Post-mortem Toxicology

DR A J JEFFERY
MBChB MD FRCPath (Forensic) MFFLM

HOME OFFICE REGISTERED FORENSIC PATHOLOGIST

Areas to Cover
Why take toxicology
What samples
How to take them
What does the toxicologist do with the samples?
How to interpret the results general considerations
Alcohol
Drugs of abuse
Toxicology in other causes of death
Other specimens
Case examples

WHY TAKE
TOXICOLOGY
?

Why take toxicology ?

To ascertain if the deceased was under the influence

of alcohol or drugs of abuse at the time of their

death.

RTAs / Accidental deaths / suicides

To confirm or refute overdose / poisoning

To confirm presence / levels of therapeutic drugs.

Eg epilepsy / antidepressants

WHAT SAMPLES
ARE
APPROPRIATE
?

Samples
Blood
Blood
Urine
Urine

(plain) (peripheral)
(preserved) (peripheral)
(plain)
(preserved)

Fluoride inhibits further alcohol production but wont undo the damage
already done.

Vitreous
Stomach Contents
Tissues
Liver
(mid R lobe)
Skeletal muscle
(eg psoas) (if embalmed buttock)

OBTAINING
THE
BLOOD SAMPLE

Femoral Vein Sampling

Vein NOT artery
Before evisceration
Before urine sampling
Ideal = tie off / clamp, then sample by wide-bore needle

below
Routine = clean catch
Ideal = dont milk the leg
Routine = required to gain sufficient sample

Problem:
MINIMAL FEMORAL BLOOD

Insufficient Femoral Blood

Take what ever you can in preserved tubes

Subclavian = reasonable alternative

Could take free-lying chest blood etc for screening for

the general presence of drugs

Make sure you say where each sample has come from
Obtain an alternative specimen

OBTAINING
THE
URINE SAMPLE

Urine Sampling
Needle and syringe

or
Open dome of bladder and aspirate with syringe
alone
Presence of a catheter may be important

toxicologically as the urine may contain artefactually

high lignocaine due to catheter lubricant gel

Vitreous

WHAT DO THE
TOXICOLOGISTS
DO WITH THE SAMPLE
?

Analysis
Screening (GC / Immunoassay)

What classes of drug are present

Confirmation (GCMS)

Specific drugs found by breaking them down & looking at the

breakdown products.

Quantification

Technique may vary dependent on the nature of the drug being

analysed.

HOW TO
INTERPRET
THE RESULTS

General Considerations
Accuracy of reference ranges
Re-distribution site matters!
Individual variation (e.g. renal disease)
Decomposition
Tolerance

Accuracy of reference ranges

Interpretation of absolute drug levels / Reference

ranges

Based on individual reports

Variable from lab to lab due to varying techniques

Need to consider the previous list

General Considerations
Re-distribution site matters!
Individual variation (renal disease)
Decomposition
Tolerance

Redistribution
Discovered with digoxin
Most drugs that undergo

redistribution do so
because of their relative
lipid solubility.
Due to

Loss of cell integrity

Diffusion

GI tract to adjacent

structures
Through conduits lymph
Diffusion from bladder

Natural Disease
Depends or route of administration

1st pass / second pass metabolism

Absorption

With or without meal

GI surgery

Elimination / Clearance

Renal impairment
Liver impairment

Decomposition
Significant redistribution
Some drug levels increase

Alcohol production by bacterial action

Others degrade
If there is a degree of decomposition make sure you

write it on the tox request

Tolerance
Increasing doses required over time to achieve same

effects.
What is lethal to a nave user may have no effect at all
in a chronic user.

First dose deaths

People walking around and working with enough drugs on board

to kill an elephant!

Prison release deaths

Alcohol

Deaths due to Alcohol

What alcohol related causes of death do you know?
How might you classify them?
Which specific toxicological causes do you know?

Alcohol
Acute alcohol toxicity
Ketoacidosis
Alcohol in combination with

other drugs

Problems with Interpretation of Alcohol

Redistribution
Dealing with decomposition
Back calculations

Acute alcohol toxicity

How does it cause death?

>30 = higher skills

Death respiratory

30 50 = deterioration in

depression due to action on

brainstem
UK legal driving limit?
Driving limit 80 mg/100ml
Less than 20 mg/100ml

generally considered
insignificant.

driving
50 100 = inhibitions /
laughter
100 150 = slurring,
insteadiness, poss nausea
150 200 = obvious
drunkenness, nausea staggering
200 300 = stupor, vomiting,
coma
300 + = stupor, coma,
aspiration &

Alcohol fatal level or not?

LD 50 = 400 mg/100ml
Alcohol has symbiotic relationship with other drugs.

e.g.

< 200mg/100ml can be fatal if opioids are taken.

> 200mg/100ml can the fatal dose of opioids
> 100mg/100ml may enhance heroin toxicity

Ethyl glucuronide (minor breakdown product) in

urine if imbibed within 5 days of death.

