Drug-Related and Toxin-Related Deaths

[gatagato]

Deaths related to drugs may be from recreational usage of illegal (‘‘street’’) drugs, or from deliberate or inadvertent misuse of over-the-counter (OTC) preparations, or prescription medications.

A particular problem in the elderly is therapeutic misadventure from the taking of incorrect dosages or the effects of polypharmacy (many drugs). Given there may be no indication of drug effect at autopsy, it is important to maintain a high level of suspicion and to perform forensic toxicology tests on postmortem blood (and/or other fluid or tissue) samples if there is the slightest suggestion of a toxicological problem.

It is a good practice for all autopsy cases to have routine samples taken and stored for a certain
period in case further information suggests that drugs may have contributed to or caused death, so that testing can then be performed.
In some offices, routine toxicology testing is performed on all cases.

Thus, several tubes of blood and urine should be collected (if possible) in every forensic case.
Forensic pathologists and death investigators should be very familiar with the types of drugs that are routinely tested for by their forensic toxicology laboratory.

Screening for toxins is a problem as the range of substances that may be toxic for humans is vast. Thus, although routine screens will identify many illicit and prescription drugs, for many other drugs and toxins the laboratory must be asked to specifically look for that particular substance.


Fig. 1
A drug-related death scene – in many cases, such as the one shown, it is obvious that drugs were involved in the death. Note the IV
(intravenous) tubing and drug paraphernalia


Fig. 2
When investigating any death scene, it is important to note the presence or absence of equipment used to take drugs


Fig. 3
Identification of alcohol bottles provides a relatively obvious clue that ethanol intoxication may have played a factor in death


Fig. 4
Death investigators should inventory all medicines present at the death scene


Fig. 5
The inventory at the scene of a suspected drug overdose should also include herbal substances and other potential toxins such as Amanita muscarina mushrooms. As well as being hallucinogenic, they are also highly toxic


Fig. 6
Datura arborea (Angel’s trumpets) is a plant which contains alkaloids with an atropine-like effect that may cause hallucinosis. Side effects include acute gastric dilatation and intense thirst


Fig. 7
In certain drug-related death scenes, there may be little or no indication that drug use played a role in death


Fig. 8
However, careful evaluation of the entire death scene (as in >Fig. 7), including areas away from the immediate vicinity of the body,
may reveal evidence of drug/toxin exposure


Fig. 9
A ‘‘dumped body,’’ found in an abandoned warehouse


Fig. 10
A closer view of the dumped body shown in >Fig. 9. Note the spoon next to the arm, and the syringe in the hand


Fig. 11
Drug paraphernalia found in the clothing of an overdose victim


Fig. 12
Two fresh needle puncture marks – these can be very subtle and difficult to detect, even with good lighting


Fig. 13
A recent injection site demonstrated by incising the skin overlying a large vein showing surrounding recent bleeding


Fig. 14
Track marks from intravenous narcotic injection


Fig. 15
Needle tracks and injection sites may be masked by tattoos


Fig. 16
An attempt to disguise an injection site in the cubital fossa with a tattoo depicting a magic mushroom, a marijuana leaf and a syringe was perhaps not the best choice for that purpose


Fig. 17
Needle tracks in an arm


Fig. 18
Another example of needle tracks


Fig. 19
Skin-popping scars on an arm


Fig. 20
Scars on the legs from skin popping


Fig. 21
Recent superficial wrist incisions in a suicidal overdose victim


Fig. 22
Vomit which is discolored yellow from the pills that were intentionally ingested by this suicide victim
Drug-Related and Toxin-Related Deaths 11 355


Fig. 23
Pill dye (pink-red) on the clothing of an overdose victim


Fig. 24
Cherry pink discoloration of the skin in a case of suicidal carbon monoxide inhalation


Fig. 25
Cherry pink discoloration of the skin of the hand in a case of suicidal carbon monoxide inhalation with healing wounds of the wrist from a previous recent suicide attempt


Fig. 26
Soot staining of the hand of a suicide victim who connected a pipe from the exhaust of his car to the cabin and succumbed to carbon monoxide toxicity


