about forensic

1. Presented by Reiam Ameer
Supervised by dr. ammar ali hussein
Higher diploma in toxicology
Baghdad university college of pharmacy

3. Abstract:-
Forensic toxicology is a branch of pharmacology, the study of the effects of
carious concentrations of drugs and poisons on human bodies. Today, forensic
scientists have become better appreciated in their role of determining whether
a certain death was caused by the use of a certain drug. Forensic medicine
serves as the basis for the connection between forensic toxicology and the
legal system. There is a high prevalence of drug-related deaths all over the
world as drugs and poisons have been proven to be among the top ten causes
of death in the world. Approximately 275 million people were estimated to have
used an illicit drug at least once in 2016. Drugs and poisons affect body organs
and thus these organs are extracted by the forensic toxicologists for tests to
determine the actual cause of death or poisoning in cases where the affected
individual has not yet died. The most important samples that the forensic
toxicologist should collect for proper examination include gastric contents, oral
fluid, exhaled air, nails, hair, urine, plasma or serum, and blood. Forensic
toxicologists should look for procedures that will make the investigation
process as reliable as possible.

4. Introduction:-
Forensic Toxicology is the study of the adverse effects of chemicals
on living organisms. Forensic toxicology takes it a step further,
including a number of related disciplines to assist in the detection
and interpretation of drugs and poisons in medicolegal death
investigations, human performance issues; e.g., Driving under the
influence, compliance and other related matters.

6. International Journal of Sciences: Basic and Applied Research (IJSBAR) (2018) Volume 42,
No 5, pp 37 -4438For a long time, there has been confusion concerning what forensic
toxicology should entail and most forensic toxicologists were referred to as “postmortem
chemists”.
However, today, forensic scientists have become better appreciated in their role of
determining whether a certain death was caused by the use of a certain drug.
Pharmacology is a wide field and involves many disciplines while forensic toxicology is
mainly concerned with the role of drugs and poisons as causes of death and/or impairment.
Forensic toxicology also has branches that involve the detection and interpretation of
poisons and drugs in body fluids and tissues.
Most importantly, the analysis and interpretation of the effects of toxins and drugs must be
done in way that it can be presented in a court of law as evidence.There are several
scientific procedures that are applied in the detection and interpretation of drugs and poisons
on the body such as Tandem Mass Spectrometry Methods and advanced immunoassays.
Moreover, recent advancements in pharmacogenomics and genetic autopsy will improve the
interpretation of lethal and therapeutic doses of substances based on the interplay of
genotypes and phenotypes on the metabolic processes of an individual.

7. Research the death investigation system in your
state
The three critical components of any death investigation are
medical/social history,
examination of the body, and
scene investigation.
If any one component is lacking, the investigation is incomplete. In counties
where non-medical Deputy Medical Examiners are being asked to conduct
the majority of a death investigation, medical expertise should be readily
accessible to them.

9. In these investigations, the three main
objectives (respectively) are to :
• Establish if toxicants are present and capable of contributing to death
• Establish if toxicants are present and capable of causing behavioral
changes
• Establish if substances are present and whether or not they represent
legitimate use or exposure, such as prescribed medications or workplace
exposures
Forensic toxicology can also be used to determine drugs and dosing for
hospital patients, for example in therapeutic drug monitoring and
emergency clinical toxicology; identify crimes where toxicants are used to
poison or sedate; resolve cases of driving under the influence; and
establish whether drugs have been used to improve human performance,
as in sport “doping”. For the purposes of this module, we will be primarily
discussing post-mortem forensic toxicology.

10. Connection between Forensic Toxicology and the Legal
Investigation of Death, Poisoning, and Drug Use
Forensic medicine serves as the basis for the connection between forensic toxicology and the legal system. Reports from postmortem toxicological
investigations that indicate the possibility of poisoning can be used as evidence in a court of law.
Therefore, forensic toxicology is an important branch of the legal system especially in the investigations of homicides and other deaths due to poisoning.
Toxicological analysis is integral to death investigations and forensic toxicologists seek to solve cases where there are deaths after a sudden and
unexpected change in the condition of a subject after the administration of a chemical substance or poison .Forensic toxicologists should understand
the effect of various substances and poisons on body organs and fluids.
Most forensic toxicologists are drawn from the fields of medicine, pharmacy, biochemistry, and chemistry because these fields involve the study of
chemical substances and/or the human body.
However, when called upon to testify, the forensic toxicologist should refrain from using complicated jargon, and testify concerning the findings in a way
that is understandable to a lay person with no special training in toxicology.
Forensic toxicologists should retain the specimens until the termination of a case in court because the importance of a toxicological investigation is
revealed days or weeks after a death due to poisoning . Forensic toxicologists should also collect the proper specimens because poisons and drugs
have different effects on different body organs and body fluid Ellis , Mc Gwin, Davis, and Dye proved deaths caused by drug poisoning even in the
absence of evidence from autopsies.
These scholars investigated whether heroine toxicity could be responsible for deaths in which 6-acetylmorphine (6-AM) is not detected during
toxicological analysis.
In the study, M/C ratio in drug users is used as the evidence of death due to heroin toxicity .The study concluded that heroin toxicity is responsible for
deaths even in cases where 6-AM is not detected in the blood provided that the M/C ratio in the IV is greater than one.