What is ketoacidosis?
Can you explain why this happens?

Ketoacidosis
Brain can utilise ketone bodies when glucose is unavailable fasting /

starvation
Ketone bodies, formed by the breakdown of fatty acids and the de-amination of

amino acids.
Ketoacidosis is an extreme and uncontrolled form of ketosis, which is a normal

response to prolonged fasting. In ketoacidosis, the body fails to adequately

regulate ketone production causing such a severe accumulation of keto acids
that the pH of the blood is substantially decreased.
Alcoholic ketoacidosis

Metabolic acidosis
Malnutrition
Binge drinking superimposed on chronic alcohol abuse

Ketoacidosis
Ketones:

Acetone (can be produced pm)

<0.5 mg/100ml

Beta hydroxybutyrate (less likely to be raised artefactually)

<0.5 mmol/L
1.26 47.2 mmol/L (assoc with fatalities)

Causes

Alcoholic ketoacidosis
Diabetic ketoacidosis

Alcoholic vs Diabetic
How might you differentiate?
Urine glucose
HbA1c

4 - 6.1%

Calculations
AVOID !
Clearance

10 25 mg/dl/hr ( about a unit an hour)

In 10 hours you can clear ~ 100-200 mg/dl
Alcoholics can clear 30 40 mg/dl/hr (due to training!)

Widmark equation

Used by some to predict amount of alcohol consumed

Decomposition
70 190 mg/100ml reported as artefact
Consider pm findings
Look for other substances produced pm
Use vitreous and urine as supportive evidence

These are relatively protected from redistribution

Normal ratios (if in equilibrium)

Urine : Blood
1.23 : 1

Vitreous : Blood
1 : 0.81

Drugs of Abuse
OPIOID AGONISTS
SYMPATHOMIMETICS

Opioid agonists

Opioid agonists

Analgesia / euphoria / dysphoria

Respiratory depression

miosis

Morphine and other opioids

Morphine
Heroin (diamorphine) IV, smoked, sniffed
Methadone (green liquid oral or IV)
Pethidine, buprenorphine
** CNS depression **

Findings
History / scene / paraphernalia
External

iv sites
Foam at nose / mouth

Limited & non specific

Pulmonary congestion and oedema

Stomach contents methadone is usu green!

Morphine / Heroin
Heroin / diamorphine synthetic morphine

derivative

Powerful opioid analgesic

Metabolised almost immediately (10 15 mins) to 6

monoacetyl morphine 6MAM and then within 24 hours to
morphine.

Presence of 6MAM is consistent with use within 12-24 hours

Ie recent intake / top up injections

Acute alcohol intoxication potentiates the effects

Total morphine : Free Morphine

Gives some idea of time since administration

Eg in IV admin

15 mins post admin

60 mins

4
9

Therapeutic
Free morphine 10 100ng/ml

:
:

1
1

Lethal_______

50 4000 ng/ml

Heroin
A contaminate of street heroin is acetylcodeine

Hence may have +ve codeine levels

Most heroin deaths occur several hours after taking

the drug

Sleepy / snoring
May have time to metabolise drug despite irreversible
respiratory depression

Methadone
Therapeutic

75 1100 ng/ml

Toxic

200 2000 ng/ml

Lethal

400 2000 ng/ml

Significant overlap

Tolerance becomes very important

Interpretation requires knowledge of drug history
Long & variable T

Methadone
Breakdown product EDDP

This is inactive

Titration is important

Many deaths occur during first few weeks of treatment

Can cause respiratory depression at therapeutic doses

Lipophilic so undergoes significant redistribution

Even peripheral samples can be 2x in

and 3x in

Opioids
Tolerance = V V important consideration

Eg. Prison release

Palliative care

Nb worth remembering that 10% of codeine will

breakdown to become morphine.

Free Codeine

Therapeutic

Lethal_______

30 340ng/ml

>1600 ng/ml

Sympathomimetics

Sympathomimetics

Incr activity of adrenaline and serotonin

Adrenalin
Hypertension
Tachycardia
Mydriasis
Serotonin
Excitement
Hyperthermia

Stimulants
Cocaine
Amphetamine
Ecstasy
Other methamphetamines
Associated with subarchnoid haemorrhage

80% of these assoc with aneurysms

Intracerebral haemorrhage

Associated with AVMs & hypertension

Findings
Hearts of stimulant users tend to be heavier than

controls
Fibrosis
Contraction band necrosis
Accelerated atherosclerosis
Non specific pulmonary changes
Crack cocaine smokers prominent anthracosis esp

in alveolar macrophages & emphysematous changes.

Cocaine
Naturally occurring plant alkaloid stimulant
Snorted, smoked, cutaneous, injected
Nb always consider in sudden death in the same way

that you might consider HOCM.

