Asthma deaths confounded by substance abuse. An assessment of fatal asthma.

BACKGROUND: The Chicago region has been identified as having a very high death rate from asthma in patients aged 5 to 34 years. We investigated circumstances surrounding the fatal attack to determine whether the death was from asthma, of indeterminate cause, or coincidental to asthma. METHODS: Cases of asthma deaths from the Office of the Medical Examiner, where the deceased were younger than 46 years of age, were used to determine clinical, toxicologic, and pathologic findings relevant to asthma. Toxicologic results were compared with homicide victims. RESULTS: From 102 cases of fatal asthma, 46 cases were classified as deaths from asthma and 17 cases were considered probably from asthma as toxicologic tests were negative. Twenty-three cases were of indeterminate cause in that the acute respiratory symptoms were accompanied by substance use or alcohol consumption. Fourteen cases were not caused by asthma but were substance related, primarily cocaine. Overall, 29 of 92 (31.5%) cases were confounded by substance abuse or alcohol ingestion, which is almost as high as in homicide victims (38/82 [46.3%]). Mucus plugging of bronchi and or hyperinflation in fatal asthma occurred in 65 of 93 (69.9%) cases. Anti-inflammatory medications were being utilized by just two patients. Sufficient information was available to identify potentially fatal asthma in 6 of 20 cases (30%). CONCLUSION: Some of the reported rise in asthma deaths is a reflection of substance use or alcohol consumption similar to that seen in victims of homicide. In that patients with asthma are hypersensitive to alpha-adrenergic agonists, the use of cocaine may be especially dangerous and induce fatal ventricular dysrhythmias.

Forensic pathology of heat-and cold-related injuries.

The human body must maintain a relatively constant temperature to function. The thermoregulatory system plus human behavior control the balance of heat loss and heat gain. Heat is produced at a relatively constant rate by the body's basal metabolism. Heat production can be increased by increasing skeletal muscular activity. Heat is lost from the body to the environment by conduction, convection, radiation, and evaporation. Illness due to heat stress develops when the body gains more heat than it loses. Illness due to cold stress develops when the body loses more heat than it can produce or gain from external sources. During periods of extreme heat, mortality may rise sharply, sometimes to epidemic proportions. Because nearly all heat-related deaths are preventable, early detection of these deaths will allow appropriate preventive measures to be implemented. The autopsy findings in both heat-related and cold-related deaths are nonspecific. Information about environmental conditions, scene investigation, and the available medical history are very important in formulating the diagnosis.

Deaths due to forklift truck accidents.

Forklift truck accidents are a common cause of occupational injury and death. The authors review deaths resulting from forklift accidents cases in the years 1984-1992 in Cook County, Illinois (which contains the large city of Chicago). The fatal injuries, the characteristics of the victims, and the circumstances of the deaths are examined. A forklift striking a pedestrian or crushing the operator when tipping over or falling off a dock or truck were the most common causes of death in this study. The authors compare their findings with those found in the literature on the characteristics and prevention of forklift accidents. Also, they comment on the role of the medical examiner's or coroner's office in the investigation of these work-related deaths.

Stomach rupture by infusion pump and Foley catheter.

A nine-month-old girl who had successfully undergone surgery for esophageal atresia sustained a rupture of the stomach when an infusion pump was inadvertently connected to the balloon port of a Foley catheter being used as a gastrostomy tube. A strong similarity in appearance and feel of the balloon port and the drainage port of the catheter was created when a clear plastic adapter was inserted in the drainage port for connection of the pump tubing. Other factors contributing to the accident were poor lighting at the time of the connection, failure of the infusion pump occlusion alarm to activate at pressures low enough to prevent injury, and the reduced size of the child's stomach following surgery.

Air embolism during intercourse in pregnancy.

Air embolism may rarely cause sudden death during or shortly after pregnancy. Certain obstetric techniques, douching procedures, and blowing air into the vagina have been associated with this phenomenon. A case of venous air embolism in a pregnant woman occurring during sexual intercourse in a rear entry position is presented.

Human body buoyancy: a study of 98 men.

The specific gravity and buoyancy of 98 men were calculated at various lung volumes. The data indicated that all subjects would be capable of floating in either freshwater or seawater at total lung capacity. At functional residual capacity, the value approximating the lung volume of a recently dead body, 69% of the subjects would float in seawater, whereas only 7% would float in freshwater. Results of this study indicate that while drowned bodies are more likely to sink than bodies dead of other causes, no conclusion regarding the cause of death can be made on the basis of whether bodies float or sink.

