Forensic Pathology Findings in Stimulant Related Deaths

Transcription

1 Forensic Pathology Findings in Stimulant Related Deaths Mary G. Ripple, MD Deputy Chief Medical Examiner Office of the Chief Medical Examiner State of Maryland New OCME Building 900 West Baltimore Street, Baltimore, MD 1

2 STATISTICS 2008 Naturally Occurring Stimulants Cocaine Absinthe Caffeine Khat Ephedrine Pseudoephedrine 2

3 Synthetic Stimulants Amphetamine Methamphetamine Phenylpropanolamine Fenfluramine??Hallucination: PCP, MDMA????Inhalants?? Investigative findings Non-specific CDS and drug paraphernalia at scene Autopsy findings Non-specific Pulmonary fibrosis, pulmonary hypertension, and granulomas Cardiovascular abnormalities from catecholamine excess HIV Hepatitis 3

4 Stimulant Deaths Maryland 2006 to 2010 Cocaine intoxication around 100 deaths per year in the last five years Cocaine deaths have shown a decreasing trend Amphetamine - 3 deaths in last five years Methamphetamine - 1 death in last five years MDMA - 3 deaths in last five years Caffeine - 7 deaths in last ten years Pseudoephedrine - 3 deaths in last five years MDPV bath salts 1 death this year Cocaine Intoxication Deaths Maryland 2006 to 2010 Includes cocaine intoxication alone and combination with other drugs and excludes cocaine use deaths where drug was only in urine Cocaine 4

5 5

6 Autopsy findings cocaine Minimal findings Perforated nasal septum Cocaine tracks Crack keratitis Tooth enamel erosions Crack thumb and hands Skin popping marks 6

7 Wetli, Mittleman and Rao, An Atlas of Forensic Pathology, First Edition, ASCP Press,

8 Wetli, Mittleman and Rao, An Atlas of Forensic Pathology, First Edition, ASCP Press,

9 9

10 Wetli, Mittleman and Rao, An Atlas of Forensic Pathology, First Edition, ASCP Press,

11 Cardiovascular Effects of Cocaine Coronary artery disease Myocardial infarction Concentric intimal hyperplasia Vascular spasm Enlarged heart Contraction band necrosis Myofibosis Endocarditis Aortic dissection Phlebitis Sudden cardiac death Cardiovascular Effects of Cocaine Around 5 cases per year involving cardiovascular complications of cocaine intoxication including - Intracerebral Hemorrhage - Ruptured Berry Aneurysm - Aortic Dissection - Myocardial Infarction - HASCVD and ASCVD - Enlarged heart 11

12 25 yo WM with history of THC and cocaine abuse, sudden death with plaque erosion in proximal LAD and embolized thrombus 32 yo BM became unresponsive in police custody after ingesting unknown quantity of cocaine; extensive contraction band necrosis Brain Autopsy findings cocaine Hemorrhagic Stroke Vasculitis Subarachnoid hemorrhage Ruptured aneuyrsm Intraventricular hemorrhage 12

13 Wetli, Mittleman and Rao, An Atlas of Forensic Pathology, First Edition, ASCP Press, 1999 Wetli, Mittleman and Rao, An Atlas of Forensic Pathology, First Edition, ASCP Press,

14 Methamphetamine ( ICE ) Autopsy findings methamphetamine Meth mouth Cardiomyopathy Non-specific myofibrosis Pulmonary hypertension Pulmonary fibrosis and granulomas Stroke Subarachnoid hemorrhage 14

15 Autopsy findings Stroke Hypertensive sequelae Intracerebral hemorrhage Autopsy findings fenfluramine Pulmonary hypertension Bath Salts Bath Salts Sold as legal synthetic drug alternatives and marketed as bath salts, growth stimulator, PH optimizer, pond scum remover, and odorizers Pixie Dust, Ivory Wave, Bliss, Ocean, Charge Plus, White Lightening, White Rush, White Girl, Scar Face, Hurricane Charlie, Vanilla Sky, Bonzai Grow, Blue Silk, Lovey Dovey, Cloud Nine, Euphoria, Aura, Zoom 2, Red Dove, and White Dove Also some plant foods Mephedrone or Methylenedioxypyrovalerone (MDPV) Norepinephrine-dopamine reuptake inhibitor 15

