Other aortic pathology: No
Vena Cava
Great vessels examined Yes
Vena cava and major tbutar Patent
[RESPIRATORY SYSTEM
Lungs examinee: Yes
‘See separate Cardiovascular No
Pathology report
‘ee Evidence of Inury section: No
‘See Evidence of Medical No
Intervention section:
‘See Postmortem Changes section: No
Lung Fight): ns
Lung tet 950
Upper and lower airways: Unobstructed, and the mucosal surfaces are smooth and yellow-tan
Pulmonary parenchyma color: Dark red-purple
Pulmonary parenchyma congestion Slight amounts of blood and frothy fuid
and edema
Pulmonary trunk: Other - See comments
Pulmonary atary thrombi: Other - See comments
Pulmonary artery atherosclerosis: None
Other siway and lung comments:
Bilateral organizing blood clots occlude the pulnonary artery vasculature. A true saddle embolism is not detected,
however the the blood clots extend from the hilum of both the right and left lungs, into the peripheral vasculature and are
partially adherent tothe arterial walls.
HEPATOBILIARY SYSTEM
Liver examined: Yes
‘See Evidence of Injury section: No
See Evidence of Medical No
Intervention section:
‘See Postmortem Changes section: No
ba xaninaton Page 4 Pied 782017 131.39 FH
Death Investigation Report page 15 of 25ese Number: 2047-00704
Liver (a
Bile vol (mt:
Gallstones autopsy:
Gallstones autopsy dese:
Hepatic parenchyma (color
Hepatic parenchyma (texture):
Hepatic vasculature:
Gallbladder:
Galetones:
Intrahepatic ilar tre:
Extrahepatic ily tree:
‘Alimentary tact examined
‘See Evidence of Injury section:
See Evidence of Medical
Intervention section:
See Postmortem Changes section
Stomach contents vol (i)
‘Stomach contents description:
brown liquid
‘Appendix found:
Cours:
Mucosa:
Pylon:
Lurminaleont
Mucosa:
Caller and continuity:
Lumina contents:
Mucosa:
Caliber and continuity:
For:
Genitourinary system examined:
See Evidence of Injury section
See Evidence of Medical
Intervention section:
‘See Postmortem Changes section:
rat Eatin
Internal Examination a
1675
No
Reé-brown
‘Unremarkable
Unremarkable and free of thrombus
‘Unremarkable
None
‘Unremarkable
Unremarkable
‘GASTROINTESTINAL SYSTEM
Yes
No
No
No
10
Yes
Esophagus
Normal course without fistulae
Gray-white, smooth and without lesions
Stomach
‘Usual rugal folds
Patent and without muscular hypertrophy
‘Sal lntestne
Partially digested food
Unremarkable
Appropriate caliber without interruption of luminal continuity
Colon
Formed stool
Unremarkable
Appropriate caliber without interruption of luminal continuity
Pancreas
"Normal tan, lobulated appearance
‘GENITOURINARY SYSTEM
Yes
No
Yes
No
Page 5 Pinte 9252017 19138 MR
Death invesigaton Roport page 16 of 26,se Number: 2017-00704 Internal Examination a
Kidneys
Kidneys capsules: ‘Thin, semitransparent
Conical surfaces: ‘Smooth
Contices: ‘Normal thickness and well-delineated from the medullary pyramids
Calyces, pelves and ureters: [Non-dilated and free of stones and masses
Kidney right (: 170
Kidney ie (g: 190
Urine volume (mt): 0
sine deserption:
Urinary Blader
Urinary bladder mucosa: Gray-tan and smooth
Female
Female: Yes
Breasts
Broast tissue: Usual fibrous and adipose mixture
Breast tise comments:
Female Gontal Tract
Uterus: ‘Other - See comments
Uterine cervix: Unremarkable
Folloplan tubes: Unremarkable
Ovaries: Unremarkable
Vagina Unremarkable
Other female genital tract,
comments
“The intact uterus is bogey and enlarged. The endometrial surfaces are red-tan and irregular. Medical intervention isin
place.
