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ICADTS \(28-30 Août 2007, Seattle, USA\) Annales de Toxicologie Analytique, vol. XIX, n° 4, 2007 ORAL PRESENTATIONS RESULTS: There were 7,673 external cause deaths in Victoria between July 2000 and June 2005. Of these, COMMUNICATIONS ORALES there were 2,086 (27%) external cause deaths contained a toxicology report where alcohol was identified as positive (greater than 0). A toxicology report was not Postmortem toxicology attached in 1,420 (18.5%) cases and the remaining Toxicologie postmortem 4,152 external cause cases contained a negative result for alcohol. Of cases with a toxicology report 455 Understanding forensic toxicology in (5.4%) had a blood alcohol concentration (BAC) of less than 0.06 g/100 mL. There were 564 (7.4%) detected relation to external-cause deaths with alcohol (0.06 g/100mL to <0.16 g/100mL) and 659 J. KILLIAN(1), O. DRUMMER(2), J. OZANNE- (8.6%) had a toxic level of alcohol (>0.16 g/100 mL). SMITH(1) Of all causes with alcohol detected, 2726 (37%) were (1) Monash University Accident Research Centre, due to intentional self-harm, followed by 2005 (27%) being transport related, 932 (12%) due to poisoning and Victoria, Australia 553 (7%) being fall related. The trends and themes of (2) Monash University Department of Forensic other drugs will also be reported especially in relation Medicine and Victorian Institute of Forensic Medicine, to traffic injuries. Victoria, Australia CONCLUSIONS: The study results provide, for the AIMS: Injuries are not only recognised as an important first time in Australia, a systematic examination of the public health problem, but are also one of the major epidemiology of licit and illicit drugs in injury deaths causes of death. Injuries accounted for 9% of the world’s due to all mechanisms. deaths in 2000 and 12% of the world’s burden of disease (Peden, M, McGee, K, et al (2002). The Injury Chart Buprenorphine-related deaths: low levels Book: a graphical overview of the global burden of may be significant injuries). It is known that drug-drug and/or drug-alcohol H. DRUID(1), M. ROMAN(2), R. KRONSTRAND(2) interactions cause an increased risk of mortality. The use (1) Department of Forensic Medicine, Karolinska of such mind-altering drugs in places of employment Institute, Stockholm, Sweden or by drivers of motor vehicles, for example, places (2) Department of Forensic Genetics and Forensic the individual and other members of the community Toxicology, National Board of Forensic Medicine, at risk. However, the full extent of the involvement of Linköping, Sweden drugs across the whole range of injury deaths is mostly AIMS: Buprenorphine is a partial mu-opioid receptor unknown. Illegal drugs are more likely to be the cause agonist, and is used for the treatment of moderate to of unintentional death than intentional. In contrast, in severe chronic pain, but has also been introduced as an Australia, pharmaceuticals are more likely in self-harm, alternative to methadone in opiate substitution therapy. where analgesics and psychoactive drugs appear to Some years after its introduction on the Swedish market, be most commonly responsible for poisoning and/or illegal use of buprenorphine started, and several deaths involving buprenorphine have been documented in suicide (Drummer OH & Odell M (2001). The Forensic Sweden. The aim of this study was to explore the femoral Pharmacology of drugs of abuse. Chapter1.1: pp2-3). blood and urine levels in buprenorphine-positive cases, The study aimed to examine the presence and contribution and to compare these concentrations with those observed of alcohol and drugs in all external cause deaths for the in driving under the influence cases (DUI). period 2000 to 2005 in Victoria, Australia (population METHODS: A slightly modified previously 20.7 million). A secondary aim was to use the research published LC-MS/MS method (Kronstrand et al, JAT results to assist with improving the National Coroners 2003;27:464-70) was used to determine buprenorphine Information System (NCIS) as a tool for alcohol and on both postmortem cases and DUI cases where subjects drug injury surveillance. either were prescribed buprenorphine, or when abuse was suspected. METHODS: The extent to which drugs and alcohol contribute to unnatural deaths can now be described at RESULTS: The mean ± SD buprenorphine concentrations in postmortem femoral blood (all cases, a population level for the first time in Australia using n = 32) and in blood from DUI cases (n = 94) were 3.1 the NCIS (a national database of coronial information). ± 4.7 and 1.6 ± 1.8 ng/g, respectively. The overlap was Associated toxicology reports were examined to substantial both for buprenorphine and norbuprenorphine determine the proportion of cases that contained alcohol levels. Additionally, in four postmortem cases, where and drugs and the type and range (therapeutic, supra- intoxication was ruled out (causes of death: hanging = therapeutic and toxic) of drugs. 