Cause and manner of death in fatalities involving methamphetamine.

We reviewed a series of deaths in which methamphetamine was detected in the decedent's blood. Analysis of postmortem whole blood was performed by gas chromatography/mass spectrometry with a limit of quantitation of 0.05 mg/L. Methamphetamine was detected in 146 cases; 52 were drug caused, i.e., a death in which the direct toxic effects of the drug caused or contributed to the death, 92 were classified as drug related, i.e., a death in which the drug was demonstrated in the blood, but did not directly cause death. A large proportion of the deaths resulted from homicidal (27%) or suicidal (15%) violence. An examination of methamphetamine concentrations in drug related deaths (n = 92), suggests that the range of concentrations in the recreational abusing population is substantial (0.05-9.30 mg/L) but with a median concentration of 0.42 mg/L, and with 90% of that population having concentrations less than 2.20 mg/L. There was substantial overlap in methamphetamine concentration between drug related deaths and drug caused deaths, although the highest concentrations were seen in the unintentional (accidental or undetermined) drug caused deaths. Methamphetamine related traffic deaths (n = 17) showed patterns of driving behavior consistent with reports elsewhere, and showed blood methamphetamine concentrations ranging from 0.05-2.60 mg/L (median 0.35 mg/L). The data show that most methamphetamine deaths occur with blood concentrations greater than 0.5 mg/L, but can occur with levels as low as 0.05 mg/L, though usually in conjunction with other drugs or significant natural disease. Neither apparently toxic nor therapeutic concentrations should be used in isolation to establish conclusively whether a death was caused by methamphetamine; proper classification of deaths involving methamphetamine requires complete death investigation, including investigation of the scene and circumstances of death, and a complete autopsy.

Cervical spine MRI in abused infants.

OBJECTIVE: To determine clinical utility of screening with cervical spine MRI to detect unsuspected cord injury in children with head injury from child abuse. DESIGN: Prospectively collected case series. Setting-Tertiary care children's hospital and county medical examiner's office. PATIENTS: Twelve children with intracranial injury secondary to child abuse. None was clinically suspected to have cord injury. Includes all eligible children whose attending felt: (a) needed follow-up cranial imaging: (b) could be safely imaged; and (c) whose caretakers consented between November, 1991 and September, 1994. INTERVENTIONS: MRI scans of the cervical spine were obtained either more than 3 days after clinical presentation or postmortem. MAIN OUTCOME MEASURES: Clinical observations by neurologist, child protection team pediatrician and medicinal examiners by prospective protocol. MRI scans evaluated by prospective radiology protocol with emphasis on cervical cord injury. RESULTS: Four of the five autopsied children had small subdural or subarachnoid hemorrhages at the level of the cervical spine; MRI scan did not identify them. MRI did not identify cord injury in any child studied. CONCLUSION: Routine cervical spine MRI scans are probably not warranted in children with head injury secondary to child abuse without clinical symptoms of cervical cord injury.

Three fatal drug overdoses involving bupropion.

Bupropion is a "second generation" antidepressant agent structurally related to the phenethylamines. Postmortem toxicology data are presented from three suicidal drug overdoses in which bupropion was detected. In two cases in which bupropion was the major toxicology finding, peripheral blood levels of the parent drug were 4.0 and 4.2 mg/L and total metabolite levels were 15 and 16.6 mg/L. Lethal doses in both cases were estimated by history to be less than 10 g.

Invasive Haemophilus influenzae infections in older children and adults in Seattle.

We recently saw two unusual manifestations of Haemophilus influenzae infection in adults in the Seattle area: fulminant sepsis in an otherwise-healthy man and three episodes of bacteremia in a woman with chronic liver disease. We retrospectively identified 79 bacteremic and 40 non-bacteremic cases of invasive H. influenzae infection developing in patients > or = 9 years of age between 1 January 1980 and 31 December 1990. The most common clinical presentations among patients with bacteremia included pneumonia (52%), septicemia (27%), meningitis (8%), gynecologic infection (5%), and epiglottitis (5%). Underlying illnesses were common in these patients, and overall mortality was 35.5%. Factors associated with mortality included underlying neurological disease, polymicrobial bacteremia, and advanced age. The clinical presentations of the 40 patients without bacteremia included soft-tissue abscesses (45%), lung abscesses (18%), peritonitis (13%), meningitis (8%), gynecologic infection (8%), epididymitis (5%), mastoiditis (3%), and osteomyelitis (3%). Thus H. influenzae disease has a variety of presentations and is associated with significant mortality in older children and adults. Further study is required to determine whether widespread administration of H. influenzae type b conjugate vaccine to infants will alter the development of subsequent disease in later life.