11. Why and when is forensic toxicology
used :
In post-mortem investigations, suspected drug overdoses are clear situations where toxicology is
required to establish if an excessive intake of the drug occurred and, if so, whether this contributed to
death. Conversely, toxicology can eliminate the possibility of a drug overdose if concentrations are
not capable of causing death, given all other factors. This means that toxicology testing can produce
a positive result even in cases where drug use is not mentioned in the police circumstances. This is
not surprising given the wide availability of potentially toxic substances, both legal and illegal. In
addition, concentrations of substances change after death making any interpretation difficult, no
matter the concentration.
In many cases, poisons may be detected by the toxicology laboratory but are not necessarily a cause
of death, rather their presence may be relevant in the circumstances of death. For example, alcohol
and impairing drugs are found in about half of all drivers killed in motor vehicle crashes in Australia,
nearly one-third (31%) of all traffic-related deaths in the United States and in a significant proportion
of other accidental deaths. Alcohol and/or drugs are also found in a significant number of other deaths
reported to the coroner; for example, in suicides that include non-drug related intentional deaths. In
death cases where natural disease is partially to blame, drugs that indicate an underlying disease are
often detected, such as drugs that have been used to treat a condition or pain. Sometimes these
drugs are regarded as contributing to the cause of death.
Regardless how the individual died, toxicology testing can determine whether levels of toxic
substances may have contributed to this death.

12. Samples to be Analyzed in Forensic
Toxicology
1. Urine
2. Blood
3. Hair sample
4. Oral Fluid or Other Body Fluids
5. Other Samples(some body organ)

13. Type of poisoning:
 Acute poisoning : Caused by an excessive single dose, or
several dose of a poison taken over a short interval of time.
 Chronic Poisoning : Caused by smaller doses over a period of
time, resulting in gradual worsening Eg: arsenic, phosphorus,
antimony and opium
 Sub-acute poisoning : Shows features of both acute and
chronic poisoning
 Fulminant poisoning: Produced by a massive dose. In this death
occur rapidly, sometimes without preceding symptoms

14. Testing
 The testing of biological fluids and/or tissues for drugs and other substances is
a complex process requiring sophisticated instrumentation and specially
trained analysts.
 Once at the laboratory, a series of tests will be conducted, usually on blood, for
a large range of over-the-counter, prescription and illicit drugs as well as
alcohol and other toxicants; e.g., metals, inhalants, environmental (pesticides,
insecticides), carbon monoxide, cyanide and many other possible toxins
depending on investigative clues or specific tests requested.
 Table 3 and the “Systematic Toxicological Analysis” many materials the medical
examiner might harvest from a body during autopsy, and how they can be
quickly screened in “truly unknown” cases. The biological evidence from
autopsies are needed to support both “common” lab tests and help investigate
some very specific potential causes of death.
 Routine testing, or testing without specific instructions to look for a particular
substance, will generally include the drugs shown below in Table 2, but not all
drugs. The list of the most common drugs detected is included in a standard
attachment to all toxicology reports.

15. How the evidence is collected
Specimens sent for toxicology testing are usually collected by the forensic pathologist (who may also be
an appointed “medical examiner” or “coroner” in some jurisdictions) or mortuary technician during an
autopsy. Specimens must be properly identified, labelled and sealed as soon as practicable after
collection. must be collected and bagged separately in containers. Unique numbered seals are used to
track all evidence for each case.
Specimen collection
Table 1 (below) show kinds of samples commonly requested when investigating different manners of
death, although there may be unique case needs that have to be addressed for some investigations. For
example, exposure to volatile substances requires a sample of the fluid in the lung. Skeletal remains can
be useful to determine prior exposure to drugs and other substances. In these cases hair can also be
sampled

16. Specimen requirements
 Blood: at least 4 ml in heparinised (green-cap) blood
tubes
 Note: for blood alcohol tests, do not use alcohol swabs
to sterilise the area to be punctured.
 Urine: at least 15 ml in sterile containers without
preservatives
 Gastric aspirate: at least 10 ml in sterile containers
without preservatives

17. Labelling and sealing
 Specimens must be clearly labelled with the name and
identification number of the subject.
 Containers must be sealed for medico-legal cases, in
order for the evidence to be legally defensible in court.
 Note: The seal must not cover the specimen label.