RETICULOENOOTHELIAL SYSTEM
Reticulendthalal system Yes
examined
‘See Evidence of Injury section: No
‘See Evidence of Medical No
Intervetion section
‘See Postmortem Changes section: No
Spleen
Spleen (a: no
‘Spleen parenchyma: Moderately firm
‘Spleen capsule: Intact
‘Spleen whit pul Prominent
Bone Marrow
Color: Red-brown, homogeneous and ample
Lymph Nodes
Regional adenopathy No adenopathy
Thymus
tora Examination Pages Pred: 9201713138 Pl
Death investigation Report page 17 of 26,Case Number: 2017-00704
Internal Examination a
‘Tyr
Parenchyma
Endocrine system examine:
‘See Evidence of Injury section:
See Evidence of Medical
Intervention section:
‘See Postmortem Changes section:
Position
Size:
Parenchyma:
‘Adrenal ight):
‘Arona lef (9
Size:
Paronehyma
Other adronal gland comments:
Absent (involution by adipose tissue)
ENDOCRINE SYSTEM
Yes
No
No
No
Pituitary Gland
Normal
“Thyroid Gand
Normal
Normal
Homogeneous
‘Adrenal Glands
10
1s
Normal
Other - See comments
‘The right adrenal is unremarkable. The left adrenal gland demonstrates hemorthagic parenchyma
‘Musculoskeletal systom examined:
‘See Evidence of Injury ect
See Evidence of Medical
Intervention section
‘ee Postmortem Changes section:
Bony framework:
Musculature:
Subcutaneous sof tissues:
MUSCULOSKELETAL SYSTEM
Yes
No
Unremarkable
‘Unremarkable
Unremarkable
‘ADDITIONAL COMMENTS
Received separately is placenta and produets of conception
‘The products of conception includes disrupted, variably identifiable fetal parts.
‘The placenta consists ofan overall, unremarkable, intact dise with <10!
‘maternal surface infarction, There is no
evidence of purulence on either the maternal or fetal surface. No evidence of placental abruption ison the maternal
surface,
‘The umbilical cord is trivascular
Reported by:
Verified by
Reviewed and approved by:
nama Exeminaton
Repot Tracking
Rebecca Asch-Kendrick, MD
Lauren E Dvorscak, MD on 52572017 9:61:14 AM
Lauren E Dvorscak, MD on 5/25/2017 1:31:28 PM
Page7 Pitot 252017 13153
Death investigation Report page 18 af 26case Number: 2047-00704 Internal Examination ——
Prat S017 1339 PM
neal Extn Pag
Death Investigation Report page 19 of 26(Case Number
2017-00704
Microscopy
Medical Investigator
‘Lauren E Dvorseak, MD
Medical Investigator Trainee
Rebecca Asch-Kendrick, MD
Microscopic description:
Hear: no significant histopathologic diagnosis
Lungs: Organizing thrombi in large and smal vessels bilaterally histologically composed of layered fibrin admixed
with erytnocytes and leukocytes into characteristic "nes of Zahn"; no definitive evidence of fetal squamous cells or
mucin (AEV/AE3 stain), acellular proteinaceous debris and fluid within alveoli; abundant alveolar macrophages
Kidney: fibrin thrombi within glomerular vasculature
‘Adrenal: predominately conical extnvasation of erythrocytes
Liver: no significant histopathologic diagnosis
Uterus: exuberant neutrophilic exudate on endometrial surface; arias-stella reaction
Cervix: dilated vascular spaces within cervical stroma associated with interstitial erythrocytes and neutrophils
Placenta: abundant acute inflammation associated with maternal surface
Products of conception: Fetal pats identified
“Unless otherwise indicated sections are stained only with hematoxylin and eosin (H&E).
Block Tissue Location Description Stain
AL Uterus
A2 Uterus and cervix
A3 Heart, liver and left adrenal
Ad Right lung
AS Leftlung
A6 Kidneys, left and right
AT Brain, hippocampus
AS POC
A9 Placenta
Report Tracking
Reported by Rebecca Asch-Kendsick, MD
Vetfied by: [Lauren E Dvorseak, MD on 5/25/2017 1:07:46 PM
Reviewed and approved by: [Lauren E Dvorseak, MD on 5/25/2017 1:31:28 PM
Marecone Paget Price: 7801713130 Po
Death investigation Report page 20 of 26Caso Number: 2017-00704
Ancillary Lab as
Medica Investigator
Lauren E Dvorscak, MD
‘Autopey date
‘Study type(s
Resuits of ancilary studies:
Microbiology cultures:
Medical Investigator Trainee