Fetal death following maternal trauma: two case reports and a survey of the literature.

When a fetus dies after its mother has suffered trauma, questions often arise about whether the fetal death was linked to the maternal injury. Many state statutes make it a criminal act to cause the death of a fetus by injuring the mother. The authors present two cases in which fetal death resulted from maternal trauma. In addition, we review the pertinent literature on this subject and offer guidelines that may help forensic pathologists evaluate these difficult and often emotionally charged cases.

Strut fracture in a Bjork-Shiley aortic valve prosthesis.

Strut fracture can be a life-threatening adverse effect of mechanical prosthetic heart valves. This complication has occurred in the DeBakey, the Beall, the Cooley-Cutter and, most recently, the Bjork-Shiley valves. We report the case of a 35-year-old man who died suddenly 16 months after a 60 degree Bjork-Shiley Convexo-Concave heart valve prosthesis was inserted in the aortic position. At autopsy, the two welded attachments of the valve's outlet strut had fractured. The valve's tilting disc was found in his abdominal aorta.

Deaths due to foreign body aspiration in children: the continuing hazard of toy balloons.

Asphyxia due to aspiration of a foreign body is a common cause of accidental death in children. Foreign body aspiration is the most likely cause of accidental fatalities in children under 1-year-of-age. Children may die due to airway obstruction by food objects such as hot dogs, nuts, candies, grapes, seeds, and egg shells. Non-food objects such as balloons, coins, pop tops of beverage cans, pills, safety pins, ball bearings, marbles, and baby powder also may be fatally aspirated. To better understand and help prevent this well recognized health risk to children, we reviewed 10 years of cases at the Cook County Medical Examiner's Office in which deaths in children 14-years-of-age and younger were due to aspiration of foreign objects. The most common item that caused fatal aspiration in our series was a toy balloon.

Deaths caused by lightning.

Though a rare cause of death, lightning is reported to be responsible for more fatalities each year in this country than any other type of natural disaster. Lightning injuries differ significantly from other high voltage electrical injuries because of the high current flow, but extremely short duration, of the lightning stroke. We present a series of cases over the period of 1985 to 1991 in Cook County, Illinois in which lightning was the direct cause of death. Our discussion reviews the nature of lightning, the effects it may have on humans, and the ways in which deaths due to lightning might be prevented.

Sudden death in mitral valve prolapse.

Four cases of sudden death in young females with clinical and pathologic features of mitral valve prolapse are discussed. The approach to postmortem examination of the mitral valve is reviewed and various risk factors are stressed. Because of the sudden nature of these deaths, this entity is more commonly seen in medical examiner's populations than hospital autopsies. A practical approach to the investigation of such cases is given.

Dispensing error causing fatal chlorpropamide intoxication in a nondiabetic.

A 38-year-old nondiabetic female developed fatal hypoglycemia when chlorpropamide (Diabinese) was accidentally substituted for acetaminophen (Tylenol) with codeine no. 3 in a pharmacy dispensing error. When found, the patient's serum glucose was less than 20 mg/dL. The serum chlorpropamide level on hospital admission was 124 micrograms/mL. The possibility of dispensing error should be considered whenever unexpected drug effects are encountered. In cases of suspected drug overdose, labels and contents of medicine vials found at the scene should be checked for discrepancy.

Deaths due to firearms injuries in children.

There has been a marked increase in firearms-related deaths in this country over the past several decades. Especially in urban areas this increase has been correlated with a greater availability of handguns. Children have become more common victims of gunfire. Both accidental and homicidal shooting deaths have increased in the lower age groups. We examined deaths due to gunfire in children ten years and younger in Cook County, Illinois, which contains the large city of Chicago. Homicidal shootings predominated in this age group with the most common circumstances being a child struck by a stray bullet. Accidental shooting deaths always occurred when one or more children were playing with a gun they found in the home.

Methanol intoxication: distribution in postmortem tissues and fluids including vitreous humor.

A 44-year-old man was found unconscious beneath an elevated rapid transit right-of-way. On admission to the emergency room, the patient was comatose in metabolic acidosis with high anion and osmolal gaps. The serum methanol was 583 mg/dL. The serum ethanol and ethylene glycol were negative. The patient was treated with ethanol, bicarbonate, and hemodialysis. He expired 40 h after admission. The postmortem methanol concentrations in body fluids were as follows: bile 175 mg/dL, vitreous humor 173 mg/dL, and blood 142 mg/dL. Urine was not available for analysis. Postmortem methanol concentrations in body tissues are given in decreasing order: brain 159 mg/100 g, kidney 130 mg/100 g, lung 127 mg/100 g, spleen 125 mg/100 g, skeletal muscle 112 mg/100 g, pancreas 109 mg/100 g, liver 107 mg/100 g, and heart 93 mg/100 g. The total amount of methanol in the gastric contents was 73 mg. Methanol determinations were performed on a Hewlett-Packard 5840A gas chromatograph with flame ionization detection using a glass column packed with 0.2% Carbowax 1500 on Carbopack C. The internal standard used was n-propyl alcohol.