18. Table 1. Recommended specimens collected
in post-mortem cases.
Type of death case Recommended specimens
Suicides, motor vehicle crashes, and industrial accidents Blood, urine, vitreous humour, liver
Homicides and/or suspicious
Blood, urine, vitreous humour, gastric contents, bile, liver,
hair
Drug-related
Blood, urine, vitreous humour, gastric contents, bile, liver,
hair
Volatile substance abuse
Blood, urine, vitreous humour, lung fluid or tied-off lung,
liver
Heavy metal poisoning and exposure to other poisons Blood, urine, vitreous humour, liver, hair, kidney

19. Table 2. Drugs included in routine post-mortem
toxicology.
Substance(s) Examples
Alcohol Chemically known as ethanol. Test also includes methanol and acetone1.
Analgesics
Paracetamol (acetaminophen), tramadol 9 (ConZip™, Ryzolt™, Ultracet,
Ultram in the U.S.), Salicylates (aspirin)
Antidepressants
Tricyclics (e.g., imipramine, amitriptyline) ; SSRIs (fluoxetine [Prozac®],
sertraline [Zoloft®])
Antihistamines (sedating) doxylamine, chlorpheniramine, diphenhydramine
Antipsychotics
old and newer generation including depot injections (subcutaneous or
intramuscular injections of long-lasting medication); Haloperidol;
Risperidone
Benzodiazepines and “Z” drugs
all available (diazepam [Valium®], alprazolam [Xanax®]; zolpidem
(Ambien®, Ambien CR, Intermezzo®, Stilnox®, and Sublinox®),
zopiclone (Imovane®, Zimovane), zaleplon (Sonata® and Starnoc)
Cannabis tetrahydrocannabinol (THC) (Marijuana, pot) and its metabolites
Cardiovascular drugs
Diltiazem (calcium channelblockers), Disopyramide (names Norpace®
and Rythmodan®), propranolol (beta blocker)
Cocaine cocaine and its metabolites
Narcotic analgesics
codeine, methadone, pethidine, morphine, hydrocodone, oxycodone,
fentanyl
Stimulants
Amphetamine, methamphetamine, MDMA (ecstasy), pseudoephedrine,
fenfluramine, phentermine, caffeine

20. Table 3. Drugs not routinely included in
death investigation toxicology screens.
Substance(s) Examples
Anti-convulsants
(some only) lamotrigine (Lamictal®), valproate,
phenytoin
Barbiturates
Phenobarbital, butalbital, many other prescribed
(or otherwise obtained) Barbs
Designer drugs
synthetic cathinones and synthetic cannabinoids
(“bath salts”, “plant food”, “spice”, etc.)
Digoxin used to treat arrhythmias and heart failure
GHB
gamma-hydroxybutyrate(“Juice”, “Liquid Ecstasy”,
Fantasy)
LSD hallucinogen rarely seen in coroners cases
Environmental Toxicants
carbon monoxide; cyanide; pesticides; herbicides;
metals

21. Drug Related Deaths
There is a high prevalence of drug-related deaths all over the world as drugs and
poisons have been proven to be among the top ten causes of death in the world.
According to United Nations Office on Drugs and Crime, approximately 275
million people were estimated to have used an illicit drug at least once in 2016 On
average, each individual in the world above 15 years of age drinks 6.2 liters of
absolute alcohol every year. Every year, 3.3 million deaths are caused by the use
of alcohol.
Cannabis is the most abused drug according to estimates of the World Health
Organization. In 2016, approximately 192 million people used cannabis
throughout the world.
Other drugs that have been linked with deaths include cocaine, heroin, and other
narcotics. Each drug will be considered individually as a potential cause of drug
related deaths.

22. Body Fluids and Body Organs Important to the
Forensic Toxicology Process
Drugs and poisons affect body organs and thus these organs are extracted
by the forensic toxicologists for tests to determine the actual cause of death
or poisoning in cases where the affected individual has not yet died. The
most important samples that the forensic toxicologist should collect for
proper examination include gastric contents, oral fluid, exhaled air, nails,
hair, urine, plasma or serum, and blood. Relevant quantitative analysis is
only possible in tests that involve blood, serum, or plasma that has been
obtained from the specific body organ that is undergoing toxicological tests
to ascertain the cause of death or poisoning.There are several procedures
that can be used to collect relevant samples from corpses to enable the
investigation process to begin .These methods either involve collection of in
vivo or postmortem samples.

