Drug and chemical blood-level data 2001.

Current blood-level data are presented for drugs and chemicals of toxicologic interest. The data represent an update of previously published compilations of therapeutic, toxic and lethal blood-levels.

Chemical burn from alkaline batteries--a case report.

A 2-year-old male was found to have a third degree (full thickness) burn on his rear right thigh. The father discovered the burn at a physician's office where the child was being treated for an ear infection. The physician notified authorities of suspected physical child abuse.

Drowning due to cyclobenzaprine and ethanol.

The deceased was a 35 year old female who was found by her husband in the bathtub with her head and face submerged in the water. Autopsy findings were unremarkable. Toxicological analysis revealed the presence of ethanol (215 mg/dL) and cyclobenzaprine (1.786 mg/l) in the blood. This high concentration of cyclobenzaprine (Flexeril) in combination with alcohol proved to be fatal.

Heroin fatality due to penile injection.

Death due to heroin overdose and/or rapid injection of heroin is a frequent occurrence among opioid addicts. We present an unusual case of heroin fatality due to the injection of the drug in the penis. Blood, urine, bile, and vitreous humor concentrations of morphine were 0.68, 0.49, 0.32 and 0.062 microg/ml, respectively. Ethanol was detected at concentrations of 104, 124, 106, and 94 mg/dl in the blood, urine, bile, and vitreous humor, respectively. The cause of death was determined to be due to heroin and ethanol intoxication.

Fatal inhalation of 1,1,1-trichloroethane.

A 13-year-old male was found dead in the woods subsequent to 1,1,1-trichloroethane (TCE) inhalation. Autopsy findings included tissue congestion of lung, liver and kidney. Certain precautions were taken in collecting and storing biological samples in order to prevent loss of TCE by evaporation. The availability of volatile solvents coupled with the increase of volatile substance abuse makes it easy for abusers to obtain.

Extraction of selected drugs from serum using microwave irradiation.

Microwave irradiation is used as an alternative heating method for extraction over more conventional hot plate methods. We describe a fast, efficient method for the determination of selected drugs in human blood/serum using microwave extraction. The microwave extraction of organic substances requires special instrumentation and the results have been compared with the results from classical liquid/liquid extraction. The present microwave extractions were performed in an 'atmospheric pressure' system. Before irradiation with microwaves, an appropriate solvent mixture was added to the buffered specimen. Lidocaine, methadone, diazepam, nordiazepam, propoxyphene and norpropoxyphene were tested as model substances. The quantitation was performed by GC/NPD. The procedure has been applied successfully to a number of forensic cases. The use of microwaves decreases the time of extraction and the solvent consumption.

Acute overdose of zolpidem.

Zolpidem (Ambien) is an imidazopyridine hypnotic recently introduced in the USA. We report a case of a fatal overdose of Ambien. A 68-year-old female ingested at least 30 tablets of 10 mg Ambien (300 mg). She was found dead at home. Toxicological analyses revealed blood concentration of 4.1, 19.3 and 2.3 micrograms/ml of zolpidem, meprobamate and carisoprodol, respectively.

The effect of storage at various temperatures on blood alcohol concentration.

There is a paucity of data available on the effect of storage on blood alcohol concentration (BAC) at elevated temperatures. Changes in serum alcohol concentration (SAC) and BAC were studied. Serum samples spiked with alcohol in the presence or absence of preservative were stored at 26.7 degrees, 32.2 degrees or 37.8 degrees C respectively. Serum alcohol concentrations were determined daily on days 1 through 14, and on days 21 and 35. Under these controlled conditions, no significant change in SAC was observed at the aforementioned temperatures. Whole blood samples submitted from outside agencies were initially analyzed (day 1), then stored for 35 days at different elevated temperatures before a second analysis. The average loss in BAC was 19.20 +/- 15.6, 9.95 +/- 5.7, and 15.60 +/- 6.9% when the samples were stored at 26.7, 32.2 and 37.8 degrees C, respectively. The alcohol loss from whole blood samples may be attributed to chemical oxidation rather than to elevated temperatures. It is, therefore, concluded that a whole blood sample obtained from a living individual and stored in a locker, glove compartment or other environment where the temperature is elevated, may lose 10-19% of its alcohol content over 35 days of storage. On the other hand, when a serum or plasma sample is exposed to the same environment, no significant change in SAC was observed. The utility of this information is significant to the forensic toxicologist. The results of this study suggest that a whole blood sample analyzed after exposure to elevated temperature may have had, originally, a higher BAC.

