ABSTRACT
La autopsia médico legal en Costa Rica, en casos sospechosos de intoxicación por cocaetileno se debe realizar bajo las normas establecidas en la Guía de estándares de trabajo para la Sección de Patología Forense del Departamento de Medicina Legal. El análisis del mecanismo fisiopatológico de cómo estas sustancias provocan alteraciones en el organismo que pueden conllevar a un eventual fallecimiento corresponde a parte del análisis requerido en la investigación ante la sospecha de esta causa de muerte. Por lo anterior, el objetivo de este artículo es describir los mecanismos fisiopatológicos que ocurren durante el consumo combinado de cocaína y etanol, los mecanismos que conllevan a la muerte de personas consumidoras de estas sustancias y las consideraciones médico legales a tomar en cuenta para el diagnóstico de esta causa de muerte. Se realizó revisión de artículos científicos, sobre los efectos del uso combinado de la cocaína y el etanol. La literatura describe que el uso combinado de cocaína y etanol potencia los efectos farmacocinéticos y bioquímicos de cada una de estas sustancias, que su derivado, el cocaetileno, es capaz de generar por sí mismo los mecanismos causantes de la muerte. Que los principales mecanismos fisiopatológicos que conllevan la muerte ante el uso combinado de estas sustancias son de origen cardiovascular y hepático. Como consideraciones médico legales a tomar en cuenta para el diagnóstico de esta manera de muerte accidental, en la Sección de Toxicología del Departamento de Ciencias Forenses de Costa Rica, la cuantificación del cocaetileno y las sustancias relacionadas no se realiza, aunque se encuentra actualmente en el desarrollo de un proyecto para la determinación de la estabilidad de las drogas en sangre bajo las condiciones de almacenamiento, con el fin de ofrecer la posibilidad de cuantificar ciertas drogas (en donde se podría incluir el cocaetileno) en un futuro próximo.
Medical-legal autopsy in Costa Rica, in suspected cases of cocaethylene poisoning must be performed under the regulations established in the Work Standards Guide for the Forensic Pathology Section of the Department of Legal Medicine. The analysis of the pathophysiological mechanism of how these substances cause alterations in the organism that can lead to eventual death corresponds to part of the analysis required in the investigation when this cause of death is suspected. Therefore, the objective of this article is to describe the pathophysiological mechanisms that occur during the combined consumption of cocaine and ethanol, the mechanisms that lead to the death of people who consume these substances, and the medico-legal considerations to be considered for the diagnosis. of this cause of death. A review of scientific articles was carried out on the effects of the combined use of cocaine and ethanol. The literature describes that the combined use of cocaine and ethanol enhances the pharmacokinetic and biochemical effects of each one of these substances, that its derivative, cocaethylene, can generate the mechanisms that cause death by itself. That the main pathophysiological mechanisms that lead to death in the combined use of these substances are of cardiovascular and hepatic origin. As legal medical considerations to take into account for the diagnosis of this type of accidental death, in the Toxicology Section of the Department of Forensic Sciences of Costa Rica, the quantification of cocaethylene and related substances is not carried out, although it is currently in the development of a project for the determination of the stability of drugs in blood under storage conditions, in order to offer the possibility of quantifying certain drugs (which could include cocaethylene) in the near future.