Fig. 27
Bilateral necrosis of the basal ganglia of the brain following survival for some time after carbon monoxide poisoning


Fig. 28
Pulmonary edema fluid exuding from the mouth, producing a so-called ‘‘foam cone’’ often seen with narcotic overdoses


Fig. 29
The belly of an obese individual who had a rather unique hiding/storage place for his crack cocaine (see >Fig. 30)


Fig. 30
Crack cocaine hidden/stored in the fold of skin/tissue underlying the sizeable anterior abdominal wall of the individual shown in >Fig. 29


Fig. 31
A long little fingernail, presumably utilized by the decedent during life for delivering powder forms of various drugs to the nostrils


Fig. 32
Gastric (stomach) mucosa (lining) discolored green by the pills used in an overdose


Fig. 33
Focal green discoloration of the intestines in a case where green-colored pills were used in an overdose


Fig. 34
An opened stomach at autopsy, showing residual gastric contents containing pill residue, along with two specimen containers that hold
the majority of the gastric contents. Note that a large amount of pill residue has settled toward the bottom of each container


Fig. 35
Intact tablets found in the stomach at autopsy in
a suspected drug overdose death


Fig. 36
Brain swelling in an overdose. This finding is ‘‘nonspecific,’’ meaning that it can occur in a variety of other situations, not just with drug toxicity


Fig. 37
A portion of the sigmoid colon opened at autopsy, revealing a foreign body composed of plastic cellophane material wrapped around numerous pills. The decedent had presumably ingested the material several days earlier


Fig. 38
The unwrapped plastic cellophane from >Fig. 11.37, with numerous oxycodone pills that were contained within the plastic. The
decedent died of a massive oxycodone overdose


Fig. 39
A toxicologist and a GC/MS machine


Fig. 40
Femoral blood collection at autopsy


Fig. 41
Postmortem bleeding in the lateral (side) aspects of the neck region, secondary to attempting to collect blood from the subclavian blood vessels. Such bleeding can cause difficulties in attempting to document the presence or absence of subtle neck injuries


Fig. 42
Urine collection at autopsy


Fig. 43
Cerebral spinal fluid (CSF) collection at autopsy, by
internal approach. After the organs of the trunk have
been removed, and before brain removal, CSF can be
withdrawn by an anterior (front) approach, using
a needle inserted into the spinal canal through an
intervertebral disk


Fig. 44
Bile collection from the gallbladder at autopsy


Fig. 45
Test tube rack of toxicology samples from an autopsy


Fig. 46
A case of cirrhosis due to excessive ethanol consumption with marked nodularity of the liver surface


Fig. 47
An example of commercially available antifreeze,
which contains ethylene glycol. Chronic alcoholics
sometimes ingest ethylene glycol because of its sweet,
ethanol-like flavor. Others use the poison for suicide


Fig. 48
Bright calcium oxalate crystals within the kidney in
a case of ethylene glycol poisoning


Fig. 49
A normal urine sample (left) compared to
a urine sample from someone who died of the
toxic effects of ethylene glycol (right), viewed
with a Wood’s lamp. Note the fluorescent
green-yellow color of the sample on the right


Fig. 50
A typical case of poor oral hygiene associated
with methamphetamine use (‘‘meth-mouth’’)


Fig. 51
Crack cocaine discovered in the pocket of a homicide victim


Fig. 52
A victim of cocaine-induced excited delirium. The victim experienced bizarre behavior, ‘‘superhuman’’ strength, paranoia, and
hyperthermia (hence the absence of clothing) prior to collapsing and dying


Fig. 53
A microscopic section of kidney, showing brown staining of myoglobin from skeletal muscle breakdown in a case of excited delirium with hyperthermia. Muscle meltdown occurs, with loss
of protein into the kidney tubules


Fig. 54
A crack pipe along with a disposable lighter


Fig. 55
An example of the ‘‘body packing syndrome,’’ wherein the stomach contains many condoms filled with illegal drugs.
The victim died of a massive overdose (Courtesy of the Dallas County Medical Examiners Office, Jeffrey J. Barnard, Chief Medical Examiner)


