Engineering evidence for carbon monoxide toxicity cases

Unintentional carbon monoxide poisonings and fatalities lead to many toxicity cases. Given the unusual physical properties of carbon monoxide-in that the gas is odorless and invisible-unorganized and erroneous methods in obtaining engineering evidence as required during the discovery process often occurs. Such evidence gathering spans domains that include building construction, appliance installation, industrial hygiene, mechanical engineering, combustion and physics. In this paper, we attempt to place a systematic framework that is relevant to key aspects in engineering evidence gathering for unintentional carbon monoxide poisoning cases. Such a framework aims to increase awareness of this process and relevant issues to help guide legal counsel and expert witnesses.

Unusual way of suicide by carbon monoxide. Case Report

OBJECTIVES

Authors discuss the case of a suicide of a 29-year-old man caused by carbon monoxide (CO) intoxication. What the authors found interesting was the unusual way of committing suicide that required good technical skills and expert knowledge.

METHODS

The level of carboxyhemoglobin (COHb) in the blood of the deceased man was routinely determined by the modified method by Blackmoore (1970), using gas chromatography/thermal conductivity detection. The level of saturation of the hemoglobin by CO in the collected blood sample is determined relatively to the same sample saturated to 100%.

RESULTS

In the blood sample of the deceased man the lethal concentration of COHb of 76.5% was determined. Within the following examinations the blood alcohol concentration of 0.05 g.kg(-1) was determined. Further analysis revealed traces of sertraline, its metabolite N-desmethylsertraline, omeprazole and caffeine in the liver tissue, traces of N-desmethylsertraline, ibuprofen and caffeine in urine sample, and only traces of caffeine in the stomach content and blood samples were proved. To commit suicide the man used a sophisticated double container-system equipped with a timer for controlled generation of CO based on the chemical reaction of concentrated sulphuric acid and formic acid. The used timer was set by an electromechanical timer switch that triggered the fatal reaction of the acids while the man was sleeping.

CONCLUSIONS

The authors discuss an unusual case of suicide by CO intoxication rarely seen in the area of forensic medicine and toxicology that is specific due to its sophisticated way of execution.

Skin messages in suicide--an unusual occurrence

Notes are found in only a minority of cases of suicide and occasionally may involve writing messages on skin surfaces. A prospective study was undertaken for cases of suicide with skin messaging over a 12-year period from 1/1/2000 to 31/12/2011. A total of 498 cases of suicide were examined with only 2 cases (0.4%) having suicide notes written on their skin. Both cases involved young males (aged 18 and 30 years respectively) with the deaths occurring by hanging. In both cases typical parchmented ligature marks were present around the neck running up to the point of suspension. Both decedents had written messages on their hands/arms expressing mixtures of sorrow and hopelessness. There were no other suicide notes present. It is not clear whether writing on skin rather than on more conventional material suggests that the suicide may not have been planned, or instead that the decedent wanted to ensure that the message was found. Messages on skin may be slightly different to messages written on other surfaces, as space is limited and pens and markers may not write as effectively. An additional problem with skin messages is their vulnerability to erasure, making clear documentation of these findings at the scene important.

[Acute poisonings in children in the years 2010-2012--single-centre study in Poznań]

Poisoning is a clinical syndrome caused by the poison, which entered into the body. Poison is every substance that taken in the specified amounts may cause adverse effects.

OBJECTIVE

Statistical analysis of acute poisoning in children in the years 2010-2012.

MATERIAL AND METHODS

The study group consisted of 308 children who went to the Admissions Room of the Specialized Health Care Mother and Child in Poznań because acute poisoning suspicion or diagnosis, in the period from 1 January 2010 to 31 December 2012.

RESULTS

In the group of 308 children, girls accounted for 57.14% and 42.86% boys. Children age ranged from 5 day old to 215 months of age (average 122 +/- 74). Toxic substances, which children have been exposed were drugs in 144 patients, ethyl alcohol in 75 children, carbon monoxide - 55 injured and chemicals in 34. The most commonly acute poisoning occurred in October (11.69%), December (11.04%) and September (10.71%). Of the 308 admitted children, 278 (90.26%) were hospitalized, including 11 patients (3.57%) in the Intensive Care Unit (ICU). In study population poisonings with drugs were dominated and related to 63.89% of girls and 36.11% of boys, aged from 2 to 213 months of age (average 120 +/- 75). In 50.69% of children intentional poisoning was diagnosed, in 18 patients (12.5%) mixture of different drugs was ingested, in five of them together ethyl alcohol. At 4.86% of the children reported a suicide attempt. This group accounted for girls with an average age of 178 +/- 8 months. Ethyl alcohol poisoning related to 56% of girls and 44% of boys between the ages of 152 to 215 months, giving an average age of 184 +/- 17 months. At 5.33% of the patients reported alcohol consumption along with medication, and 2.66% in addition took psychoactive substances. Because carbon monoxide poisoning aid granted to 50.91% girls and 49.09% boys between the ages of five day old to 209 months of age (mean 96 +/- 64). Poisoning with household chemicals related to 58.82% of boys and 41.18% of girls (mean age 32 +/- 36 months). Detergents were the most frequent ingested chemicals in 50% of children with an average age of 3 years.