Determination of absorption time of ethanol in social drinkers.

This study was designed to determine the peak, plateau and absorption times of ethanol in a social drinking setting. For the purpose of this study, subjects who had drinking times of 30 min or greater were considered to fit the 'social drinking' category. Healthy subjects (31 male and two female) were tested immediately after they finished drinking. Blood alcohol concentrations (BACs) were measured using a breath testing instrument (Intoxilyzer 5000). Drinking time, type and volume of alcoholic beverage consumed, subject's weight, and a brief description of the breakfast meal were recorded for each subject. The peak, plateau and absorption times were determined for each subject. Peak time was the time interval between the end of drinking and the maximum blood alcohol measurement. Plateau time was the time interval between peak time and the end of absorption time, i.e. the interval between peak time and the beginning of dissipation. Absorption time was defined as the peak time plus plateau time. Among 31 subjects with drinking times of 30 min or greater, 23 (74.2%) had peak and absorption times of < 30 and < 60 min, respectively. Twenty four out of 31 (77.4%) social drinkers had an absorption time of < 60 min, regardless of their peak time. Overall, the average peak and absorption times were 17.4 +/- 17.3 (range 0-74) and 42.2 +/- 31.5 (range 1-130) min. Plateau times averaged 24.9 +/- 23.1 with a range of 0-74 min. It can be concluded from this study that in a social drinking setting, a shorter time to peak and faster rate of absorption may occur when ethanol is consumed over an extended period of time. This is in contrast to results reported in earlier studies involving bolus drinking, where longer absorption times occurred.

Accidental death by nitrous oxide inhalation.

Nitrous oxide is a popular inhalation anesthetic-analgesic agent. Its euphoric action and its availability have led to its abuse. We report a case of fatal accidental asphyxia due to nitrous oxide abuse. The deceased was a hospital worker who had access to the hospital supply of nitrous oxide. His death was due to hypoxemia and asphyxiation, secondary to nitrous oxide inhalation.

Ingestion of lye.

This paper reports on the case of a 13-year-old white male who committed suicide by ingestion of heavy duty drain and sewer opener. He left behind a note indicating his suicide. This teenager was grieving over the suicide of one of his friends and was under counseling by a mental health therapist at school. Results of autopsy and toxicological analyses indicated the ingestion of a highly alkaline substance that is consistent with the ingredients of the drain opener mentioned.

The role of trauma in postmortem blood alcohol determination.

In postmortem cases, a blood sample is frequently obtained by transthoracic (TT) puncture. The purpose of this study was to determine if, in traumatic death, blood samples collected by TT provided a valid sample for blood alcohol analysis. A retrospective study (1980-1986) was conducted to evaluate possible contamination of blood by GI alcohol in traumatic death cases. Out of 6000 cases reviewed, 19 cses with BACs > 500 mg/dl were found and 8 of these cases involved traumatic death with GI laceration and/or transection. The results of this study support the hypothesis that blood samples from the 8 cases had been contaminated, resulting in a falsely elevated BAC. A transthoracic study (1987-1989) was conducted under controlled conditions, where blood alcohol content of TT blood samples was compared with samples collected from the intact heart chamber. Seven out of 28 cases of traumatic injury revealed trauma to the GI tract. The results showed that when GI traumatic injury occurs and unabsorbed ethanol is present in the stomach, contamination of TT blood samples occurs and artificially elevated BACs are obtained. It is recommended that, in cases of traumatic injury, heart blood samples from the intact heart chamber, as well as samples of additional biological fluids, be collected to rule out the possibility of contamination and to ensure that the BAC used for forensic interpretation is accurate.

The study of tricyclic antidepressants in formalin-fixed human liver and formalin solutions.

