toxicology

DR FRANK KAKUBA G
MD, Mmed Path(mak)
• Toxicology-related deaths are often determined days,
weeks, or even months after an autopsy is performed.

• A drug toxic death is first suspected because of information

from the scene investigation and the decedent’s history.
• There may be syringes, spoon cookers, or bongs suggestive of
recreational drug abuse.

• A tourniquet may still be on an arm, and needles may be on or

near the body.

• A small trickle of dried blood may be on an arm, hand, or foot.

• Empty prescription bottles or suicide notes may be seen

• In cases where the history is suggestive of drug death,
yet nothing is found at the scene, consider that the
scene may have been “cleaned up” or altered by others
attempting to hide drug-related evidence.

• Perhaps the friends or family members of the victim desired to

absolve themselves from any illicit drug activity, or they
may have intended to cover up a suicidal drug ingestion.
• In a suspected poisoning, open household products and
suspicious liquids and powders should be confiscated.
• In some cases, despite investigative suspicion, detailed
and careful toxicology testing will fail to reveal toxic
levels of drugs or may fail to reveal any drugs at all.
• At autopsy, there may be no findings to indicate that
the death is drug related.
• Sometimes, however, clues such as a “foam cone” at the mouth
or in the nares, injection sites, needle track marks, pulmonary
congestion and edema, pills in the stomach, or “packets” of
drugs in the intestine are indications that a death may be due to
drug toxicity.
• Also, one may see liver necrosis caused by acetaminophen
toxicity or hemorrhagic gastric mucosa and the faint smell of
bitter or burnt almonds, characteristic of cyanide poisoning.
• Some pills have colorful dyes added to them—this may be
reflected at autopsy by colorful discoloration of the gastric
mucosa or colorful clumps of pill material in the stomach or
proximal small intestine.
• The smell of ethanol/alcohol may be detected in the
gastric contents, or may even be detected on approaching
the body before performance of the autopsy.
Collection of toxicology specimens

• Toxicology specimens such as blood and vitreous fluid

are collected before the autopsy is performed.
• Blood is ideally obtained with clean needles from the
peripherally located femoral veins, because this location
provides relatively easy access to blood located outside of the
body cavities.
•
• Peripherally located blood is preferred for toxicologic testing
because it is relatively isolated from the internal organs in the
chest and abdomen and hence is likely to provide a more
accurate level of drugs.
• Blood obtained from the heart or other central regions in
the chest and abdomen may have falsely elevated drug
levels due to postmortem drug diffusion down concentration
gradients—a process referred to aspostmortem redistribution
postmortem release .
or
• Routine toxicology specimens include four glass vacutainer test tubes of
blood totaling approximately 40 to 50 milliliters, with three of the tubes
containing a preservative such as sodium fluoride.
• In particular, sodium fluoride inhibits the activity of cholinesterase
and is essential in retarding the degradation of cocaine and other
substances such as 6-monoacetylmorphine.
• The preservative is often combined with an anticoagulant such as
potassium oxalate, sodium citrate, or EDTA.
5

• The blood in the test tube without preservatives may be used for clinical
analyses such as thyroid hormone studies or infectious disease testing
(hepatitis, HIV,syphilis), or to provide samples for DNA testing in cases
with paternity or other issues.
• Gastric contents should be saved in cases of suspected
drug ingestion.
• In such cases, to aid in possible calculation of the total amount
of drug in the stomach, it is advantageous to record the total
volume of gastric contents.
• Liver or other solid organ samples may be collected in cases
where the parent drug and the drug metabolite levels and
possibly their ratios are important.
• Lung tissue is useful when volatiles are suspected, and
kidney tissue is useful if heavy metals (such as lead, mercury,
and arsenic) are suspected, because heavy metals tend to
concentrate in the kidney.
• Adipose tissue is another potential toxicologic specimen,
because it acts as a depot of certain substances and may prove
useful in the analysis of volatile agents.
• If inhalational agents are suspected, toxicology specimens
should be placed in gas-tight containers.
• In decomposing bodies where blood can not be found, skeletal
muscle is also a good specimen for drug testing because its
drug levels will most closely approximate antemortem blood
drug levels.
• The skeletal muscle should be sampled from an extremity
(usually a thigh) to minimize the possibility of altered drug
levels due to postmortem redistribution.
• In severely decomposed bodies, it may be worthwhile to
collect maggots from the body for toxicologic testing.
• It is possible that the maggots may test positive for a drug,
Drug classes that have been identified in maggots include
cocaine, opiates, barbiturates, benzodiazepines, and
antidepressants.
•
Ethanol (alcohol)

