competent interpretation of pm bac & use of alternative ... · coroner called to scene, doa,...
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Competent Interpretation of PM BAC & Use of Alternative Matrices
ACMT ASMHuntington Beach, CA
March 17, 2016
Michael G. Holland, MD, FAACT, FACMT, FACOEM, FACEPAssociate Professor, SUNY Upstate Medical University
Consulting Medical Toxicologist, Upstate New York Poison Center, Syracuse, NYOccupational Medicine Director, Glens Falls Hospital Center for Occupational Health; Glens Falls, NY
Senior Medical Toxicologist, Center for Toxicology and Environmental Health; North Little Rock, AR
Ethanol Case #1 SF, 38 yo WF, had 3 drinks & meal over 2 hrs On drive home failed to negotiate a curve Struck a light post, SF ejected (no SB), flew
30 feet into building wall Suffered massive thoracoabdominal/head
injuries Coroner called to scene, DOA, examined body Collected PM specimens, released to FH
Ethanol Case #1 PM alcohol 0.268g% by State Police Crime
Lab Family brings Dram shop lawsuit vs. bar
owner– Allege improperly served her too much alcohol– Proximate cause of her death
Bartender testifies served 3 standard rum & cokes (one shot, i.e. 1.25 oz rum per drink)
Pt weight (145 lb), and 3 standard drinks over 2 hrs does not seem to correlate
Ethanol Case #2 AJ, 47 yo male, motorcycle accident
~ 6/17/05 in south Texas, missing for 3+ days
Body and cycle found by squirrel hunters down roadside embankment 6/20/05
Autopsy performed 6/21/05
Ethanol Case #2 Body extremely bloated, Severe decompositional
Δ’s: – blisters, green-tan skin discoloration, extensive skin
slippage & sloughing– All cavities contain gas and decomposition fluid &
severe decomposition odor– All organs show extensive decomposition, but no
other abnormalities Fx neck C1-2 Cause of death: C-spine fx & spinal cord
transection Manner of death: accident
Case #2 Toxicology Specimens sent to forensic lab Lab report: Heart blood specimen
– Ethanol 0.09g/dL– Methanol ND– N-propanol +– Acetone +– Drugs of abuse ND
No urine or vitreous sampling done
Case #3: Alcohol
DS, 38 yo male went fishing alone in a small boat spring 2006 in Minnesota.
Empty boat washed up on a nearby shore a day later.
Body was found (no life vest) by dredging the lake, and was promptly refrigerated.
Autopsy revealed a COD: drowning; MOD: accident
Case #3: Alcohol
Peripheral BAC of 0.20 g%, other volatiles were negative;
Vitreous ethanol 0.24g%; Urine ethanol 0.24 g%. Insurance death benefits denied due to
alcohol intoxication; family appeals the decision, claiming he does not drink alcohol, and post-mortem alcohol production was the cause.
PMR and/or quality of results also depends on:
Manner of death- trauma Stomach contents Conditions of storage of body- refrigeration Amount of decomposition/putrefaction Storage of blood: temp., preserv (NaF)., time Type of blood tube (Li) Site of blood sample- C vs. P; ligated? Method of blood sampling (i.e. blind stick) Interpretation depends on type of blood
tested: serum (plasma) v whole blood
Post-Mortem Ethanol Production
Ethanol produced from fermentation of blood glucose & lactate
Begins only after at least 2 days of decomposition through ≈ day 10
Bacteria, yeast, Candida all can ferment Generally levels produced are < 50mg/dL
(0.05gm%)– Although levels of 200mg% (0.20gm%) have
been reported
Post-Mortem Ethanol Production When fermentation does occur, other volatiles are also
produced:– Methanol, n-propanol, acetaldehyde, acetone
Simultaneous urine, VH testing can distinguish– VH [EtOH] lags behind BAC, avg. 0.9-1.3 x BAC– Caveat: urine in DM can have higher PM EtOH production
Cocaethylene NOT produced via this mechanism Ethyl glucuronide (ETG)
– Used to monitor abstinence, present for 4-5 days post-ingestion– NOT produced by fermentation– Quandry: is +ETG due to acute intoxication, or just recent use
Method of sampling Blind chest stick to obtain blood
– Most often by local coroners (often morticians, not MD’s)
– Cardiac blood or great vessels– Contaminated with gastric contents, esp.
with thoracoabdominal trauma– Can markedly elevate ethanol, drug levels
if recently ingested
Alternative Matrices:Vitreous Humor Sampling VH Essentially 98% water with salt solution Very little protein Very isolated, not subject to PMR Useful when blood is not acceptable or
available– Severely burned bodies– Exsanguinating trauma – Extensive decomposition: VH can remain sterile
Vitreous Humor
Lags behind BAC Usually BAC is < VAC since most deaths occur
in post-absorptive, metabolizing phase of BAC-time curve
Occasionally BAC > VAC, indicating death occurred during rising arm of BAC-t curve
Very useful for corroborating BAC values Especially useful when blood is not available,
or to confirm or dismiss PM fermentation
Urine Alcohol
Usually 25% higher than BAC (wide variability)
More prone to PM fermentation than WB, especially DM- EtS & EtG can discriminate
Useful for corroborating BAC & VHAC values Especially useful when blood is not available,
or to confirm or dismiss PM fermentation
Cavity Blood Alcohol Testing
WB collected from hemothorax, hemoperitoneum
Very prone to dilution, contamination from gastric/intestinal spillage
Worst possible specimen for PM tox Useful only for qualitative Should always prompt VH, urine testing
Other Specimens for BAC Testing
Subdural/Epidural hematoma blood Isolated from general circulation, no metabolism Acts as a snapshot of BAC at time of head trauma Can be tested days later
Skeletal muscle alcoholNext most preferred/accurate specimen when WB,
VH, Urine not available Fair estimate of BAC at time of death
Conclusion of Ethanol Case #1 3 drinks in 145 lbwould give BAC of 116mg% if
100% absorption, no metabolism– Cb= Dose/(Vd)(wt in kg)= (3x14)/(0.55 x 66)– Approx 86mg% if over 2 hrs
Avg female needs 4 drinks to achieve BAC 0.08g% Family alleges bartender lying to protect himself, that
drinks with double the alcohol would predict this BAC– 172-232mg% if 3 “doubles” were served, with complete
absorption, no metabolism Any other explanation? Important Issues?
Conclusion of Ethanol Case #1 Coroners record: blood obtained via transthoracic No autopsy; “severely traumatized body”: DOA Very possible gastric rupture/spillage
– 3 drinks, MVA a few minutes after leaving bar– Transthoracic specimens notorious for gastric alcohol
contamination1
This could explain BAC higher than what was predicted
Settled out of court, no details on award
1. Winek. Forensic Sci Int. 1995 Jan 21;71(1):1-8.
Ethanol Case #2 Conclusion Due to severe decomposition, PM ethanol
fermentation very possible– Appropriate temperature, lag time, conditions– Positive co-volatiles found:
N-propanol, acetone Indicates + PM fermentation Heart blood more susceptible- earlier bacterial contamin.
– This means fermentation did take place Conclusion: Ethanol may be all due to PM
fermentation Without VH alcohol, unable to conclude DWI
Case #3: Recap:
Peripheral BAC of 0.20 g%, other volatiles were negative
Vitreous ethanol 0.24g%
Urine ethanol 0.24 g%
Alcohol Case#3
Body properly handled, stored Specimens appropriately obtained &
analyzed Alcohol in peripheral blood corroborated
by levels in VH, urine Conclusion:
– Acute alcohol intoxication despite family contention that he does not drink
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