Rebecca Aseh-Kendrck, MD
2/4/2017 9:13:00 AM
Microbiology cultures
Uterine swab (A): few Aerococcus species
Uterine tissue (A): no growth on aerobic culture rare Dialister micraerophilus isolated on anaerobic culutre
Uterine swab (B): rare Aerococcus species
Uterine tissue (B): no growth on aerobic culture, rare growth of Aerococcus species on anaerobic culture
Heart blood: Klebsiella oxytoca, Citrobacter species, Streptococeus anginosus, Streptococcus salivarius group,
Streptococcus, alpha, not entero- or pneumo-coccus
Lung, right: moderate growth Streptococcus, alpha, not entero- or pneumo-coccus, few Streptococcus salivarius group,
rare Streptococcus anginosus
Lung, left: moderate growth Streptococcus salivarius group, moderate growth Streptococcus alpha, not entero- or
peumo-corcus
Reported by:
Verified by
Reviewed and approved by:
Posty Lb Stes
Repot Tracking
Rebecea Asch-Kendrick, MD
Lauren E Dvorseak, MD on 5/25/2017 10:08:45 AM
Lauren E Dvorscak, MD on 5/25/2017 1:31:28 PM
Page 1 Prot 8282017131347
oath investigation Roport page 21 of 26Case Number: 2017-00704 Procedural Notes ae
‘case Number 2017-00704
Decedent Name: —
Pathologist: Lauren E Dvorseak, MD
FollowResident: Rebecca Asch-Kendick, MD
Date of Examination: 2/4/2017 9:13:00 AM
Morphology tecnican(s) present
Yellow Sheet ‘Morphology Techni
‘Angeles Macstas
‘Attendees " Angelea Maestas
Identification ‘Angeles Macstas
‘Autopsy Angelea Maestas
Evidence Angelea Maestas
Evidence Angelea Maestas
Radiology Angelea Maestas
Retention ‘Angelea Maestas
Morphology tecnicansupervisor(s) present
Yellow Sheet Morphology Technician Lead
Identification Brandon Phinney
Autopsy Kimberly Marquez
Evidence Brandon’ Phinney
Radiology Brandon Phinney
Retention Brandon Phinney
Labother (Cassandra Toledo
Attendees Brandon Phinney
Prout Notes Rept Page t Ponat S52017 13:25PM
Death investigation Report page 22 of 26,Case Number: 2017-00704 Procedural Notes ——
‘Autopsy attondees
‘Other morphology technicians present:
Daria Koehlert-Student Tech
Prowl Nets Ropar Page2 Pine 8252047 13128
Death Investigation Roport page 23 of 26Case Number: 2017-00704 Procedural Notes ae
‘Specimens obtained fr laboratory testing
HIV serology: No
HIV spin and store: Yes
HCVIHBV serology No
Influenza serology: No
Other serology: No
Freezer protoco! No
DNA card Yes
Metaboicsereen: No
cytogenetics: No
MedX protocol: No
Urine dipstick: No
Blood cultures (bacterial) Yes
Lng cultures (bacterial No
(SF culture (bacteria) No
‘Spleen culture (bacteria No
‘Stool culture (bacterial): No
ther bacterial culture (spect)
x2 Uterine tissue(A,B)
x2 Uterine swabs(A,B)
Mycobacterial culture (ung) No
Mycobacterial culture (ther No
Viral Cutures: No
‘Approach to autopsy dissection
Rokitanshyevisceration: Yes
Virchow evisceration: No
Mosifed evscertion: No
Proce Netes Repat Page 3 Pons S252017 13138 PM
‘Death investigation Report page 2 of 25,Case Number: 2017-00704
HIV serology:
Pereranial membrane removal:
Neck anterior dissect
Neck posterior dissection:
Facial dissection:
Vertebral artery dissection in st)
Cereal spine removal:
Layered anterior trunk dssection
Anterolatra bare dissection:
Back dissection:
Posterior rib are dissection:
Extremity soft tissue dissection:
Eye enucleation:
Inner middle ear evaluation:
Maxila or mandible resection:
‘Spinal cord removal (antrot
‘Spinal cord removal (posterior)
Other dissections):
‘Stock ar with standard issue
retentior
Rib sogment
Pituitary gland
Breast tissue (women on
Brain retention:
Spina cord retention:
Cervical spine retention:
Heart retention:
HeartJung block retention:
Rib cage retention
Long bone retention:
Other retenton.specty:
‘Specimen outcome:
Prowl Nate Report
Procedural Notes —
i Special autopsy techniques
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
‘Tiesues retention
Disposition of tissues retained for extended examination
Not applicable; no tissues were retained for extended examination.