• Deaths due to the toxic effects of acute over ingestion of

ethanol are due to severe respiratory and central nervous
system depression and usually involve blood ethanol
levels of 0.35 percent or higher.
• This number should only be used as a guide, however, because
one must be reminded that a tolerant chronic alcoholic may
appear to act normal or only slightly impaired at a blood ethanol
level of 0.30 to 0.40 percent; and a novice, nontolerant
individual may die from a blood ethanol level as low as
0.20 to 0.30 percent or lower.
• The blood ethanol level may be even lower in a fatal case if
positional asphyxia is a factor in the death, or if the ethanol is
combined with an opiate, benzodiazepine, or other type of
respiratory depressant.
• The ethanol levels recorded in the blood and vitreous fluid are
not necessarily the highest level that the individual had achieved,
because he or she may have metabolized ethanol to some
degree during the time period while they were comatose, before
dying.
• It is always advised to compare vitreous and blood ethanol
concentrations to determine if the person was in an absorptive
or metabolic state.
• The precise cause of death of chronic alcoholics is not
always evident at autopsy, and it is not unusual to
encounter the sudden death of an alcoholic with essentially a
negative or nearly negative autopsy.
• It has been proposed that in some, if not many of these cases,
the death may be related to alcoholic ketoacidosis.
• Documentation of alcoholic ketoacidosis involves detecting
ketone bodies, namely, acetone, acetoacetate, and
betahydroxybutyrate in the blood and/or vitreous fluid.
• In some cases in which an alcoholic is unable to obtain
alcoholic beverages, he or she may ingest household products
that
contain ethanol such as mouthwash or hair spray.
• These products may contain alcohol at very high concentrations.
• Clues to their consumption may be empty containers at the
scene or a peculiar odor of the gastric contents.
Drug abuse
Body “stuffer” versus body “packer”

• Drugs of abuse can be ingested, not only for their effects,

but also for purposes of concealment.
• Packaged drugs may be ingested in an attempt to hide them
from law enforcement officials or others.
• If the drug was carefully packaged with the intent of being
swallowed and carried "internally” (in the intestines) into another
body packing.
country, it is referred to as
• If the drug was not packaged with the intent of being consumed,
but instead was hastily swallowed to escape detection, it is
body stuffing .
referred to as
• Regardless of the means of swallowing drugs, it is a hazardous
act and can easily lead to a toxic death, particularly if one or
more of the packages should leak their contents into the bowel
and be absorbed into the circulation.
• Cyanide is a rapidly acting and generally colorless compound
that may be quickly fatal.
• A clue to its presence at autopsy is bright red discoloration of
the blood and a faint odor of bitter almonds, although the ability
to smell cyanide is a genetically determined trait that is absent
in up to 50 percent of the population.
• Read clinical features of cyanide and organophosphate
poisoning in pharmacology
Summary of clues at autopsy that the person
may have died of a drug overdose
• Foam cone” over nose and/or mouth
• Colorful discoloration of lips, tongue, oral mucosa, or stomach
• Granular, grainy, or pasty pill material in mouth and/or stomach
• Pills in stomach
• Pulmonary congestion and/or edema (heavy lungs, often
greater than 500 to 600 grams each)
• Frothy fluid in bronchi and trachea
• Mucus in bronchi