CONCLUSIONS

Acute poisoning with the exception of household products ingestion were more common in girls than in boys. The most common cause of poisoning in children were drugs overdose and ethanol ingestion. Cases of suicidal poisoning target group included only female sex. Accidental poisoning were observed mainly in young children and usually caused by chemicals.

Generation rate of carbon monoxide from burning charcoal

Charcoal, often used as cooking fuel at some restaurants, generates a significant amount of carbon monoxide (CO) during its combustion. Every year in Japan, a number of cooks and waiters/waitresses are poisoned by CO emanating from burning charcoal. Although certain ventilation is necessary to prevent the accumulation of CO, it is difficult to estimate the proper ventilation requirement for CO because the generation rate of CO from burning charcoal has not been established. In this study, several charcoals were evaluated in terms of CO generation rate. Sample charcoals were burned in a cooking stove to generate exhaust gas. For each sample, four independent variables -- the mass of the sample, the flow rate of the exhaust gas, CO concentration in the exhaust gas and the combustion time of the sample -- were measured, and the CO generation rate was calculated. The generation rate of CO from the charcoal was shown to be 137-185 ml/min/kW. Theoretical ventilation requirements for charcoals to prevent CO poisoning are estimated to be 41.2-55.6 m(3)/h/kW.

An unusual case of suicidal carbon monoxide poisoning

The authors present a case of suicide by carbon monoxide poisoning in a confined space with interesting elements related to the method and the circumstances in which it took place. Carbon monoxide poisoning is a very common cause of death in accidental and suicidal cases, but the method used in this case, consisting of burning charcoal in a small office bathroom, presents some particularly interesting aspects. The circumstances, moreover, appear very interesting because the person who committed suicide was an employee of the Public Administration and he had received notification regarding his involvement in a legal prosecution.

Out-of-hospital cardiac arrest caused by acute intoxication

We experienced 20 cases of out-of-hospital cardiac arrest (OHCA) caused by acute intoxication between April 1999 and March 2008. The causative agents were organophosphates in 8 cases, carbon monoxide in 5 cases, and barbiturates in 3 cases. Other agents were paraquat, tricyclic anti-depressants, lime sulfur, and amphetamine. Cardiac arrest was witnessed by bystanders while waiting for the ambulance arrival in 3 cases, and by emergency medical personnel during transfer to our hospital in 4 cases. In these 7 witnessed cases, prehospital resuscitation was provided in 6 cases. No case demonstrated ventricular arrhythmia at the prehospital scene. The restoration of spontaneous circulation was achieved in 8 cases, and 4 cases were discharged alive with overall performance category 1. All the survivors were victims of organophosphate or barbiturate intoxication. It is assumed that these agents caused myocardial depression or respiratory insufficiency following cardiac arrest. From the review of the OHCA caused by organophosphate or barbiturate intoxication, cardiopulmonary resuscitation alone seemed to be effective for restoration of spontaneous circulation and should be emphasized in the prehospital care setting as well as in cardiogenic OHCA.

[Students knowledge on carbon monoxide toxicity]

The results of questionnaire research on carbon monoxide (CO) poisoning in students of State Higher Vocational School in Nowy Sacz (Institutes of Economy, Pedagogic, Technical and Health) are presented in the study. The mean age of the group examined, with a female predomination (77.6%) was 22.7 +/- 4.94 years. The questionnaire covered demographic data and knowledge on CO source, exposure, most frequent and most severe symptoms, most severe sequels, risky behavior and risk groups in CO poisoning. The results obtained indicate on inadequate knowledge on CO poisoning even in young students population. The proper education and prophylaxis activity is necessary to avoid accidental CO poisoning, especially that they also occur in spring-summer season.

Demand for poison control center services “surged” during the 2003 blackout

BACKGROUND

Beginning 8/14/03, for 24 hours, the largest geographic power failure in U.S. history occurred. Our Poison Control Center (PCC) catchment area was one of the most severely affected, with most of the population left without electricity, fuel, water pressure, or municipal potable water. The paucity of reports on the impact of disasters on PCC operations led us to summarize our experience.

