Lethal Carbon Monoxide Generated from Small Internal Combustion Engines.

Fuel-burning small engines have the potential to emit dangerous and potentially lethal concentrations of carbon monoxide when used in poorly ventilated environments. The North Carolina Office of the Chief Medical Examiner investigated seven cases from 2013 - 2020 involving lethal carbon monoxide from small internal combustion engines. Evaluation of percent carboxyhemoglobin saturation was determined in these case studies as ratios of carboxyhemoglobin to reduced hemoglobin, using HP 8453 and Agilent 8454 UV-Visible Spectrophotometers (Agilent Technologies, Santa Clara, CA). Sources of carbon monoxide included a pressure washer, a propane-powered forklift, an inboard engine boat, a motorcycle, propane and kerosene heaters, and home-use generators. It was demonstrated during one death investigation that the Dräger X-am 2000 electrochemical gas monitor often used by first responders, falsely reacted to acetylene gas, initially misleading investigators to the source of the carbon monoxide. Educating first responders about not only the hazards of these unexpected carbon monoxide sources, but the limitations of their equipment, is a valuable goal of disseminating complete medical examiner case information. The details of these cases will educate first responders, the forensic science community, and public health leaders on potential small engine sources of carbon monoxide in death investigations, responder safety, and the limitations of portable air quality monitoring equipment during death investigation.

Suspected North Carolina counterfeit pill-involved deaths, 2020-2022.

The NC Office of the Chief Medical Examiner regularly assumes jurisdiction over deaths that are suspicious, unusual or unattended by a medical professional. In recent years, the presence of counterfeit pills is occasionally suggested by investigatory notes and/or scene findings that document reported consumption of prescription drugs, or prescription drugs on scene, which are not reflected in the final autopsy findings after toxicological analysis of the decedent's blood samples. Counterfeit pill consumption is a major public health hazard worthy of attention from the forensic toxicology community. Seventy-five cases from January 2020 to December 2022 serve as a convenience sample of cases where prescription pills including formulations of alprazolam, oxycodone and hydrocodone were specifically referenced during the death scene investigation as recently consumed, yet an unexpected substance was found during toxicological analysis rather than the expected pharmaceutical drug. Of note, novel benzodiazepines detected included flualprazolam, etizolam, clonazolam metabolite (8-aminoclonazolam), bromazolam, flubromazolam and desalkylflurazepam. Decedents' ages ranged from 16 to 69, across 33 different NC counties. Case notes indicated that eight of the decedents obtained pills through direct personal relationships, six decedents obtained them from "the street" and one decedent likely purchased pills online. Pills were largely consumed orally or through insufflation. Seven case reports contained indication that decedents knew or suspected the counterfeit nature of their pills. This study describes the context and characteristics of 2020-2022 suspected counterfeit pill-involved deaths in NC to further the understanding of the forensic science community, law enforcement partners, public health stakeholders and those potentially at risk through the consumption of counterfeit pills.

Endogenous carbon monoxide due to hemolytic anemia: A forensic red herring.

Carbon monoxide (CO) toxicity associated with exposure to an environmental, exogenous source, is routinely investigated in the field of forensics. Paramedics responded to the home of a 60-year-old woman who complained of persistent nausea, dizziness, and fatigue. Her initial carboxyhemoglobin (COHb) saturation was 25% as measured by paramedics in the field via pulse CO-oximetry (SpCO) and was, 2 hours later, confirmed by hospital laboratory spectrophotometric analysis to be 16% after initial treatment in the emergency department. The clinical presentation of environmental CO exposure and subsequent death notification to the North Carolina Office of the Chief Medical Examiner prompted an extensive investigation into the suspected residential source of CO, which ultimately ruled out all exogenous sources. The medicolegal death investigator later discovered an updated hematology consultation note, which determined the actual source of the CO to be endogenously produced from disease. Herein, we report an unusual fatality involving enhanced endogenous CO production caused by warm autoimmune hemolytic anemia. This unique case report and brief literature review of disease-related elevation of endogenous CO will shed light on this lesser-known phenomenon alerting the forensic community to its potential occurrence and need for consideration when sources of environmental exposure have been exhausted.