16 Bath Salts Snort, inject or smoke the powders Is also absorbed through the skin Parent drug Cathinone from African plant Khat CNS stimulant with amphetamine and methamphetamine-like effects Hallucinations Paranoia Tachycardia Increased BP Suicidal thoughts Psychosis Excited delirium Some states have banned their sale Bath Salts first reported death in MD 4/13/11 39 yo WM with history of depression, back pain, drug and alcohol abuse Was emergency petitioned by family Found outside wandering, talking to self, dressed inappropriately for the weather and delusional Tachycardic on admission to hospital with temp of F Hospital urine tox positive for benzodiazepines and PCP Postmortem blood positive for MDPV, promethazine and diphenhydramine and bile positive for the above plus diazepam, nordiazepam and salicylate Excited Delirium (ED) First documented in 1849! Acute delirium with disorientation and disorganized, inconsistent thought processes, and inability to distinguish reality from hallucination. Associated with combative and/or violent behavior and sometimes the use of restraint. Autopsy fails to reveal evidence of sufficient trauma or natural disease to explain death. DiMaio TG and DiMaio VJM Excited Delirium Syndrome: Cause of Death and Prevention CRC Taylor & Francis New York,

17 Excited Delirium Most are under the influence of illegal stimulants, such as amphetamine, cocaine or phencyclidine (PCP). There can be an associated increase in core body temperature. It can be seen in persons with psychiatric illnesses who experience an acute psychotic episode. Occurs across a dynamic spectrum. It starts, gets worse, and the person can die. The vast majority are caught early and are treated and they don t die. Law enforcement gets to these cases when they are at their worst. If late in the spectrum, they are probably going to die. If resuscitation is started after it is severe or in cardiopulmonary arrest, these people usually do not survive. Excited Delirium Cessation of struggling is an ominous event. Usually die within 1 hour of first contact with police. 75% die at the scene or during transport. Unsure of the mechanism of death. Respiratory arrest appears to occur first. Death may be due to a cardiac arrhythmia due to stress on the heart from catecholamine release and/ or increased oxygen demand. Medical emergency - must sedate and intubate as soon as possible. Excited Delirium Typical Scenario Acute onset Mental health issues Excited, emotional changes, extreme agitation Delusional, confused, disoriented, distracted Hallucinate Insensitive to pain/superhuman strength Aggression toward objects (glass or mirrors) Large belly, loud incoherent speech, screaming Strip off clothing Sweat profusely Intense paranoia 17

18 Doctors Disagree ED or No ED The bible of psychiatry (DSM-IV) does not recognize ED International Classification of Diseases only mentions something similar to ED Certain heart rhythms are unique to ED Recent research shows brain abnormalities in people exhibiting ED AMA at CSAPH in June 2009 and ACEP in October 2009 finally acknowledged the existence of excited delirium Excited Delirium There have been cases of excited delirium which resulted in death with and without TASER use. There have been 17 deaths involving the use of a TASER in MD in the last 7 years and 10 of them involved excited delirium syndrome. Toxicology CED Involved Deaths with Excited Delirium Case Urine Heart Blood 1 N/A 0.18% w/v ethanol, (0.23% w/v vitreous) 2 Cocaine & Metabolites, Diltiazem 0.3 mg/l Cocaine, 2.4 mg/l Benzoylecgonine 3 Citalopram 0.1 mg/l Citalopram 4 Cocaine & Metabolites, Morphine 0.1 mg/l Cocaine, 0.7 mg/l Benzoylecgonine 5 Phencyclidine 0.4 mg/l Phencyclidine 6 Cocaine & Metabolites, Diltiazem, Quinine, Lidocaine, Hydroxyzine, Diphenhydramine, Morphine, 6-MAM 0.3 mg/l Cocaine, 5.3 mg/l Benzoylecgonine, 0.1 mg/l Hydroxyzine, 40 mcg/l Morphine 7 Lamotrigine, Quetiapine 1.5 mg/l Lamotrigine 8 Cocaine & Metabolites, Diltiazem, Quinine, Lidocaine, Hydroxyzine, Methadone & Metabolites, Morphine, 6-MAM, Cyclobenzaprine 0.3 mg/l Cocaine, 3.6 mg/l Benzoylecgonine, 0.5 mg/l Hydroxyzine, 34 mcg/l Morphine, 0.06 mg/l Cyclobenzaprine 9 N/A 0.18% w/v ethanol, (0.23% w/v vitreous) 10 N/A 11 mg/l Cocaine, 6.9 mg/l Benzoylecgonine, 2.1 mg/l Diltiazem 11 Negative Negative 12 N/A Negative 13 N/A Negative % w/v ethanol (postmortem) 0.14% w/v ethanol (hospital) 15 Negative Negative 16 Cocaine Metabolite Benzoylecogonine 0.4 mg/l 17 Negative (hospital urine screen) % w/v ethanol (hospital) * N/A=not applicable; 6-MAM=6-monoacetylmorphine 18

