Petechial hemorrhages, ethanol, and opioids in victims from intoxication.

Petechial hemorrhages are of interest to forensic pathologists because of their association with pressure on the neck. This study shows the associations between ethanol, opioids in blood and the risk of petechiae in conjunctivae and eye lids of 865 medico-legally examined victims from intoxication, 112 (12.9 %) with petechiae. Livor mortis on the front, face down body position, higher body weight, and younger age of the victims were independently associated with higher risk of petechiae. These variables were used for adjustment in the logistic regression analyzes. We found associations between ethanol, opioids, and the risk of petechiae when analyzed simultaneously. The association between ethanol and the risk of petechiae differed in opioid negative and positive victims (interaction, p = 0.028). In the opioid negative group, the association was J-formed, victims with low to medium level ethanol having lower risk (OR = 0.77) than those without ethanol or opioids, whereas high ethanol level gave a 4-fold higher risk (OR = 3.97). In the opioid positive group, the J-formed pattern was reversed. Victims with low to medium level ethanol had more than 4 times higher risk (OR = 4.65), whereas high level ethanol gave a slightly elevated risk (OR = 1.34) only compared to no ethanol or opioids. The results suggest that ethanol and opioids have a complex association with the risk of petechiae independent of livor mortis, initial body position, body weight, and age in victims from intoxication. Of practical value for the post-mortem examination is that the pathologist must consider both the ethanol level and the presence of opioids when judging the significance of petechiae in the eye regions.

A man in his forties with impaired cognitive and circulatory function after a fall. / En mann i 40-årene med mental og sirkulatorisk påvirkning etter falltraume.

Falls can be dangerous, but sometimes whatever caused the fall can be even more dangerous. Here we present the case of a man who was hospitalised after a fall, but for whom identifying the cause and appropriate treatment took some time. A man in his forties was brought to the trauma unit of a university hospital. According to the information received by the Emergency Medical Communications Centre, he had fallen down a 3­4 m slope, possibly as a result of intoxication. The ambulance team reported both cognitive and circulatory impairment. There was no information to suggest previous illness or a history of substance abuse.

Petechial Hemorrhages in Suicide by Hanging: Possible Contributing Variables in Petechial Development.

Hemorrhagic petechiae in the conjunctiva and the skin have been related to type of suspension and body height of the victims of hangings. In 265 cases of hanging, we retrospectively examined whether petechiae relate to type of suspension, body weight and height, body mass index (BMI), age, sex, type and thickness of the ligature, and blood alcohol content. The type of suspension was divided into completely suspended, incompletely suspended, and found with feet touching the ground. There was no significant difference in the frequency of petechiae between the feet touching the ground and complete suspension, and they were therefore considered as one group (complete suspensions). Incomplete suspensions had more (58.7%) petechiae than the complete suspension group (30.2%). Statistical analysis showed that incomplete suspension was significantly stronger related to the development of petechiae than complete suspension. Body mass index was the only variable able to add information to the type of suspension. In victims of incomplete hangings, high BMI yielded 2.58 times higher probability of developing petechiae than low BMI. These findings suggest that body size may contribute to the development of petechiae in hangings.

Differences in combinations and concentrations of drugs of abuse in fatal intoxication and driving under the influence cases.

BACKGROUND: In toxicology, international classification systems focus on single intoxicants as the cause of death. It is, however, well known that very few drug related deaths are caused by a single substance and that information concerning the drug concentrations as well as the combinations of drugs are essential in order to ascertain the cause of death. The aim of the study was to assess whether those prone to fatal intoxications differ significantly from chronic drug users - in terms of demographics and drug exposure patterns. MATERIAL AND METHODS: Fatal psychoactive drug intoxications in Norway during 2012, where a forensic autopsy including toxicological analysis were performed, were included. Analytical findings in blood were compared with concentrations in blood from apprehended drivers under the influence of drugs and ethanol (DUID) during the same time period. The opioid and benzodiazepine concentrations were assessed as morphine and diazepam equivalents, respectively, in order to compare concentrations across the different groups. RESULTS: A total of 194 autopsy cases and 4811 DUID cases were included. Opioids were detected in around 90% of the drug intoxication cases, but in only 16% of the DUID cases. The number of substances detected in fatal intoxications was 4.9 compared to 2.6 in the DUID cases. The total opioid concentrations were significantly higher in the fatal intoxication cases compared to DUID cases (229ng/mL versus 56.9ng/mL morphine equivalents, respectively). Benzodiazepines were detected in 90% of the fatal cases. Only one fatal opioid mono-intoxication was found; a case with a very high methadone concentration (1238ng/mL). DISCUSSION: Mono-intoxication with heroin was not seen in any of the fatal intoxications in Norway, and single drug intoxications were rare (1.5%). Fatal intoxications were caused by a combination of drugs with significantly more substances as well as higher total drug concentrations among the fatal cases compared to the DUID cases. The combination of opioids and benzodiazepines seemed to represent an increased risk of death. CONCLUSION: The total load of drugs influence the degree of intoxication and the total concentration level must be considered, including the total number of substances. Our findings imply that international statistics regarding an opioid being the main intoxicant should have a shift in focus towards combinations of drugs (especially opioids and benzodiazepines) as a major risk factor for fatal drug overdoses.