Subject(s)
Humans , Cause of Death , Cocaine/adverse effects , Ethanol/analysis , PoisoningABSTRACT
As intoxicações decorrentes do uso de drogas de abuso representam atualmente um grave problema para a saúde pública. Dentre os principais agentes envolvidos, destaca-se a cocaína. Ela se tornou uma das drogas mais consumidas ao redor do mundo, sendo um dos principais motivos de atendimentos em pronto-socorro (PS) devido ao uso de substâncias ilícitas. Seu uso ocorre principalmente em associação com bebida alcóolica. Existem poucos estudos realizados que relacionem a concentração sanguínea de cocaína e a gravidade das manifestações clínicas em populações que a utilizam como droga de abuso, e que envolvam pacientes atendidos em PS. O objetivo do presente estudo foi verificar a possível relação entre concentração sanguínea de cocaína e cocaetileno (produto da interação de cocaína com etanol) com a gravidade das manifestações clínicas apresentadas por pacientes com hipótese diagnóstica de intoxicação por cocaína. As concentrações sanguíneas foram determinadas por cromatografia líquida de alta eficiência (HPLC) e a gravidade das manifestações clínicas foi avaliada através do Stimulant Intoxication Score (SIS). Dos 81 pacientes incluídos no estudo 77,8% são homens com idade média de 32,5 anos ± 8,5 e SIS médio de 3,4 ± 2,5. Do total de pacientes incluídos no estudo 20 (24,7%) tiveram resultados positivos em sangue para os analitos de interesse, sendo a concentração sanguínea média de cocaína igual a 0,34 µg/mL ± 0,45 e de cocaetileno igual a 0,38 µg/mL ± 0,34. A concentração sanguínea de cocaína e cocaetileno não se mostrou informação útil para tratamento e prognóstico dos pacientes, porém a detecção no sangue destas substâncias no momento do atendimento, independentemente de sua concentração, pode ser um indicador de gravidade, mostrando que quaisquer concentrações destas substâncias devem ser consideradas potencialmente tóxicas. A aplicação do score SIS revelou-se como importante alternativa capaz de predizer a gravidade dos pacientes atendidos devido a intoxicação por cocaína de maneira rápida e simplificada
Currently, poisoning resulting from the abuse of drug represents a serious problem for public health. Among the main agents involved, cocaine stands out. It became one of the most abused drugs around the world, being one of the main reasons for visits to the emergency room due to the use of illicit substances. The use of cocaine is primarily in combination with alcoholic beverages. There are few studies that relate cocaine blood concentration and the severity of its clinical manifestations in patients attended in the Emergency Room. The aim of the present study was to verify the possible relationship between the blood concentration of cocaine and cocaethylene (product of the interaction of cocaine with ethanol) with the severity of the clinical manifestations presented by patients with cocaine intoxication. Blood levels were measured by high-performance liquid chromatography (HPLC) and the severity of clinical manifestations was assessed using the Stimulant Intoxication Score (SIS). Of the 81 patients included in the study, 77.8% were men with a mean age of 32.5 years ± 8.5 and mean of SIS 3.4 ± 2.5. From the total of patients included in the study 20 (24.7%) had positive blood results for the analytes of interest, being the mean blood concentration of cocaine equal to 0,34 µg/mL ± 0,45 and of cocaethylene equal to 0,38 µg/mL ± 0,34. The blood concentration of cocaine and cocaethylene has not been shown to be useful information for the treatment and prognosis of patients, but blood levels of these substances at the time of treatment, regardless of their concentration, may be an indicator of severity, showing that any concentrations of these substances should be considered as potentially toxic. The application of the SIS score proved to be an important alternative capable of predicting the severity of the patients attended due to cocaine intoxication in a fast and simplified way
Subject(s)
Humans , Male , Adult , Cocaine/adverse effects , Alcoholic Beverages/adverse effects , Blood Circulation/drug effects , Chromatography, High Pressure Liquid/methods , Substance-Related Disorders , ToxicokineticsABSTRACT
La interacción constante del organismo humano con diferentes sustancias, que incluso en muchas ocasiones se consideran inofensivas, tiene un alto impacto sobre todos los sistemas, siendo el cardiovascular uno de los más afectados. Por lo tanto, es vital reconocer los mecanismos por los cuales estas sustancias ejercen su efecto tóxico sobre este sistema, bien sea afectando la estabilidad de membrana y la función contráctil o generando disfunción de organelos intracelulares y estrés oxidativo. Numerosos estudios han descubierto efectos lesivos de sustancias, como la clozapina y las catecolaminas, que han tenido amplio uso durante largos años. En la actualidad aún se realizan investigaciones que buscan esclarecer los mecanismos cardiotóxicos de medicamentos de formulación común, entre ellos antineoplásicos y anti-inflamatorios no esteroideos (AINE), así como de sustancias de uso habitual que causan adicción, tales como alcohol, cocaína y cocaetileno, su metabolito activo.
The constant interaction of the human body with different substances that are even in many cases considered harmless has a high impact on all systems, being the cardiovascular system one of the most affected. Therefore, it is vital to recognize the mechanisms by which these substances exert their toxic effect on this system, either affecting the membrane stability and the contractile function, or generating intracellular organelles dysfunction and oxidative stress. Numerous studies have found that drugs which have been widely used for many years such as clozapine and catecholamines, have harmful effects. Research is still being done seeking to clarify the cardiotoxic mechanisms of drugs commonly formulated, including anticancer and non steroidal anti-inflammatory drugs (NSAIDs), as well as commonly used substances that cause addiction, such as alcohol, cocaine and cocaethylene, its active metabolite.