Fig. 56
Chronic intravenous drug abuse frequently introduces abundant foreign material into the bloodstream. This foreign material can become entrapped within the lungs, causing inflammation and scarring. The material is not readily visible in routinely stained histology
sections (Photo courtesy of Dr. Patrick E. Lantz, MD, Wake Forest University, Winston-Salem, NC)


Fig. 57
Using polarized light, the foreign material present within the lung shines brightly in>Fig. 11.56 is much more apparent
(Photo courtesy of Dr. Patrick E. Lantz, MD, Wake Forest University, Winston-Salem, NC)


Fig. 58
A markedly distended urinary bladder (arrows) in a victim of opiate toxicity. This finding is not specific for opiates and it can also be seen
with other drugs, most notably ethanol


Fig. 59
Black (or brown) tar heroin found in the clothing of a heroin overdose decedent


Fig. 60
A Fentanyl patch found within the gastrointestinal system of an individual who was abusing the drug


Fig. 61
Plastic wrap containing marijuana


Fig. 62
A block of compressed marijuana


Fig. 63
A decedent who was high on LSD when he jumped through a plate glass window, suffering lethal sharp force injuries (Courtesy of the Dallas County Medical Examiners Office, Jeffrey J. Barnard, Chief Medical Examiner)


Fig. 64
The gastric contents of a man who committed suicide by ingesting three entire bottles of Tylenol. Note the abundant pill residue within
the container


Fig. 65
Multiple subcutaneous insulin injection sites of the abdomen in a diabetic are different from the track marks of the arms of narcoticabusers


Fig. 66
A large ‘‘foam cone’’ exuding from the mouth and nose of an individual who died from inhalant abuse


Fig. 67
Paint on hands of an individual who died from inhaling paint fumes


Fig. 68
A readily available whipped cream container


Fig. 69
A close-up of the ingredients of thewhipped creamcontainer shown in>Fig. 68. Note that the whipping gas is nitrous oxide


Fig. 70
A commercially available nitrous oxide tank


Fig. 71
A man found dead in a laboratory, with a plastic
garbage bag over his head and face. He had been
abusing nitrous oxide (laughing gas)


Fig. 72
A small ‘‘foam cone’’ in the man depicted in
>Fig. 71


Fig. 73
An elderly woman was found dead in her home, which was filled with natural gas. A stove burner was in the ‘‘on’’ position, but the pilot light was extinguished


Fig. 74
A suicide death scene. The victim’s head is totally within a black garbage bag. Note that a hose connects the inside of the bag to a wallmounted natural gas supply


Fig. 75
Mixed hydrocarbons, such as gasoline, may be abused in a similar manner to other inhalants


Fig. 76
A child victim of gasoline inhalational abuse. Note the extensive pulmonary edema fluid on the face


Fig. 77
A can used to inhale gasoline at a scene with the decedent wrapped in blankets on the floor


Fig. 78
A man found in the back of his van, with his head/face within a clear plastic bag, which he had filled with Freon gas. Note the green Freon gas container in the foreground of the photograph


Fig. 79
A young man found dead in his residence. The scene findings shown in the accompanying image (>Fig. 80) clearly indicate the likely cause of death (Courtesy of the Dallas County Medical Examiners Office, Jeffrey J. Barnard, Chief Medical Examiner)


Fig. 80
Numerous empty containers of correction fluid (trichloroethane) and plastic bags utilized by the victim shown in>Fig. 79 (Courtesy
of the Dallas County Medical Examiners Office, Jeffrey J. Barnard, Chief Medical Examiner)


Fig. 81
A victim of a slow-speed, train versus pedestrian collision. The engineer claimed that the victim was ‘‘acting drunk’’ prior to being struck by the locomotive engine. Note the spray-paint can near the body. There was spray paint on the victim’s face and hands. Toxicology revealed the presence of toluene in his blood


Fig. 82
This young man was found dead in his apartment.
A plastic garbage bag and a helium tank were also present at the scene. The autopsy was negative