The magnitude of acute and chronic alcohol abuse in trauma patients.

OBJECTIVE: To assess the incidence of acute alcohol intoxication and the proportion of trauma patients with evidence of chronic alcohol abuse. DESIGN: Prospective cohort study. SETTING: Regional level I trauma center. PARTICIPANTS: Patients aged 18 years and older admitted with blunt or penetrating trauma. MAIN OUTCOME MEASURES: Admission blood alcohol concentrations (BACs), the Short Michigan Alcohol Screening Test (SMAST), and biochemical markers for chronic alcohol abuse. RESULTS: Of the 2657 patients enrolled, 47.0% had a positive BAC and 35.8% were intoxicated (BAC > or = 100 mg/dL) on admission to the emergency department. Intoxicated patients were more likely to be 25 to 34 years old, male, and nonwhite; the highest proportion of intoxicated patients was among victims of stab wounds. Three fourths of acutely intoxicated patients had evidence of chronic alcoholism as indicated by a positive SMAST, and 25% to 35% of acutely intoxicated patients had biochemical evidence of chronic alcohol abuse. CONCLUSIONS: The high prevalence of both acute intoxication and chronic alcoholism in trauma patients indicates the need to diagnose and appropriately treat this pervasive problem in trauma victims.

The effect of acute alcohol intoxication and chronic alcohol abuse on outcome from trauma.

OBJECTIVE: To determine the effect of acute alcohol intoxication and chronic alcohol abuse on morbidity and mortality from trauma. DESIGN: Prospective cohort study. PATIENTS: Blunt or penetrating trauma patients at least 18 years of age admitted to one trauma center or dying at the injury scene. MAIN OUTCOME MEASURES: Mortality, complications (infection, pneumonia, respiratory failure, or multiple organ failure), and length of hospital stay. RESULTS: Acute intoxication had no effect on risk of dying--at the injury scene, within the first 24 hours of hospitalization, after the first 24 hours, or overall. Acute intoxication also did not increase the risk of complications and was associated with shorter lengths of stay. Patients with both biochemical and behavioral evidence of chronic alcohol abuse had a twofold increased risk of complications, particularly pneumonia and any infection, compared with those with no evidence of chronic alcohol abuse. CONCLUSIONS: Chronic, but not acute, alcohol abuse adversely affects outcome from trauma. Attention to the problem of chronic alcohol abuse in trauma patients is necessary, and screening trauma patients for chronic alcohol abuse appears to be warranted.

Confirmation of human identification using computerized tomography (CT).

Computerized tomography (CT) was used to assist in confirming a human identification. The potential utility of comparing lateral scout views and lateral skull X-rays for identification purposes is proposed. Antemortem CT scans with scout views of the human skull are useful for comparison with postmortem radiographs and should be considered as a potential modality for establishing definitive identification when antemortem radiographs are not available.

The use of antibodies targeted against the neurofilament subunits for the detection of diffuse axonal injury in humans.

Axonal injury is a common feature of human traumatic brain injury. Typically, damaged axons cannot be recognized unless a patient survives the injury by at least 10-12 hours (h). Limitations associated with the use of the traditional silver methods have been linked with this inability to recognize early posttraumatic reactive axonal change. Recently, we reported that antibodies targeting the neurofilament subunits proved useful in recognizing early traumatically induced axonal change in traumatically brain-injured animals. Accordingly, in the present communication, we employed antibodies to detect at the light microscopic level the 68 kD Nf-L and 170-200 kD Nf-H neurofilament subunits in head-injured patients who survived the traumatic event for periods ranging from 6 h to 59 days. Antibodies targeting all of the above-described subunits revealed a progression of reactive axonal change. Antibodies to the 68 kD subunit proved most useful, as they were not complicated by concomitant immunoreactivity in surrounding nuclei and/or dendritic and somatic elements. These immunocytochemical strategies revealed, at 6 h postinjury, focally swollen axons which appeared intact. By 12 h, this focal swelling had progressed to disconnection, with the immunoreactive swelling undergoing further expansion over 1 week postinjury. These findings demonstrate the utility of the previously described immunocytochemical strategies for detecting reactive axonal change in brain-injured humans, particularly in the early posttraumatic course. More importantly, these methods also demonstrate in humans that reactive axonal change is not necessarily caused by traumatically induced tearing.