23.  Blood is the specimen of choice for detecting, quantifying and interpreting
drugs and other toxicant concentrations. Concentrations of drugs and
other toxicants in blood may be useful for establishing recent drug
ingestion and to determine the effect of a drug on the deceased at the
time of death, or at the time the blood was taken. For cases involving
hospital treatment before death, blood samples taken soon after
admission and immediately before death, should also be investigated
particularly when poisoning is suspected before admission into hospital.
Any treatment given can change the results of toxicology tests or be
helpful in the investigation.
 Post-mortem blood presents problems due to often variable condition and
changes to concentrations from one place to another in the body after
death. The degree of decomposition can also interfere with testing as
these specimens can be difficult to analyse. in living patients the dose of
a drug is most closely correlated with its concentration in blood or
plasma. Therefore, historically, blood has been used as one of the
primary specimens in postmortem toxicology.

24. Cardiac Blood: is always collected for forensic toxicological investigations.
30ml of cardiac blood is collected and stored in a plastic container with
screw cap. The plastic container may or may not contain a preservative.
Mostly used for qualitative analysis and quantitative analysis should only be
used in cases where it is absolutely necessary. Most experts prefer to
collect cardiac blood from the right chamber
Kidney: is normally collected for ethylene glycol analysis or for the
investigation of the presence of heavy metals that are concentrated in the
kidney during excretion. The kidney is only useful for qualitative analysis.
Normally, 30g of the kidney is collected in a plastic container with a screw
cap without preservatives. The capsule is removed before the kidney is
stored in the plastic container. The kidney is important in toxicological
investigations that lack urine as a specimen

25. Urine is the most common sample used for drug testing in the workplace, but it is not always
available for post-mortem testing. Urine testing results do not directly correlate to drug effects at the
time of sample collection because of the time it takes the body to eliminate these drugs or their
metabolites in the urine. Its usefulness lies in the fact that the presence of a substance in the urine is
a sign that the substance had been in the blood at an earlier time (detecting these metabolites gives
proof that the drug had been ingested). When urine is available, tests are also conducted for
presence of drugs of abuse. Depending on the case and the results of initial testing other tissues may
need to be analyzed, possibly including stomach contents, liver, etc., (see Table 1).
liver is a primary solid tissue for use in post-mortem toxicology because the body metabolizes
most drugs and toxicants. Many drugs become concentrated in the liver and can be found even when
there are no levels in the blood.
Vitreous Humour - is the clear, gel-like substance that fills the eye. is commonly analyzed
for blood alcohol concentrations. This is of particular interest in motor vehicle trauma, workplace
accidents, suicides and homicides. Vitreous humour alcohol concentrations are a little higher than
blood (about 20% on average), Interpretation of other toxicological findings in vitreous humour is
somewhat more complex.

26. Other samples less commonly used for post-mortemtoxicology
 Stomach Contents. In many cases of acute poisoning, undissolved capsules or tablets
may be discovered and allowing identification. The total amount of a drug or poison present in the
stomach is more important than its concentration because it has not been processed by the body
yet.
 Bone and Bone Marrow can be used for testing when necessary, but the availability of
bones in skeletal remains may limit their usefulness. There are no data to suggest that bones from
one part of the body are better than others for toxicology tests. However, it is always easier to
extract samples from larger bones. Interpretation of these findings is often difficult when assisting
in a death investigation, because the time that these toxins were deposited in the bones cannot be
determined.
 Hair and Nails - Hair specimens, usually taken from the back of the head, can be used to test
for exposure to heavy metals and drugs over a period of weeks to months. Hair is used to test for
drugs such as amphetamines, cocaine and heroin, and more recently tests to determine if was
drinking heavily in the last few months before death. Drug analysis can also be done on finger-
and toenails in order to provide an even longer potential of exposure than hair. However, relatively
little is known about how the nails process toxins, so interpretation of results is more difficult. Hair
is subject to external contamination issues that can mitigate its value, so special sample
preparations in the lab may be needed for a given case.

28. multiple stab wounds
Multiple stab wounds are very common features of homicidal stabbing.
The common findings differentiating homicidal and suicidal stabbing
are well described in the medical literature. Among the features
mentioned are location, shape, and direction of the wounds. These
features are vital in differentiating suicide from homicide. However, this
case has an unusual presentation. We discuss the importance of
interpretation and differentiation of the stab wounds to determine the
manner of death and facilitate the investigation.