Pages Pn S282017 13135
Death Investigation Report page 25 of 26cave Number: 2017-00704
Scene Photo:
‘Autopsy Photos:
FBI blood tube:
Blood spot card
‘APD blood cad
Thumbprint:
Fingerprints:
Palmorints:
Print hol
Oral swab:
‘Vaginal sv:
‘Anal eva:
Other swab:
Fingerais:
Scalp hair
Pubic hair:
Puble hair combi
Projectiles)
Retain clothing
Retain valuable
Retain trace evidence:
Retain body bag
Retain hand bags:
Ligature:
Other evidence retain:
Property Type
Valuables
Valuables
Property Type
Clothing
Clothing
CClthing
Clothing
Prossiai Noles Rep,
Procedural Notes —
Number of scene photos produced by the OMI
Number of autopsy photes produced by the OMI
26
Evidence collected
Personal effects
Property Description Property Detail
Hair te nla
Misc Body Jewelry la
Clothing
Property Description Property Detai
Hat la
Shir ia
Gloves nla
Blanket or Shoot ola
ge 5 Printed Sano 13135 PM
Death investigation Report page 26 of 25NMS Labs
‘3701 Welsh Road, PO Box 439A, Wilow Grove, PA 19090-0437
Phone: (218) 657-4900 Fax: (215) 657-2972
[=scAnseen ‘ema: nms@nmsabs. com
Robert A Middleberg, PRD, F-ABFT, DABCC-TO,
CONFIDENTIAL
aboratory Director
Toxicology Report Patient Name AS
Patient ID 2017-00704
Reportlssued 04/10/2017 15:01 Ration zara
Age23Y 10 zn
Gender Female
To: 20164
New Mexico Office of Medical Investigators Workorder 27099868
‘Attn; Yvonne A, Villalobos cD
1101 Camino de Salud NE- Ste B
Albuquerque, NM 87105
Positive Findings:
|Compound Result Units Matrix Source
Oxycodone - Free 28 ngiml ‘001 -Antemortem Blood
Oxymorphone - Free 40 ngimL ‘004 -Antemortem Blood
‘See Detaled Findings section for additonal information
Testing Requested:
‘Analysis Code Description
Do Postmortem, Basis, Blood (Forensic)
Specimens Received:
1D TubelContainer Volume! Collection Matrix Source Miscollaneous
Mass Date/Time Information
O07 Cavender Vii Zink. Oa]0SOVT W70S —Ariemoriam Blood
002 Bue Vial 25ml 021032017 17-08 _Antemortem Blood
003 Fol Top Vial 325ml 021032017 17:08 Antemortem Blood
‘All sample volumes/weights are approximations
Specimens received on 03/31/2017,
NMS v.16.0NMS woe
Page 20f3
Detailed Findings:
Rpt.
Analysis and Comments Result Units Limit. Specimen Source Analysis By
(Oxycodone - Free’ 38 ‘agit. 50 (001-Antemortem Blood LC-MS/MS
Oxymorphone - Free 10 glmL. 10 (001 -Antemortem Blood LC-MS/MS
Other than the above findings, examination of the specimen(s) submitted did not reveal any positive findings of
‘toxicological significance by procedures outlined in the accompanying Analysis Summary.
Reference Comments:
1. Oxycodone - Free (OxyContin; Roxicodone®) - Antemortem Blood:
Oxycodone is a DEA Schedule Il controlled semi-synthetic narcotic analgesic. Its used to control pain
associated with such ailments es bursts, injuries, simple fractures and neuralgia. The addiction liability of
‘oxycodone Is about the same as for morphine. This compound should be administered inthe smallest effective
‘dose and as infrequently 28 poselbie, The usual adult dose of the hydrochlorie salts § mg every 6 hr.
Following the oral administration of oxycodone as both sustained-rolease (Oxycontin®) and regular
formulations, peak plasma concentrations of the compound are generally less than 100 ngimL; however, the
sustained-reiease preparation may also result in peak concentrations of oxycodone less than 10 ng/mL serum.
‘Oxymorphone is @ pharmacologically active metabolite of oxycodone that may be seen in blood in very low
concentrations.
In overdose, oxycodone can produce stupor, coma, muscle flaccdity, severe respiratory depression,
hypotension and cardiac arrest, In twelve oxycodone-related deaths, blood concentrations averaged 1600
!ngiml. (range 240 to 8400 nglmL), However, sustained-release preparations appear to produce adverse
reactions, up to and including death, at concentrations of oxycodone well below 1000 ngimiL, especially in
‘combination with other central nervous system depressants, depending on use pattern and route of
‘administration.
2. Oxymorphone - Free (Numorphan®; Opana®; Oxycodone Metabolite) - Antemortem Blood
‘Oxymorphone is @ Schedule II semisynthetic opioid analgesic. It's indicated for use inthe relief of moderate to
severe pain and as a preanesthetic medication. The compound may be administered by injection or by mouth
(Oral preparations are available as immediate-release tablets (5 of 10 mg) and as extended-release tablets (5 to
40 mg), Oxymorphone is also a pharmacologicaly active metabolite of oxycodone.