2, pulmonary embolism = 1 and severe liver cirrhosis = 256 Article available at http://www.ata-journal.org or http://dx.doi.org/10.1051/ata:2007030 Annales de Toxicologie Analytique, vol. XIX, n° 4, 2007 1), the mean (median) concentration was 7.8 (4.3) ng/g. detected using gas chromatography with nitrogen- Hence it seems impossible to define a fatal level. It may phosphorus detector and confirmed using gas be argued that buprenorphine was actually not involved at chromatography-mass spectrometry full scan mode all in any of these deaths, explaining these toxicological after solid-phase extraction using Chem-Elut columns. results. However, in at least eleven of the intoxication An additional high-performance liquid chromatography cases, buprenorphine was apparently the most suspected coupled to diode-array detection screening also drug based on circumstances, and the yet the mean ± obtained the same results. Quantitative analysis of the SD were only 2.0 ± 2.0. Further, these subjects typically two local anaesthetics, lidocaine and mepivacaine, was presented with massive pulmonary edema with lung undertaken by GC-NPD by comparison of each peak- weights averaging 1394 ± 312 g as compared to 1142 area ratio with that of the IS against blood calibration ± 297 g in postmortem controls (hangings, n = 1,979), curves (1, 5, and 10 mg/L). Limits of detection were and often with froth in the airways, suggesting that an 0.05 mg/L, the upper limit of linearity was 10 mg/L, overstimulation of the mu-opioid receptors in the brain accuracy was > 95%, and precision (n=3) demonstrated stem resulting in respiratory depression as the basic CV’s < 7% at 5 mg/L for both compounds. mechanism for their demise. No other opioid drugs RESULTS: Autopsy results showed general congestion were present in their blood. The ratio norbuprenorphine with no specific signs of anaphylactic shock. to buprenorphine in postmortem cases (mean 1.15) was Toxicological analysis revealed the presence of lidocaine similar to that in DUI cases (mean 1.55), but in 20 of the and mepivacaine in heart blood, at concentrations of postmortem cases the buprenorphine concentration was 4.9 and 16.2 mg/L, respectively. There are no defined higher than that of norbuprenorphine suggesting recent anatomic or microscopic markers for toxicity caused by intake. In addition, urine analysis indicated a period of local anesthesia and toxicology remains the diagnostic abstinence before the last dose. mainstay. CONCLUSIONS: In eleven postmortem cases effects CONCLUSIONS: Based on the autopsy findings, case of buprenorphine was considered the main cause of history, and toxicology results, the forensic pathologists death even though the blood concentrations were ruled that the cause of death was due to an overdose comparable to those of DUI cases and postmortem of local anesthetic agents. The low complication rates controls. This corroborates the notion that interpretation achieved in lipoplasty are due to adequately trained of postmortem levels of opioid drugs warrants caution surgeons and anesthesia providers, and the diligent and comprehensive review of each case. intraoperative and postoperative monitoring, which were mostly neglected by the operating surgeon involved in A fatality occurring during tumescent our case. Therefore the manner of death was considered liposuction accidental although due to gross medical negligence. M.A. MartÍNEZ(1), S. BALLESTEROS(1), L.J. SEGU- RA(2), M. GARCÍA(2) Dyadic death – an unusual family (1) Instituto Nacional de Toxicología y Ciencias tragedy Forenses, Ministerio de Justicia, C/ Luis Cabrera 9, D. Gerostamoulos(1), O.H. DRUMMER(1), 28002 Madrid, Spain M. BURKE(1), M.J. LYNCH(1), P. BYRNE(2) (2) Instituto Anatómico Forense de Madrid, Ciudad (1) Victorian Institute of Forensic Medicine and Universitaria s/n, 28040 Madrid, Spain Department of Forensic Medicine, Monash University CASE REPORT: Over the past decade, liposuction (2) State Coroners Office, 57-83 Kavanagh St., has become the most frequently performed procedure Southbank, Victoria 3006, Australia in aesthetic plastic surgery in many countries although CASE REPORT: This report involves the death it should not be considered without complications. of two women (mother and daughter) in unusual Tumescent local anesthesia is subcutaneous infiltration circumstances. A 15 year old girl (Ms A) had stayed of very dilute lidocaine and epinephrine to produce overnight at the residence of a 26 year old man thought subcutaneous swelling. Mepivacaine has never been to be her boyfriend. The boyfriend claimed he located mentioned to be used in this kind of surgery. We report the young girl deceased in his room when he awoke at a case of overdose with mepivacaine and lidocaine in about 10:00 a.m. the next morning. The boyfriend was a 38-year-old patient who died during a procedure of also an acquaintance of the mother (41Y) of the young tumescent liposuction of abdomen and both thighs in an girl. The young girl’s brother was also at the boyfriend’s outhospital clinic.
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