29. Multiple stab wounds to the left anterior
ches

30. Stab wound cutting the pericardium, anterior left
atrium, and right ventricle

31. Systematic toxicological analysis - The
usual practice in toxicological examination begins with the
preliminary identification of alcohol and screening of a wide
spectrum of acidic, neutral and basic organic drugs or
poisons. If a toxin is detected, confirmatory and, if
necessary, quantitative testing has to be performed.
Quantitative testing determines how much of the substance
is involved. In general, a positive identification is achieved
using at least two independent analyses and preferably
using different testing methods. For example, using an
immunoassay for initial testing and then GC-MS or LC-MS
to confirm results would suffice. A chromatographic
confirmation test could also determine quantification,
simplifying the testing process.

32.  Immunoassays - Most commonly used drug screening tests involve immunoassay
techniques. Immunoassays are laboratory tests that use antibodies to detect a reaction
with specific substances. Immunoassay screening tests are designed to detect whether a
sample is positive or negative for the targeted drug. Four interpretations of a screening
drug test are possible:
 a true-positive result occurs when the test correctly detects the presence of a
drug
 a false-positive result is one where the test incorrectly detects the presence of a drug
where no drug is present
 a true-negative result occurs when the test correctly confirms the absence of a
drug
 a false-negative result is one where the test fails to detect the presence of a
drug when it is present
 For those samples that give positive screening results, confirmation tests should be
performed, preferably using mass spectrometry (MS) detection. Specific immunoassay
tests are available for many drug classes including all the drugs of abuse as well as a
range of novel compounds such as buprenorphine, “Bath Salts” and “Spice” and other

34. Crime Scene Investigation - Estimating
Time of Death
It's time to put on your forensics engineer hat.
You've been called to the scene of a bloody shooting where a
dead body has been found. Arriving to the site (an office
building), you immediately take the temperature of the body. It's
found to be 83°F. You check the thermostat and camera footage
and deduce that the room has been kept at a constant 72°F.

37. Report for evidence :

38. The following information is required for
the request form:
Toxicology request form
 Name and identification number of the subject.
A brief medical history, including signs and symptoms.
Name of suspected drug or poison (if any).
Tests required.
For police cases: police name, division and report number.
Any other information which may help the analyst identify the drug or poison.
Name and organization of the person requesting the analysis.

42. Turnaround time
You can get a formal report typically within 7 - 28 days of
submission, depending on the analyses requested.

43. The Centre of Forensic Sciences
is an accredited forensic testing laboratory. for reporting results and providing
scientific opinions. This allows for investigative information to be provided in a
timely manner and to ensure that reported results are clearly understood.
Report Types
Interpretive Report - Formal, written release of information documenting the
results of the laboratory examinations, including the interpretation of any
findings, opinions and quantification of the significance of associations along with
statements of limitations, where required.
Analytical Report - Formal, written release of information documenting the
results of the laboratory analysis only, with limited interpretations if required.
Notification Letter - Formal written release of preliminary investigative
information.
Letter of Opinion - A formal letter providing a scientific opinion based on the
information or a scenario provided to the scientist.

44. All reports will include the following identifying
information:
•address of the reporting laboratory
•report title
•CFS case file number and request number
•submitter’s file number (Incident Number), where available
•contact information for the report writer or the Section
•report recipient and names of the investigators, where required
•reference to the parties involved

45. Such information would include:
evidence continuity reports
details of examination and analysis methods
dates of the examinations/analyses performed
examination notes
submission information

46. Conclusion:-
Forensic toxicology is a wide field that encompasses many disciplines. Most
importantly, all these fields converge at the intersection of drugs and poisons
and their effects on the human body.
Drugs and alcohol cause millions of deaths every year throughout the world. It
is therefore necessary to understand the effect of drugs on the body,
especially the effect of these substances on body fluids and organs.
However, there are defined procedures for the extraction of in vivo and post-
mortem samples before the toxicological examination begins. Forensic
toxicologists should adhere to these rules to ensure the reliability of their
findings. With the rise in the number of people that use recreational drugs and
alcohol, the number of deaths related to alcohol and drugs is also likely to
increase.
Therefore, forensic toxicologists have a more important role today because
they will be called upon to ascertain deaths caused by alcohol and drug use

47. Forensic appraisal of death due to acute alcohol
poisoning: three case reports and a literature
review
Abstract
Death due to acute alcohol poisoning lacks specific anatomical
characteristics, compared with other deaths due to drug poisoning. We
report three forensic cases of death from acute alcohol poisoning due
to inhibition of the respiratory centre and eventual asphyxia. Blood
alcohol concentrations in the three fatalities were 5.28, 3.33 and
3.78 mg/mL, respectively. Lethal doses and blood alcohol
concentrations showed differences between individuals. Detailed
auxiliary tests besides autopsy were undertaken. These cases show
that forensic scientists should exclude other causes of death, combine
the autopsy with auxiliary tests, and then make an appraisal.