Asphyxiation death caused by oxygen-depleting cargo on a ship.

The extreme danger associated with entering enclosed spaces loaded with oxygen-depleting organic cargo in ships and tanks is obviously underestimated, both among crew and management. We present a case report to highlight this occupational hazard and to increase the knowledge about the imperative precautions, in order to prevent future accidents. An experienced customs officer was found lifeless at the bottom of the unattended cargo hold on a ship loaded with woodchips. The oxygen content in the cargo atmosphere was below 2%, which is incompatible with life. Forensic autopsy revealed injuries related to the fall, and there were no positive toxicological findings in blood, lung or urine. Management and workers must be taught about the extreme rapidity of developing unconsciousness and asphyxiant death when entering enclosed spaces loaded with oxygen-depleting cargo. Even a single inhalation can result in unconsciousness and death. Dozens of annual deaths and severe injuries can easily be prevented if simple precautions are followed.

Petechial Hemorrhages and Ethanol in Deaths from Intoxication.

Petechiae in conjunctivae and in the palpebrae/skin of the eyelids are of particular interest for the forensic pathologist, because of their association with pressure on the neck. They have been described in the eyelids of intoxicated persons both in case reports and in text books of forensic pathology. We studied 590 deaths caused by intoxication, and 75 had petechiae either in the conjunctivae, the eyelids, or in both locations. We examined the influence of drugs and ethanol on the location of the petechial hemorrhages in these deaths. Deaths with ethanol in blood and in urine/vitreous humor more often had petechiae in both locations than those without. This association was statistically significant, independent of body position and livor mortis. No association between the location of petechiae, medicinal drugs, or narcotics was found. These results suggest that ethanol may contribute to the development of petechial hemorrhages in deaths from intoxication.

The hazard of sharp force injuries: Factors influencing outcome.

The risk of dying from sharp force injury is difficult to ascertain. To the best of our knowledge, no study has been performed in Norway regarding mortality due to sharp force injury or factors that impact survival. Thus, the objective of the present study was to investigate and assess mortality in subjects with sharp force injury. This retrospective study comprises data on 136 subjects (34 female, 102 male) with suspected severe sharp force injury (self-inflicted or inflicted by others) admitted to Haukeland University Hospital between 2001 and 2010. The majority of subjects were intoxicated, and the injury was most often inflicted by a knife. The incidence of sharp force injury in Western Norway is similar to the incidence in other European countries. Almost half of the subjects with self-inflicted injury died. In cases with injury inflicted by another individual, one in five died. Mortality rates were higher in those with penetrating chest injuries than those with penetrating abdominal injuries and higher in cases with cardiac injury compared to pleural or lung injury. Sharp force injury can be fatal, but the overall mortality rate in this study was 29%. Factors influencing mortality rate were the number of injuries, the topographic regions of the body injured, the anatomical organs/structures inflicted, and emergency measures performed.

Identification of Missing Norwegian World War II Soldiers, in Karelia Russia.

This article presents the multidisciplinary effort in trying to identify the skeletal remains of 100 Norwegian soldiers serving in the German army, killed in Karelia Russia in 1944, from the recovery of the remains through the final identification using DNA. Of the 150 bone samples sent for DNA testing, 93 DNA profiles were obtained relating to 57 unique individuals. The relatives could not be directly contacted as the soldiers were considered as traitors to Norway; therefore, only 45 reference samples, relating to 42 cases of the missing, were donated. DNA matches for 14 soldiers and 12 additional body part re-associations for these individuals were found. Another 24 bone samples were re-associated with 16 individuals, but no familial match was found. More than six decades after the end of WWII, DNA analysis can significantly contribute to the identification of the remains.

Deaths from violent causes and accidents in Hordaland County 2003-04.

BACKGROUND: Studies of the epidemiology of deaths from violent causes can provide valuable information for the treatment of traumas. We wished to ascertain whether the victims had survivable injuries and were accessible for treatment at the time of discovery of the injury. The purpose was to identify areas of intervention that may help save lives. MATERIAL AND METHOD: An overview of deaths from violent causes in Hordaland County in 2003 and 2004 was retrieved from the Cause of Death Registry, and information from autopsy records, hospital records and police reports was reviewed. In each case, an assessment was made of whether the injuries were survivable. If the patient was alive and could be reached and treated at the time when the incident was reported, he/she was defined as accessible for treatment. RESULTS: Altogether 191 deaths were included. We assessed the injuries as survivable in 26 cases. A total of 18 of these 26 patients were also assessed as accessible for treatment. All of these 18 patients died from falls or traffic accidents. 11 of the 18 patients were in the age group 75 years or older; this age group accounted for 41 cases (21.5%) of the total material. The records showed that in 12 of these 18 cases, it had been decided following an overall assessment not to initiate, or to discontinue, further life-saving treatment. INTERPRETATION: A small number of patients were deemed to have sustained survivable injuries while also being accessible for treatment. The results indicate that primarily efforts to prevent injuries will help reduce the number of deaths from violent causes.