Fig. 83
The helium tank found at the scene of the individualshown in >Fig. 11.82


Source:

The Atlas of Forensic Pathology

for Police, Forensic Scientists, Attorneys and Death Investigators (2012)

References
Armstrong EJ, Engelhart DA, Jenkins AJ, Balraj EK. Homicidal ethylene glycol
intoxication – a report of a case. Am J Forensic Med Pathol. 2006;27:151–5.
Austin A, Winskog C, van den Heuvel C, Byard RW. Recent trends in suicides
utilizing helium. J Forensic Sci. 2011;56:649–51.
Baselt RC. Disposition of toxic drugs and chemicals in man. 7th ed. Foster City:
Biomedical Publications; 2004.
BatalisNI, PrahlowJA.Accidental insulin overdose. J Forensic Sci. 2004;49:1117–20.
Byard RW. The potential forensic significance of traditional herbal medicines.
J Forensic Sci. 2010;55:89–92.
Byard RW, Gilbert JD. Narcotic administration and stenosing lesions of the upper
airway – a potentially lethal combination. J Clin ForensicMed. 2005;12:29–31.
Byard RW,Musgrave I. Herbal medicines and forensic investigations. Forensic Sci
Med Pathol. 2010;6:81–2.
Byard RW, Gilbert J, James R, Lokan RJ. Amphetamine derivative fatalities in
South Australia - is "Ecstasy" the culprit? Am J Forensic Med Pathol.
1998;19:261–5.
Byard RW, Kostakis C, Pigou PE, Gilbert JD. Volatile substance use in sexual
asphyxia. J Clin Forensic Med. 2000;7:26–8.
Byard RW, Gilbert JD, Klitte A ° , Felgate P. Gasoline exposure in motor vehicle
accident fatalities. Am J Forensic Med Pathol. 2002a;23:42–4.
Byard RW, James RA, Felgate P. Detecting organic toxins in possible fatal poisonings
– a diagnostic problem. J Clin Forensic Med. 2002b;9:85–8.
Byard RW, Chivell WC, Gilbert JD. Unusual facial markings and lethal mechanisms
in a series of gasoline inhalation deaths. Am J Forensic Med Pathol.
2003;24:298–302.
Byard RW, Klitte A ° , James RA, Gilbert JD. Changing patterns of female suicides:
1986–2000. J Clin Forensic Med. 2004;11:123–8.
Byard RW, Gilbert JD, Terlet J. Death associated with volatile substance inhalation
– histologic, scanning electron microscopic and energy dispersive X-ray
spectral analyses of lung tissue. Forensic Sci Int. 2007;171:118–21.
Byard RW, Summersides G, Thompson A. Muscle pallor – a macroscopic marker
of cocaine-induced rhabdomyolysis. Forensic Sci Med Pathol (in press).
Caldicott DGE, EdwardsNA, Kruys A,Kirkbride KP, Sims DN, Byard RW, PriorM,
Irvine R. Dancing with ‘death’; P-methoxyamphetamine overdose and its
acute management. J Toxicol Clin Toxicol. 2003;41:143–54.
Caldicott DGE, Chow FY, Burns BJ, Felgate P, Byard RW. Fatalities associated with
the use of g-hydroxybutyrate and its analogues in Australasia. Med J Aust.
2004;181:310–3.
Denton JS, Donoghue ER, McReynolds J, Kalelkar MB. An epidemic of illicit
fentanyl deaths in Cook County, Illinois: September 2005 through April
2007. J Forensic Sci. 2008;53:452–4.
Drummer OH. The forensic pharmacology of drugs of abuse. London: Arnold;
2001.
Gill JR, Stajic M. Ketamine in non-hospital and hospital deaths in New York City.
J Forensic Sci. 2000;45:655–8.
Green H, James RA, Gilbert J, Harpas P, Byard RW. Methadone maintenance
programs – a two edged sword? Am J Forensic Med Pathol. 2000;21:359–61.
Hirsch CS, Adelson L. Ethanol in sequestered hematomas. Am J Clin Pathol.
1973;59:429–33.
Jentzen JM, Mont EK, Revercomb C. Volatiles and inhalants (chemical asphyxia)
(chapter 26). In: Froede RC, editor. Handbook of forensic pathology. 2nd ed.