Embolization of cotton pledgets following insertion of porcine cardiac valve bioprostheses.

A variety of complications involving heart valve implants have been documented. Embolism originating from thrombosis of the valve has been a recurrent problem in mechanical and to a lesser extent porcine implants. We report two accidental deaths as a result of embolization of cotton pledgets from porcine valves. Hospital personnel failed to remove this cotton material from the valves before surgical placement. In the first case, when portions of the pledgets embolized to both carotid arteries, fatal cerebral infarction occurred. In the second case, portions of the pledgets embolized to a coronary artery producing severe left ventricular failure.

Atypical gunshot wounds of entrance: an empirical study.

Atypical gunshot wounds of entrance occur when bullets deviate from their stable nose-on trajectory before entering the body. When this occurs, the resulting wound may have an atypical D-shaped appearance. Ray-like abrasions or bruises may radiate from the corners of the wound. Unstable nonaxial flight may be caused by intermediate targets, ricochets , inappropriate weapon/ ammunition combinations, poor weapon construction, or use of misaligned silencers . If a bullet is deformed before entrance the configuration of the resulting wound may be bizarre, and the wound configuration may closely resemble the configuration of the striking bullet. Nine cases are presented showing the effects of various intermediate targets. A number of methods for the investigation of atypical wounds are discussed.

Fatal intracranial hemorrhage following pediatric oral surgical procedure.

Deaths during dental and oral surgical procedures may lead to litigation alleging malpractice. For this reason, and because of their sudden and unexpected nature, they often come to the attention of forensic pathologists. We review the clinical and anatomic findings of a 3-year-old boy who expired following an oral surgical procedure in the temporomandibular region. During the operation, perforation of the base of the skull occurred causing laceration of a branch of the middle meningeal artery and fatal subdural and epidural bleeding.

The general toxicology unknown. I. The systematic approach.

The general toxicology unknown often presents challenges and interests to toxicologists. A systematic analytical approach to search for drugs or poisons is presented here. The preliminary screening analyses were as follows: alcohol by gas chromatography (GC), ethchlorvynol colorimetric analysis, enzyme multiplied immunoassay technique (EMIT), basic drug screening by GC, and neutral and weakly acidic drug screening by GC. Other additional analyses were performed depending on the special circumstance of each individual case and the results of these preliminary analyses. Positive findings were confirmed by computerized gas chromatography/mass spectrometry when practical. Quantitation was performed by GC whenever possible.

The general toxicology unknown. II. A case report: doxylamine and pyrilamine intoxication.

A general toxicology unknown case is presented to demonstrate our systematic approach. A 20-year-old male was found dead with multiple suicide notes. Overdose was suspected but substances were not known. Blood alcohol was negative. Urine was analyzed by enzyme-multiplied immunoassay technique and was negative for all drugs assayed. Urine was then extracted with ethyl acetate:hexane (1:1) at pH 10 and back-extracted into 1.0N sulfuric acid. The acidic layer was adjusted to pH 10, and re-extracted with ethyl acetate:hexane (1:1). The residue was analyzed by gas chromatography (GC) on a 3% OV-101 column. It was found to be negative for all commonly screened substances. However, several unknown peaks were observed. Electron impact mass spectra of these unknown peaks were obtained and searched for in our computer library of more than 25000 mass spectra. These unknown peaks were identified as doxylamine and pyrilamine by gas chromatography/mass spectrometry. The base peak and molecular ion for pyrilamine were at m/z 121 and 285, respectively. The base peak for doxylamine was at m/z 58. No molecular ion was observed for doxylamine. Both doxylamine and pyrilamine are antihistamines, but are promoted and used in the management of insomnia. Quantitation was performed on a GC using dexbrompheniramine as an internal standard. Blood concentrations for doxylamine and pyrilamine were 0.7 and 7.0 mg/L, respectively. Concentrations in other tissues were determined. Death was caused by combined doxylamine and pyrilamine intoxication; the manner of death was suicide.