Methyl tert-butyl ether (MTBE) detected in abnormally high concentrations in postmortem blood and urine from two persons found dead inside a car containing a gasoline spill.

Two deep frozen persons, a female and a male, were found dead in a car. There had been an explosive fire inside the car which had extinguished itself. On the floor inside the car were large pools of liquid which smelled of gasoline. The autopsy findings and routine toxicological analyses could not explain the cause of death. Carboxyhemoglobin levels in the blood samples were <10%. Analysis with a headspace gas chromatography revealed methyl tert-butyl ether (MTBE) concentrations of 185 mg/L (female victim) and 115 mg/L (male victim) in peripheral blood. The urine MTBE concentrations were 150 mg/L and 256 mg/L, respectively. MTBE is a synthetic chemical which is added to gasoline as a fuel oxygenate. Gasoline poisoning is likely to be the cause of the death in these two cases, and MTBE can be a suitable marker of gasoline exposure, when other volatile components have vaporized.

Fatal injury as a function of rurality-a tale of two Norwegian counties.

BACKGROUND: Many studies indicate rural location as a separate risk for dying from injuries. For decades, Finnmark, the northernmost and most rural county in Norway, has topped the injury mortality statistics in Norway. The present study is an exploration of the impact of rurality, using a point-by-point comparison to another Norwegian county. METHODS: We identified all fatalities following injury occurring in Finnmark between 2000 and 2004, and in Hordaland, a mixed rural/urban county in western Norway between 2003 and 2004 using data from the Norwegian Cause of Death Registry. Intoxications and low-energy trauma in patients aged over 64 years were excluded. To assess the effect of a rural locale, Hordaland was divided into a rural and an urban group for comparison. In addition, data from Statistics Norway were analysed. RESULTS: Finnmark reported 207 deaths and Hordaland 217 deaths. Finnmark had an injury death rate of 33.1 per 100,000 inhabitants. Urban Hordaland had 18.8 deaths per 100,000 and rural Hordaland 23.7 deaths per 100,000. In Finnmark, more victims were male and were younger than in the other areas. Finnmark and rural Hordaland both had more fatal traffic accidents than urban Hordaland, but fewer non-fatal traffic accidents. CONCLUSIONS: This study illustrates the disadvantages of the most rural trauma victims and suggests an urban-rural continuum. Rural victims seem to be younger, die mainly at the site of injury, and from road traffic accident injuries. In addition to injury prevention, the extent and possible impact of lay people's first aid response should be explored.

Different mechanisms of decapitation: three classic and one unique case history.

Three classic cases and one exceptional case are reported. The unique case of decapitation took place in a traffic accident, while the others were seen after homicide, vehicle-assisted suicide, and after long-jump hanging. Thorough scene examinations were performed, and photographs from the scene were available in all cases. Through the autopsy of each case, the mechanism for the decapitation in each case was revealed. The severance lines were through the neck and the cervical vertebral column, except for in the motor vehicle accident case, where the base of skull was fractured. This case was also unusual as the mechanism was blunt force. In the homicide case, the mechanism was the use of a knife combined with a saw, while in the two last cases, a ligature made the cut through the neck. The different mechanisms in these decapitations are suggested.

Traumatic dissection of the vertebral artery in a toddler following a short fall.

Spontaneous subarachnoid haemorrhage (SAH) in children is uncommon, but is sometimes seen after rupture of aneurysms, and in different disorders. Traumatic SAH is common after serious accidental head injury, but is also reported after child abuse with vigorous shaking. To avoid unnecessary accusations of innocent care givers, it is important not to misinterpret the findings as abusive head trauma in small children with SAH. In the presented case, a nearly two-year-old girl was brought to the hospital after a fall witnessed by her father. The girl was unconscious, with elevated intracranial pressure, SAH and bilateral retinal haemorrhage (RH). She was pronounced dead after 9h. Premortem angiography revealed a dissection of the right vertebral artery, and postmortem examination revealed a traumatic lesion deep in the neck, at the base of the skull. Cerebral edema, in combination with SAH and RH, is highly suggestive of abusive head trauma. However, no external lesions, no skeletal lesions, especially no long bone metaphyseal lesions, or subdural haematomas occurring at the same time as SAH, were found. There was no report of previous child abuse in the family. Based on the radiological and postmortem findings, we believe that an accidental fall caused a blunt force trauma with a subsequent dissection of the right vertebral artery. To our knowledge, accidental tear of one of the vertebral arteries, leading to SAH in a toddler, has previously not been described. Child abuse is an important exclusion diagnosis with serious legal implications.