‘The mean oral bioavailabilty of oxymorphone is approximately 10%. The compound is extensively metabolized
by reduction to 6-axymorphal and conjugaton to oxymorphane glucuronide and oxymorphone sulfate
Approximately 50% of an oral dase of axymorphone is eliminated in the urine over § days primarily as,
‘conjugated oxymorphone and smaller amounts of free oxymorphane and free and conjugated &-oxymorphl.
‘The mean elimination hal-life of oxymorphone is approximately 7.6 to 95 hours.
‘Thity minutes folowing a single 5, 10, or 20 mg immediste-elease tablet, mean peak plasma concentrations
were 1.1, 1.9 and 4.4 nglml, respectively. Twenty mg extended-release tablets given every 12 hours for 3 days.
resulted in a mean peak plasma concentration of 2§ ngimL within 3.5 hours folowing the last dose, Doubling
the dose to 40 mg increased the mean peak plasma concentration to 4.6 ng/mL,
‘Adverse effects of exymorphone ae typical of the opioid group of compounds. Peripheral blood concentrations
in 20 oxymorphone related fatalities ranged from 30 to 120 ng/ml.
‘Sample Comment
001 _PhysicianvPathologist Name: Rebecca Asch-Kendrick MD/Lauren E Dvorscak MD
‘Chain of custody documentation has been maintained forthe analyses performed by NMS Labs.
Uniess alternate arrangements are made by you, the remainder of the submitted specimens will be discarded six (6)
weeks ffom the date ofthis report, and generated data will be discarded five (5) years from the date the analyses were
performed,
NMS v.16.0CONFIDENTIAL Workorder_—_+7099868
NMS Chain 74405
Patent 2017-00704
Page 3 of 3
Workorder 17089888 was electronically
signed on 04/10/2017 14:15 by:
Wither th Ambuon
William H. Anderson, Ph.D, F-ABFT
Forensic Toxicologist
Analysis Summary and Reporting Limits:
All ofthe following tests were performed for this case. For each test, the compounds listed were included in the scope. The
Reporting Limit listed for each compound represents the lowest concentration of the compound that will be reported as being
positive. Ifthe compound is listed as None Detected, its not present above the Reporting Limit. Please refer tothe Positive
Findings section ofthe repor for those compounds thet were identified as being present,
‘Acode 500168 - Opiates - Free (Unconjugated) Confirmation, Blood (Forensic) -Antemartem Blood
Analysis by High Performance Liquid Chromatography!
TandemMass Spectrometry (LC-MS/MS) for:
Compound ot Limit ‘Compound ‘Bot Limit
@-Monoacetyimorphine - Free 4.0 ngimt Hydromorphone - Free 1.0 ngimt.
Codeine - Free SO ngimt. Morphine - Free 5.0 ngimt
Dinydrocodeine / Hydrocadol-Free 5.0 ngimt Oxycodone - Free 5.0 ngimt
Hydrocodone - Free 50 ngimL ‘Oxymorphone - Free 1.0 ngimt
‘Acode 621988 - Cannabinoids Confirmation, Bioad (Forensic) -Antemortem Blood
Analysis by High Performance Liquid Chromatography!
‘TandemMass Spectrometry (LC-MSIMS) for:
Compound Rot Limit Compound Bot Limit
‘1-Hydroxy Delte-9 THC 4.0 ngimt Detta-9 THE 0.50 agit.
Delta-2 Carboxy THC 5OngimL,
‘Acode 60518 - Postmortem, Basic, Blood (Forensic) -Antemortem Blood
Analysis by Enzyme-Linked Immunasorbent Assay (ELISA) fer
‘Compound ‘Bot. Limit Compound Rot Limit
‘Amphetamines 20 agit. Fentanyl / Acetyl Fentanyl 0.50 ngimt.
Barbiturates 0.040 megimt. Methadone / Metabolite 25 ngimL.
Benzodiazepines 100 ngimi. Methamphetamine / MDMA 20 ngimL.
Buprenorphine / Metabolite 0.50 ng/mL, Opiates 20 ngim
Cannabinoids 10 ngim. ‘Oxycodone / Oxymarphone tongimt.
Cocsine / Metabolites 20 ngimt. Phencycidine 10rgimL
Analysis by Headspace Gas Chromatography (GC) for
‘Compound Bot Limit ‘Sompound Rot Limit
‘Acetone 5.0 mgldL |sopropano! SOmgiat
Ethanol tomolct, Methanol 5.0 mglal
NMS v.16.0