48. Case 1
A 44-year-old male was found deceased at home at 10 pm. After collection,
his body was stored frozen. We conducted an autopsy 10 days after his
death. External examination showed that his face, lips and nails were
marked by cyanosis. A small rupture (0.3 cm × 0.3 cm) was found on his
right occipitalise muscle. Internal examination revealed a thickened intima
and lipid deposition in the left anterior descending coronary artery (LADCA),
type-I stenosis of the LADCA lumen, cardiac and pulmonary interstitial
congestion, severe pneumo-oedema and light haemorrhage of the gastric
mucosa (Figure 1). The pathological diagnosis was:
(1) severe pneumo-oedema,
(2) cardiac and pulmonary congestion,
(3) small rupture of the right occipitalise muscle (0.3 cm × 0.3 cm).

49. Figure 1. Light haemorrhage of the gastric
mucosa (arrow).

50. Central blood (without a fluoride preservative) and gastric contents were
taken for toxicology testing, and samples were stored at 4 °C before testing.
The BAC was estimated by headspace gas chromatography using a
method described previously . A total of 0.10 mL of blood was diluted with
tert-butanol (40.0 µg/mL; 0.50 mL as the internal standard).
The same method was employed for the two cases described below.
Toxicology testing showed that the BAC was 5.28 mg/mL. Common toxins,
including hypnotic sedative drugs, insecticides and tetramine, were not
detected in the submitted samples of blood or gastric contents. After
investigation, we found that this man had consumed a whole bottle
(500 mL) of spirit (ethanol content: 52%) at noon on the same day that he
died. Thus, we concluded that this man’s cause of death was consistent
with AAP.

51. Case 2
The deceased was a 27-year-old female. She drank ∼450 mL of Hennessy cognac (ethanol
content: 40%) with some people over the span of one night, and then went with other people
to a restaurant, where she drank ∼150 mL of spirit (ethanol content: 35%). Subsequently, the
woman slipped into a coma and was sent to a hospital. The attending physicians gave her
an intravenous drip, but the woman died. The clinical diagnosis noted that the woman had
drunk alcohol before slipping into a coma, her breathing and heartbeat had stopped, and her
carotid pulse had disappeared by the time the ambulance arrived. After collection, her body
was stored frozen.
We conducted an autopsy 17 days after her death. External examination showed that the
face, lips and nails of both hands were marked by cyanosis (Figure 2). There was an
injection-needle mark on the dorsum of her left hand which was set during medical
treatment. Internal examination revealed pale-red oedematous fluid in some alveolar spaces.
The pathological diagnosis was pneumo-oedema due to alcohol consumption. Central blood
(without a fluoride preservative) was taken for toxicology and stored at 4 °C before tests.
Toxicology revealed the BAC to be 3.33 mg/mL. Blood tests (monoclonal antibody board
test) for morphine, pethidine, cocaine, marijuana, ketamine, methadone, amphetamine and
methamphetamine were negative. Thus, we concluded that the woman’s cause of death was
consistent with AAP.

52. Figure 2. Lips (A) and nails of both hands (B) were
marked by cyanosis.

53. Case 3
A 19-year-old male who had been healthy was found in an abnormal state at ∼10 pm after drinking two paper cups of spirit
(ethanol content: 36%) and a paper cup of beer (ethanol content: 8%) at a party. The capacity of each paper cup was
∼250 mL. Without too much delay, he was sent to a hospital, but efforts to revive him proved futile. After collection, his body
was stored frozen.
We conducted an autopsy 18 days after his death. External examination showed his lips and nails to be marked with
cyanosis. There was an injection needle mark on the dorsum of his left hand (due to insertion of an intravenous drip at the
hospital). Internal examination revealed some meaningful signs. The cut surface of the lungs showed congestion, and there
were some small haemorrhagic spots on the lung bases (Figure 3). Most of the alveolar space was filled with pale-red
oedematous fluid. The schistose regions of alveolar spaces were filled with red blood cells. Blood capillaries of alveolar walls
were ectatic and congestive, and pulmonary interstitial congestion was present. A few haemorrhagic spots were observed on
the schistose regions of the fundus gastric mucosa. A high level of congestion was found in the blood vessels of the gastric
mucosa. Subarachnoid and cerebral parenchymal vascular congestion were also documented.
The pathological diagnosis was:
(1) pulmonary congestion, pneumo-oedema and localized pneumorrhagia,
(2) focal haemorrhage of the gastric mucosa, and
(3) cerebral haemorrhage and encephaloedema.
Central blood (without a fluoride preservative), urine and gastric contents were taken for toxicology testing, and all samples
were stored at 4 °C before testing.
Toxicology testing revealed the BAC to be 3.78 mg/mL. Urinary tests for opioids, amphetamines and ketamine were
negative. Hypnotic sedative drugs, insecticides or tetramine were not detected in his blood, urine or gastric contents.
After investigation, we found that this man drank alcohol heavily at the party and had not slept well for 2 days previously.
Thus, we concluded that the cause of this man’s death was consistent with AAP.