Suicide in the home in relation to gun ownership.

BACKGROUND: It has been suggested that limiting access to firearms could prevent many suicides, but this belief is controversial. To assess the strength of the association between the availability of firearms and suicide, we studied all suicides that took place in the homes of victims in Shelby County, Tennessee, and King County, Washington, over a 32-month period. METHODS: For each suicide victim (case subject), we obtained data from police or the medical examiner and interviewed a proxy. Their answers were compared with those of control subjects from the same neighborhood, matched with the victim according to sex, race, and age range. Crude and adjusted odds ratios were calculated with matched-pairs methods. RESULTS: During the study period, 803 suicides occurred in the two counties, 565 of which (70 percent) took place in the home of the victim. Fifty-eight percent (326) of these suicides were committed with a firearm. After excluding 11 case subjects for various reasons, we were able to interview 80 percent (442) of the proxies for the case subjects. Matching controls were identified for 99 percent of these subjects, producing 438 matched pairs. Univariate analyses revealed that the case subjects were more likely than the controls to have lived alone, taken prescribed psychotropic medication, been arrested, abused drugs or alcohol, or not graduated from high school. After we controlled for these characteristics through conditional logistic regression, the presence of one or more guns in the home was found to be associated with an increased risk of suicide (adjusted odds ratio, 4.8; 95 percent confidence interval, 2.7 to 8.5). CONCLUSIONS: Ready availability of firearms is associated with an increased risk of suicide in the home. Owners of firearms should weigh their reasons for keeping a gun in the home against the possibility that it might someday be used in a suicide.

Positional asphyxia during law enforcement transport.

Three cases of positional asphyxia are described that occurred while victims were in a prone position in rear compartments of police patrol cars. These deaths are attributed to positional asphyxia. Autopsy findings and specific scene and circumstantial correlations of the investigation are discussed with emphasis placed on the limitations of interpretation of the anatomic changes at autopsy.

Effects of alcohol intoxication on the initial assessment of trauma patients.

STUDY OBJECTIVES: To evaluate the influence of alcohol intoxication on the initial assessment and treatment of trauma patients. DESIGN: A prospective study of 2,237 trauma patients 18 years of age or older admitted to a Level I trauma center over a 19-month period. RESULTS: The study population was primarily male (78%) and white (73%) and had sustained blunt trauma (79%). One thousand fifty-three patients (47.1%) had positive blood alcohol concentration (BAC); median BAC in patients with any detectable alcohol was 179 mg/dL. When stratified by injury severity categories and compared with nonintoxicated (BAC less than 100 mg/dL) patients, intoxicated patients with an Injury Severity Score (ISS) of 1 to 15 were more likely to undergo the following: field and/or ED intubation (relative risk [RR], 2.22; 95% confidence interval [CI], 1.7 to 2.7); diagnostic peritoneal lavage (RR, 1.83; CI, 1.43 to 2.3); head computed tomography scanning (RR, 1.18; CI, 1.0 to 1.4); and intracranial pressure monitoring (RR, 1.41; CI, 0.74 to 2.7). The effects were less pronounced for those patients with an ISS of more than 15, except for intracranial pressure monitoring where patients with an ISS of more than 15 were 47% more likely to have intracranial pressure monitoring if intoxicated (RR, 1.47; CI, 1.2 to 1.9). CONCLUSION: Acute intoxication appears to alter the initial assessment of injury severity, resulting in an increased use of invasive diagnostic and therapeutic procedures.

Human atherosclerosis. III. Immunocytochemical analysis of the cell composition of lesions of young adults.

There have been only limited immunocytochemical studies of the cell composition of the early lesions of human atherosclerosis, and none that incorporate a comprehensive panel of antibodies to various cell types and subsets. The authors thus performed a prospective study of 27 lesions from 16 different individuals ranging in age from 15 to 34 years. These were all lesions that appeared grossly as slightly raised, yellow fatty streaks in the posterior ascending aorta, but on histologic examination had varying degrees of round-cell, spindle-cell, and foam-cell accumulation. Using a panel of antibodies, including monoclonal antibodies specific for smooth muscle cells [HHF35], human macrophages [HAM56], endothelial cells [monoclonal antibodies to F. VIII related antigen], lymphocytes [anti-CD45, anti-CD20, anti-CD45RO, anti-T-cell receptor], it was revealed that the predominant cell type in these early lesions was the smooth muscle cell, including the vast majority of the foam cells, which tended to appear in the deeper regions of the lesions. There were variable numbers of smooth muscle cells and lymphocytes; the latter were exclusively T cells. It is concluded that in atherosclerotic lesions of young adults, which may represent various stages of fatty streak formation and advanced fatty streaks, smooth muscle cell accumulation may be an early event.