The stability of amitriptyline, nortriptyline, desipramine and imipramine in formalin-fixed human liver tissue and formalin solutions was investigated. The levels of the tricyclic and its primary demethylated metabolite in the frozen liver were determined and compared with levels obtained in the formalin-fixed liver and formalin solutions in which the liver was stored. It was obvious that some methylation of the secondary amine, nortriptyline, to the corresponding tertiary amine, amitriptyline, and of desipramine to imipramine took place in the formalin environment. Nortriptyline was not detected in most cases, suggesting that it may degrade more rapidly than desipramine. There was no consistent ratio between the concentration of the drug in the frozen liver tissue versus formalin-preserved tissue or versus formalin solution. The methylation rates of the secondary amines could not be quantitated. Storage of the liver tissue in formalin at room temperature resulted in leaching of the drugs into the formalin solution. The drugs tested may be detected for up to 22 months in the formalin-fixed liver and in the formalin medium.

Blood versus synovial fluid ethanol concentrations in humans.

Many tissues have been analyzed for their relevance in prediction of blood ethanol concentrations, with varying results. Synovial fluid is contained and protected by the bursa sac. Because of its high water content, it may be a suitable biological fluid for analysis if a linear correlation could be established between blood and synovial fluid ethanol concentrations. Blood-synovial fluid ratios of ethanol in 28 human cadavers, using an internal standard, exhibit a good distribution ratio with an average of 0.99 +/- 0.29 and a correlation coefficient of 0.89. This study shows that synovial fluid is a good alternative biological sample for prediction of blood ethanol levels within a range.

Interference of herbal drinks with urinalysis for drugs of abuse.

Recently there have been claims among drug users that some herbal drinks interfere with urinalysis for drugs of abuse and yield false positive results. Proof of such claims has yet to be shown. Screening for drugs of abuse is usually carried out using fluorescence polarization immunoassay (FPIA) or thin-layer chromatography (TLC). Fifty herbal samples which are considered among the most purchased herbs in the consumer market were used to investigate such claims. The drug groups that were tested for included amphetamines, opiates, barbiturates, cocaine metabolite, methadone, and their analogs. The herbs were analyzed at different concentrations (0.1, 1, 3, and 5 g/100 mL of distilled water) using TLC and FPIA to determine if any interfere with urinalysis for drugs of abuse and yield false positive results. For the FPIA test, the sample infusions were analyzed directly using the automated ADX analyzer (Abbott Laboratory). For TLC, infusions of the herbs were added to a solid-phase extraction column (pH 9.25), then extracted with a methylene chloride-isopropanol solvent system. At this pH, neutral, basic, and acidic drugs of abuse are extractable. The developed chromatographic plates were sprayed sequentially with several reagents. None of the herbs in the concentration ranges screened showed any interference with TLC or FPIA, indicating the invalidity of such claims.

The use of bone marrow in the study of postmortem redistribution of nortriptyline.

Thirty-two New Zealand Albino rabbits (1.5-2.0 kg) were dosed on a daily basis with 20 mg/kg nortriptyline (NT) prior to feeding for a period of five days. On the fifth day of dosing, the animals were sacrificed approximately 1.5 h after the final dose. A comparison was made of nortriptyline concentrations in the blood and bone marrow at the time of sacrifice, and between bone marrow collected at the time of sacrifice and bone marrow collected at 2, 4, 6, 12, 24, 36, and 48 h after sacrifice. The results indicate that a linear relationship exists between blood and bone marrow NT concentrations, with an average marrow-to-blood ratio of 29.98 +/- 3.91 and a correlation coefficient of 0.956. Additionally, there was no significant difference (p > 0.05) observed between NT concentrations in bone marrow at the time of sacrifice and its concentration up to 24 h after sacrifice. The results indicate that bone marrow may be used to predict blood concentrations of NT up to 24 h after death when a suitable blood sample is not available.

An outbreak of designer drug--related deaths in Pennsylvania.

3-Methylfentanyl ("China White") is a "designer" opiate that has caused more than 100 overdose deaths in California since 1979, but that has not been associated previously with deaths east of the Rocky Mountains. During 1988, 3-methylfentanyl was identified in 16 fatal overdose cases in Allegheny County, Pennsylvania, contributing to a fourfold rise in overdose mortality during October of that year. Morphine was detected in the blood of five persons (31%) and cocaine in the blood of three persons (19%) dying of 3-methylfentanyl overdoses; these were demographically similar to 99 other fatal overdose cases investigated by the county coroner from 1986 through 1988. This documents the contribution of 3-methylfentanyl to overdose mortality in an eastern city and the use of 3-methylfentanyl with other illegal drugs. Drug abusers in the northeastern United States should be considered at risk for more "designer drug" overdose outbreaks in the future.