Lethal methemoglobinemia and automobile exhaust inhalation.

Inhalation of automobile exhaust gas often leads to death by CO intoxication. In some cases the measured carbon monoxide hemoglobin saturation level (COHb) is considerably below what is considered to be lethal. The death in such cases has been attributed to a combination of a high CO2 and a low O2 tension. In a recent case the deceased was found dead in a car equipped with a catalytic converter, with a hose leading exhaust from the engine to the interior of the car. Analysis revealed a moderately elevated COHb and a high methemoglobin saturation level (MetHb) in peripheral blood. No ethanol, narcotics or drugs were detected. Reports mentioning MetHb or methemoglobinemia in post-mortem cases are surprisingly scarce, and very few have related exhaust gas deaths to methemoglobinemia. High-degree methemoglobinemia causes serious tissue hypoxia leading to unconsciousness, arrhythmia and death. The existing literature in this field and the knowledge that exhaust fumes contain nitrogen oxide gases (NOx) that by inhalation and absorption can result in severe methemoglobinemia, led us to postulate that this death could possibly be attributed to a combination of methemoglobinemia and a moderately high COHb concentration.

Mercury in human brain, blood, muscle and toenails in relation to exposure: an autopsy study.

BACKGROUND: The main forms of mercury (Hg) exposure in the general population are methylmercury (MeHg) from seafood, inorganic mercury (I-Hg) from food, and mercury vapor (Hg0) from dental amalgam restorations. While the distribution of MeHg in the body is described by a one compartment model, the distribution of I-Hg after exposure to elemental mercury is more complex, and there is no biomarker for I-Hg in the brain. The aim of this study was to elucidate the relationships between on the one hand MeHg and I-Hg in human brain and other tissues, including blood, and on the other Hg exposure via dental amalgam in a fish-eating population. In addition, the use of blood and toenails as biological indicator media for inorganic and organic mercury (MeHg) in the tissues was evaluated. METHODS: Samples of blood, brain (occipital lobe cortex), pituitary, thyroid, abdominal muscle and toenails were collected at autopsy of 30 deceased individuals, age from 47 to 91 years of age. Concentrations of total-Hg and I-Hg in blood and brain cortex were determined by cold vapor atomic fluorescence spectrometry and total-Hg in other tissues by sector field inductively coupled plasma-mass spectrometry (ICP-SFMS). RESULTS: The median concentrations of MeHg (total-Hg minus I-Hg) and I-Hg in blood were 2.2 and 1.0 microg/L, and in occipital lobe cortex 4 and 5 microg/kg, respectively. There was a significant correlation between MeHg in blood and occipital cortex. Also, total-Hg in toenails correlated with MeHg in both blood and occipital lobe. I-Hg in both blood and occipital cortex, as well as total-Hg in pituitary and thyroid were strongly associated with the number of dental amalgam surfaces at the time of death. CONCLUSION: In a fish-eating population, intake of MeHg via the diet has a marked impact on the MeHg concentration in the brain, while exposure to dental amalgam restorations increases the I-Hg concentrations in the brain. Discrimination between mercury species is necessary to evaluate the impact on Hg in the brain of various sources of exposure, in particular, dental amalgam exposure.

Unnatural death in the elderly : A forensic study from western norway.

The objective of the study was to determine the unnatural manner and causes of death in older people, defined as individuals at least 60 years of age at the time of death. A series of medico-legally examined deaths in older people, who were examined between January 1, 1999 and December 31, 2003, and whose deaths were considered unnatural after forensic examination were studied. All deaths took place in western Norway, in two whole counties and the north part of a third county, including one large Norwegian city and one medium-sized city on the west coast of Norway. Of the 2425 forensic examinations performed in the time period, 1169 were 60 years or older at the time of death. Of these, 228 deaths were categorized as accidental, suicidal, or homicidal. Drowning was the most common lethal accident in elderly males, whereas fatal traffic accidents were more frequent in women. Alcohol intoxication was very common among male drowning victims, and none of the drowning victims had used a life-saving floating device. None of the elderly traffic victims were intoxicated. Death after a falling accident in the home is probably underreported. Suicide is more common among elderly men than women. Among men, hanging was the most common cause of death, whereas intoxication resultiong from drug overdose and drowning were the most frequent causes of death in women. Cancer was present in 19% of the suicide victims, all men. Serious disease may be a predisposing factor for suicidal behavior. Homicide is uncommon as a manner of unnatural death among the elderly.