54. Figure 3. Small haemorrhagic spots on lung
bases (arrow).

55. Discussion and conclusion
he relationship between CNS depression and alcohol intoxication has been demonstrated. Hence, people who
appear to die from AAP often have asphyxia-related features. The three cases reported in the present study
exhibited some important signs of asphyxia, such as cyanosis of the lips and nails, pneumo-oedema,
pulmonary congestion and alveolar spaces being filled with pale-red oedematous fluid under microscopic
examination. In Case 1, there was some haemorrhage in the gastric mucosa.
In Case 3, we found some haemorrhagic spots on the schistose regions of the fundus gastric mucosa. These
features were caused by acute injury to the gastric mucosa due to excessive consumption of alcohol. Alcohol
can stimulate the gastric mucosal epithelium and submucosal vessels directly, and can change hormone levels
in the gastrointestinal tract by mediating inflammation and thereby aggravating gastric mucosal injury.
The autopsy results of AAP-related death are not specific, so we should exclude other causes of death, such as
sudden death, mechanical injury, mechanical asphyxia or electrocution. Alcohol intake is a risk factor for sudden
cardiac death .
In Case 1, we found a thickened intima, lipid deposition in the LADCA and type-I stenosis in the LADCA lumen,
but the latter was too light (Grade I: lumen area decreased by 1%–25%) to interrupt the cardiac blood supply, let
alone cause cardiac arrest. We did not find pathological changes leading to sudden cardiac death either, so we
ruled out this possibility. In addition, although a rupture (0.3 cm × 0.3 cm) was found on the right occipitalis
muscle, its range was limited, and we did not detect a skull fracture or obvious intracranial haemorrhage.
Therefore, we could exclude death by craniocerebral injury. Alcohol intoxication can result in vomiting, food
regurgitation and paralysis of the pharyngeal reflex, which make it easier to die from asphyxia via aspiration of
gastric contents .According to the anatomy of asphyxia-related death caused by aspiration, vomit in the trachea,
bronchi and bronchioles may be found. In the three cases reported here, there was no blockage in the trachea,
bronchi or bronchioles due to foreign bodies.

56. In addition to autopsy, we used auxiliary tests, including a BAC test and other routine toxicology tests, to determine the
cause of death. Through case investigations, it has been established that AAP-related death is often associated with a
history of heavy drinking. Compared with chronic alcoholism, AAP shows a higher BAC but the acetone concentration is not
increased remarkably. These findings may be related to alcohol-related damage to organs and tissues, chronic tolerance to
alcohol, positional asphyxia/suffocation, hypoglycaemia or ketoacidosis .
Different authorities have different views on the lethal blood concentration associated with AAP, and range from 3.50 to
4.00 mg/mL .The mean BAC in 175 fatal cases recorded by Heatley and Crane was 3.55 mg/mL. As a result of differences
between individuals, the lethal threshold of the BAC is undefined and seems to be lower than conventional
acknowledgement .Jones stated that the BAC of a driver in Sweden was >5.00 mg/mL but he was alive. The lethal dose of
alcohol is related to sex, age and genetic factors, though the speed of alcohol consumption, type of beverage and drinking
habits can also exert influences. showed that, in AAP-related death, overweight drinkers showed more significant BAC levels
for the heart and peripheral circulation than normal-weight drinkers.
The BAC in the three cases in the present study was 5.28, 3.33 and 3.78 mg/mL, respectively. Because of the high BAC in
Case 1 (5.28 mg/mL), there is little doubt that the cause of death was AAP. In Case 2, the deceased consumed a large
amount of high-alcohol-concentration spirit, which may resulted in a decrease in alcohol tolerance. She had a history of
coma before death, which confirmed that her BAC had reached a lethal concentration. In Case 3, the deceased was only
19 years of age. Compared with adults, adolescents are more sensitive and less tolerant to alcohol .
Further investigation revealed that the deceased drank quickly and had not slept for 2 days before the incident, which may
have reduced his tolerance to alcohol. A history of intravenous-drip rescue was found in Cases 2 and 3, which may have led
to the decline in the BAC. The relationship between alcohol intake and the BAC is expressed by the Widmark formula:
A(g)=BAC(mg/g)×BWt(kg)×rho‐factor
A(g)=BAC(mg/g)×BWt(kg)×rho‐factor