METHOD

Data sources included 1) Toxicall human exposures during 8/03 (with comparison to 2002 and to national trends) and 2) an after-action report completed by Specialists-in-Poison Information (SPI's) on duty during the disaster.

RESULTS

The average call volume for 8/03 increased by 7.8%. Significant increases in human exposure and information calls occurred in four categories: gasoline, carbon monoxide, food poisoning, and water contamination. After-action report findings included: vulnerability of PCC operations to interruptions in power supply; lack of redundant communication methods; staffing challenges; and exclusion of PCC staff from hospital disaster plans despite co-location.

CONCLUSION

During the blackout of 2003, there was a measurably increased demand for poison center services. PCC disaster plans should address increased staffing needs during the time of disaster, communication system redundancy, back-up power supply, and SPI needs (food, water, transportation, environmental safety, and rest/rotation).

Cerebral palsy due to nonlethal maternal carbon monoxide intoxication

BACKGROUND

Carbon monoxide (CO) poisoning in pregnancy is a relatively rare occurrence, but it can result in fetal mortality and neurologic complications in fetuses who survive to term.

CASE

We describe the course of an infant who was acutely exposed to CO at 20 weeks of gestation.

CONCLUSIONS

We conclude that despite maternal well-being, CO intoxication at critical periods of human brain development can lead to hypoxic-ischemic lesions in the globus pallidus and that dystonic cerebral palsy may develop in the infant during long-term follow-up.

[Two cases of diphenhydramine related suicide]

Two suicidal cases associated with ingestion of diphenhydramine (DPH) were reported. Case 1 is a typical DPH overdose case of a young man with the blood DPH concentration of 12.2 microg/ mL. Case 2 is a double suicide of a man and a woman. They ingested DPH and fell asleep in a vehicle which had a cooking clay charcoal stove. Their blood DPH concentrations were 0.4 and 0.7 microg/mL, which were high enough to make them sleep. Their cause of death, however, was carbon monoxide poisoning with blood CO-Hb concentration of 14 and 19%. DPH is a low toxic agent and is available as an OTC drug in Japan. Similar fatal cases can be expected to happen in Japan.

Carbon monoxide: the bad and the good side of the coin, from neuronal death to anti-inflammatory activity

The double origin of carbon monoxide (CO) as an atmospheric pollutant or as an endogenous gaseous modulator of many pathophysiological processes prompted us to review some aspects of the bad side and of the good side of coin among the pleiotropic effects of CO. On the bad side of the coin, we focus on the interval form in acute CO poisoning, discussing experimental evidence suggesting that the delayed neuropathology after CO poisoning is a free radical-driven event. In this context, we challenge the mandatory place of hyperbaric oxygen therapy (HBO) in CO poisoning as a possible summation of oxy-radicals generated by HBO and the free radical cascade set in motion during the reoxygenation phase of acute CO-poisoning. We also discuss an opposing view, which provides evidence suggesting that HBO therapy actually decreases the load of free radicals in acute CO-poisoning and may be beneficial in preventing delayed neuropsychiatric sequelae.On the good side of the coin, we briefly outline the endogenous generation of CO and the leading role of heme-oxygenases (HO) in relation to the place of CO in biology and medicine. The main focus of this section is on the growing literature on CO and inflammation. Here we report on in-vitro and in-vivo studies on the modulation afforded by exogenously administered/endogenously produced CO in a variety of experimental and clinical settings of inflammation. Our recent studies on experimental models of allergic inflammation are also discussed, and the CO-releasing molecules envisaged as potential anti-inflammatory drugs suitable for clinical use.

Effect of melatonin and atenolol on carbon monoxide cardiotoxicity: an experimental study in rats

The aim of this study was to define the characteristics of heart rates and myocardial changes in rats exposed to carbon monoxide (CO), and the effects of reoxygenation, atenolol (a beta-blocker) and melatonin after sublethal CO intoxication. Widespread use of beta-blockers in cardiology practice and growing literature on the positive effect of melatonin in ischaemia reperfusion lead us to question their effects in case of CO intoxication. Rats were exposed to CO. After sublethal intoxication the rats were reoxygenated with ambient air. Subsequently blood values, electrocardiographic recordings and pathological changes were examined for each groups. Five rats died after CO intoxication in the control group: no myocardial changes were seen in light microscopy. However, myocardium of seven reoxygenated rats presented contraction bands. Seven reoxygenated rats pretreated with atenolol had a higher number of contraction bands of myocardial cells. Seven reoxygenated rats pretreated with melatonin had more contraction bands than reoxygenated rats, and heart rate recordings of these animals revealed a profund and sustained bradycardia. Thus, melatonin and atenolol appear to have some adverse effects in CO intoxication on the myocardial cells.