19 CED Involved Deaths with Excited Delirium Case Obese Heart Clinical Body Drugs Mental Health History Disease Temperature 1 Yes Yes Not recorded Alcohol Bipolar Disorder and Schizophrenia 2 Yes Yes Not recorded, but sweating Cocaine None Reported 4 Yes Yes Not recorded Cocaine None Reported 5 Yes No Not recorded Phencyclidine None Reported 6 Yes No Not recorded, but sweating Cocaine, heroin, & hydroxyzine None Reported 7 Yes Yes Not recorded Lamotrigine Bipolar Disorder 15 Yes Yes Not recorded Negative None Reported * 17 Yes Yes Not elevated Alcohol Schizophrenia *History of agitation when hypoglycemic Table excludes those 2 cases of excited delirium which were blunt force injury and gunshot wound homicides 11 & 13 Case #2 Investigation year old white male Walked or ran for ½ mile prior to trying to break into a business by jumping into the window without breaking it Walked or ran another ½ mile where he was found by police sitting beside a mailbox He was short of breath, sweating profusely, and talking senseless Officers tried to pat him down and he ran into traffic and collided with a passing van Ran into a nearby corn field TASER deployed but failed because one probe went into the officer s finger A long struggle ensued and three officers restrained him with handcuffs, and used the TASER in drive stun, and after the struggle he was observed to be unresponsive Case #2 - Autopsy Obese 6 3 and 259lbs Contusions and abrasions of head, torso and extremities Soft tissue and muscular hemorrhage of back and neck TASER pressure marks grossly suspicious for discharge on upper chest and right thigh not confirmed by microscopic sections Drive stun mark on neck with microscopic evidence of electrical activity No probe injuries identified Enlarged heart with coronary artery disease Toxicology positive for cocaine (0.3 mg/l) 19

20 Case #2 Death Certificate COD: Cardiac arrhythmia during police restraint associated with cocaine intoxication Manner: Undetermined Case #2 Autopsy Lateral right thigh Case #2 Autopsy

21 Investigation Procedures and Questions Time lines are important! When did the subject go unresponsive? When the subject went unresponsive was someone on top of the individual? When the subject went unresponsive in what position was the individual? Types of force used? What was the subject s reaction before and after? Drugs at scene? Chronic drug abuse or alcohol history? Recent activity and emotional state? Has the individual acted this way before? Any significant medical history (cardiac or seizures)? Did EMS or ER take temperature of body? What was the ambient temperature at the scene? Investigation Procedures and Questions Obtain and review EMS, medical, and psychiatric records Get hospital blood and run toxicology First rhythm reported? Review witness and police reports and any video or photographic evidence Investigate the scene and the place of residence A complete autopsy must be performed including histologic sections and toxicologic analysis and findings should correlate with investigation. 21

22 Autopsy procedures must be thorough and should correlate with investigative findings! Each case must be evaluated on an individual basis! Inhalants 22

23 23