Northfield: College of American Pathologists; 2003. p. 237–42.
Karch SB. Drug deaths (chapter 25). In: Froede RC, editor. Handbook of forensic
pathology. 2nd ed. Northfield: College of American Pathologists; 2003.
p. 231–6.
Kugelberg FC, Jones AW. Interpreting results of ethanol analysis in postmortem
specimens: a review of the literature. Forensic Sci Int. 2007;165:10–29.
National Institute on Drug Abuse. www.nida.nih.gov
O’Neal CL, Poklis A. Postmortem production of ethanol and factors that
influence interpretation – a critical review. Am J Forensic Med Pathol.
1996;17:8–20.
Pestaner JP, Southall PE. Sudden death during arrest and phencyclidine intoxication.
Am J Forensic Med Pathol. 2003;24:119–22.
Prahlow JA. Deaths due to animals, plants, and other natural environmental
hazards (chapter 37). In: Froede RC, editor. Handbook of forensic pathology.
2nd ed. Northfield: College of American Pathologists; 2003. p. 361–74.
Ruttenber AJ, Lawler-Heavner J, Yin M, Wetli CV, Hearn WL, Mash DC. Fatal
excited delirium following cocaine use: epidemiologic findings provide new
evidence for mechanisms of cocaine toxicity. J Forensic Sci. 1997;42:25–31.
Sheil AT, Collins KA, Schandl CA, Harley RA. Fatal neurotoxic response to
neuroleptic medications – case report and review of the literature. Am
J Forensic Med Pathol. 2007;28:116–20.
Shields LB, Hunsaker JC, Corey TS, Ward MK, Stewart D. Methadone toxicity
fatalities: a review of medical examiner cases in a large metropolitan area.
J Forensic Sci. 2007;52:1389–95.
Smialek JE, Spitz WU, Wolfe JA. Ethanol in intracerebral clot. Report of two
homicidal cases with prolonged survival after injury. Am J Forensic Med
Pathol. 1980;1:49–50.
Tse R, Sims N, Byard RW. Alcohol ingestion and age of death in hanging suicides.
J Forensic Sci. 2011;56:922–4.
Westveer AE, Trestrail JH, Pinizzotto AJ. Homicidal poisoning in the United
States: an analysis of the Uniform Crime Reports from 1980 through 1989.
Am J Forensic Med Pathol. 1996;17:282–8.
Wetli CV. Fatal cocaine intoxication. A review. Am J Forensic Med Pathol.
1987;8:1–2.
Wetli CV, Mittleman RE. The ‘body packer syndrome’ – toxicity following
ingestion of illicit drugs packaged for transportation. J Forensic Sci.
1981;26:492–500.
Wick R, Gilbert JD, Felgate P, Byard RW. Inhalant deaths in South Australia: a 20-
yeard retrospective autopsy study. AmJ ForensicMed Pathol. 2007;28:319–22.
Winston DC. Suicide via insulin overdose in nondiabetics: the New Mexico
experience. Am J Forensic Med Pathol. 2000;21:237–40.
www.drugfree.org
www.streetdrugs.org
www.whitehousedrugpolicy.gov/streetterms

[Sharon]

Really fantastic thread, informative and what people love

Sad incidents, these type.

[kellyhound]

Great info read
You're never too old to learn.

A long little fingernail, presumably utilized by the decedent during life for delivering powder forms of various drugs to the nostrils.

[spudigitti]

Great post fantastic

[DaFuq???]

It really makes me sad that life can become so unbearable that some people have to use drugs to find a bit of peace for themselves.
My heart goes out to them.
May they have that peace now...

[gimlet]

Picture 2, gotta have a well used Bible when you are using drugs...

[Broadjumper]

The shit people do yo themselves for a high...

[Broadjumper]

^^ TO themselves

[Lion-hearted Girl]

Great thread!

[BadmouthBetty]

Awesome post!