Positional asphyxia in individuals with severe cerebral palsy.

The authors report the accidental death by positional asphyxia of three individuals with cerebral palsy occurring after they had been placed in bed for the night. During the five-year period between 1984 and 1989, 12 per cent of deaths from positional asphyxia in King County, Washington, involved individuals with cerebral palsy. Such accidents are similar to those occurring among healthy young children, perhaps because both groups have limited motor skills. Further research into accidents among disabled persons may clarify their special risks and possibly lead to modifications in bed design.

Death notification.

Family notification in sudden, unexpected, and violent death is a major responsibility of law enforcement, medical examiner, and coroner offices. This report reviews and discusses the process and procedures utilized in death notification and provides suggestions to accomplish this difficult task more effectively.

Atlanto-occipital disarticulation. Accident characteristics.

A retrospective study of cases of atlanto-occipital disarticulation was conducted to describe incident characteristics: 24 cases were identified, including nine motor vehicle drivers, two passengers, seven pedestrians, and five motorcyclists; one other person had fallen four stories. The highest rates were found among motorcyclists and pedestrians. Atlanto-occipital disarticulations occur in high-energy impacts and collisions and are associated with aortic laceration in 25% and basilar skull fracture in 21% of such cases. Current restraint systems and motorcycle helmets do not appear to prevent this generally rapidly fatal injury.

The epidemiology of traumatic rupture of the thoracic aorta in children: a 13-year review.

Traumatic rupture of the thoracic aorta (TRA) is a rare but highly lethal injury in children that occurs as a result of car versus pedestrian accidents and motor vehicle accidents. TRA is often associated with life-threatening injuries to other organ systems. Therefore children with TRA like adults sustaining TRA must be treated urgently but systematically. The rarity of this injury makes it all the more important for physicians treating pediatric trauma victims to be cognizant of the importance of the injury and the clinical and radiographic signs. Even when TRA is promptly recognized in children it is associated with a high in-hospital mortality. The proper use of child restraint systems and adherence to the 55 M.P.H. speed limit may be important factors in reducing the mortality of TRA in children after MVA.

Validating survey responses to questions about gun ownership among owners of registered handguns.

While survey-based data on firearm ownership are essential for epidemiologic studies of the relation between gun ownership and injuries, the validity of respondent answers to questions about gun ownership has not been confirmed. In order to assess the accuracy of interview data about firearms, in June to August 1987, the authors attempted to contact residents of 75 homes in the cities of Memphis, Tennessee and Seattle, Washington listed as the address of the owner of a recently registered handgun. Despite problems with inaccurate registration data, contact was ultimately made with 55 households, 35 of which consented to a general interview that included a series of questions about gun ownership. Respondents in 31 of these 35 households (88.6%) readily acknowledged that one or more guns were kept in their home. Respondents in three of the remaining four households (8.6%) stated that guns were recently kept in their homes but were no longer kept there. Only one respondent (2.9%) denied categorically that guns of any kind were kept in her home. The authors conclude that, at least among registered gun owners, respondent answers to questions about gun ownership are generally valid and that survey data of this type can be utilized with confidence.

Drug use in trauma victims.

We examined the prevalence and characteristics of drug use in a large sample of fatally and nonfatally injured trauma victims. Routinely collected urine specimens from 452 emergency room patients and 160 persons autopsied at the Medical Examiner's Office (MEO) were analyzed for the presence of marijuana, cocaine, opiates and benzodiazepines using EMIT enzyme immunoassays. Blood alcohol levels were also measured. Tests were positive for at least one drug in 40.3% of the ER and 18.7% of the MEO samples. Marijuana was the most commonly detected drug in both groups. Specimens were more likely to be positive in younger persons and in males, and in victims of assaults and traffic accidents. Alcohol was present in the blood in more than one third of ER and MEO samples. Only 39.8% of ER samples and 52.3% of MEO samples were negative for both alcohol and drugs.