57. where BAC represents blood-alcohol concentration in mass/mass unit; BWt
represents the body weight (kg); A represents the quantity (g) of alcohol absorbed
and distributed in all body fluids and tissues at the time the blood sample was
taken; and the rho-factor differs in different individuals. This formula provides a
preliminary inference of the BAC, and verifies the accuracy of the case
investigation and BAC-test results.
Results of ethanol determination in specimens postmortem can be affected by
several factors, of which putrefaction and diffusion of gastric contents postmortem
are the most common. Ensuring timely submission to the test after death and
keeping corpses frozen to inhibit bacterial activity can reduce the interference of
putrefaction postmortem. Currently, n-propanol is used as an internal standard.
However, the theory has been invalidated that if the deceased did not have prior
alcohol consumption, the ratio of alcohol/n-propanol in his/her blood should be
<20 .Therefore, the expected ratio of alcohol/n-propanol must be determined.

58. Ethyl glucuronide (EtG) and ethyl sulfate (EtS) are products of alcohol metabolism, and can be produced only by enzymatic metabolism from the body.
Under some circumstances, analyses of these ethanol metabolites can be useful to estimate putrefaction postmortem. However, EtG has a long half-life
and may be unstable at 30 °C or 40 °C if blood samples are stored without preservatives .
Therefore, EtG cannot show that alcohol consumption is related directly to the death, and is not suitable for highly putrefactive corpses.
The urine alcohol concentration (UAC) can help to analyze alcohol metabolism. The UAC/BAC ratio could help to ascertain if the absorption and
distribution of alcohol in all fluids is complete. Usually, a low ratio (both mean and median, 1.18:1) suggests that alcohol has been absorbed and
distributed completely .
Besides its watery nature, the vitreous humour is less affected by bacterial spread from the intestinal tract, which makes it undergo less putrefaction
post-mortem and has less redistribution postmortem .
Therefore, it can be used as a substitute and reliable assessment if blood is deficient or if there is putrefaction or redistribution postmortem .Our three
cases were sent for autopsy and toxicology tests 10, 17 and 18 days after death but the bodies were frozen, and organ autolysis was not obvious
according to histology. Thus, we consider the BAC results to be reliable. Usually, the liquor pericardii exhibits the highest alcohol concentration, followed
by the left pulmonary vein, aorta, left heart, pulmonary artery, superior vena cava, inferior vena cava, right heart, right pulmonary vein and femoral vein,
in decreasing order .Therefore, taking femoral venous blood simultaneously for a BAC test may help reduce the error from diffusion of gastric contents.
In fatal cases of AAP, detection of other drugs is not infrequent, of which diazepam is predominant . Alcohol can interact with other drugs and promote
their toxicological effects. Studies have shown that alcohol consumption increases the risk of death for heroin users . Methamphetamine and cocaine
can enhance the toxicological effects of alcohol . Meanwhile, the BAC decreases if the number of other drugs in blood increases, which has an impact
on results .
There are cases of death due to alcohol combined with other poisons (e.g. injecting drugs while consuming alcohol). Indeed, some criminals taint
alcoholic beverages to commit crimes. In China, there is a tradition of drinking medicated wine, which may contain toxic components such as venin or
aconitine .Therefore, for cases of death due to AAP, routine toxicology tests should be done to exclude the possibility of death by other poisons. There
are many types of toxic substances, so some rare toxic substances may be omitted from routine toxicology analysis. Thus, it is necessary to combine the
autopsy, case details, and the crime-scene investigation with toxicology tests to make a comprehensive analysis. In all three cases, routine toxicology
tests were carried out, and we did not find other meaningful discoveries through case investigation and autopsy. Therefore, other poisons could be
excluded from the causes of death.

59. References
 International Journal of Sciences: Basic and Applied Research
(IJSBAR)
 HAIKU DECK.
 TAYLOR FRANCIS ONLINE

62. Thank you all