Breakdown Products

Benzoylecgonine
Methylecgonine
Cocaethylene

Inactive
As active as cocaine itself & indicative of alcohol
consumption at the same time

Cocaine Toxicity
Less than 50 ng/ml cocaine is considered not to produce

measurable physiological effects

T can be as little as 40 mins
Benzoylecgonine 1-4 days in urine
Toxic

>900 ng/ml

Lethal

>1000 ng/ml

Benzoylecgonine

Lethal - >1000 ng/ml *

Cocaine
But lethal nature not dose related
Long term effects:
Cardiovascular damage

incr ischaemic event / Coronary Art thrombosis

coronary artery spasm
contraction band necrosis
fibrosis / sudden arrhytmia
myocarditis/cardiomyop/valvular/aortic
dissection/hypertensive crisis

Non cardiac -

Cerebral infarction / intracerebral haemorrhage

So death can be attributed to cocaine even if not found in blood.

Cocaine can decrease rapidly in unpreserved blood samples stored

at room temperature.

Cocaine, death & Excited delirium

Excited delirium

Hyperthermia
Mental & physiological arousal
Excited, erratic & sometimes bizarre, violent behaviour
May have florid psychosis
May exhibit extra-ordinary strength

Tends to result in sudden respiratory arrest

Blood cocaine and benzoylecgonine may be low but there is usually

concentration of benzoylecgonine within the brain indicating long
term use
Marked decease in D2 receptors in hypothalamus in psychotic
cocaine abusers.

D2 receptors play a role in temperature regulation

Amphetamine
Prevalence second only to cannabis
Synthetic stimulant
Effects similar to cocaine
Stimulate release of catecholamines, particularly

adrenaline
Tolerance & dependence develop
Absorbed by GIT, clinical effects commence within
20 minutes, last 4-6 hours.

Amphetamine
Toxic

>500 ng/ml amphetamine

>1800 ng/ml methamphetamine

Lethal

Usu > 1000 ng/ml amphetamine

But can be seen if >50ong/ml
Usu > 10 000 ng/ml methamphetamine

Different Forms
Amphetamine (Benzedrine, uppers, 'A', speed, whizz, cranks,

wake-up, sulph, hearts)

Dextroamphetamine (Dexedrine, dex, dexy, dexies)
Methamphetamine (ICE, crystal, glass, meth)
Methylenedioxyamphetamine (MDA, EVE)
3 ,4, Methylenedioxymethamphetamine (MDMA, ADAM,

Ecstasy, 'E', doves, Dennis)

Amphetamine
Alcohol can potentiate effects on the heart.
Rare toxic effects:
Coma
Cerebral vasculitis
Cerebral haemorrhage
Rhabdomyolysis
D.I.C.
Renal dysfunction
Cardiac long term users
Accelerated coronary atherosclerosis
Microvascular disease

MDMA / Ecstasy
Amphetamine-like drugs

3,4-methylenedioxymethamphetamine

Serotinergic and noradrenergic effects

Hyperthermic effects

Liquid ecstasy GHB

Gamma hydroxybutyrate

Other

Benzodiazepines
Diazepam 20 4000 ng/ml

Nordiazepam 20 1800 ng/ml

Need in the order of thousands to consider fatal.

Cannabis
Cannabinoids

THC tetrahydrocannabinol
Delta 9 THC carboxylic acid

Rapidly distributed into tissues

Blood levels drop >90% within 2 hours of intake
THC can only be found within 4-12 hours post intake

>2 ng/ml suggestive of recent intake

THC metabolites remain in

Blood up to ~ 5 days
Urine up to ~ 12-36 days

Volatile substance abuse - VSA

Adhesives, aerosols, petrols, paint stripper, nail varnish

remover .. amongst others

Increased risk taking behaviour
Accidental suffocation
CNS depression
Deaths thought to be due to cardiac arrhythmias

Sensitisation of myocardium to effects of adrenaline

Deaths often seen in association with physical exertion

Blood sample must be in a glass tube with a foil top filled

to the top.
Tie off whole lung and place within a nylon bag.

Head space

New Drugs
Mephadrone
Cream

Toxicology
IN
OTHER
CAUSES OF DEATH

Fire deaths
Carboxyhaemoglobin

Normal <10%
Toxic 15 35%
Lethal >48%

Cyanide

Normal < 0.1mg/L

Develops within the potted blood sample if not preserved

Carbon Monoxide
In an individual breathing air

T = 4 hours

Breathing O2 in Hospital

T = 60 minutes

Therefore always consider survival time.

Therapeutic Drugs
Anti-depressants
Anti-convulsants

Overdose
Aspirin

Therapeutic

Toxic

20 100mg/l
>150 mg/l

Lethal

>500 mg/l

NB those on reg Rx (eg arthritis 3g/day) 44-

330mg/L

T up to 36 hours in massive OD

Findings
Pm

Blood stained gastric content / frank haematemesis

Rarely skin petechiae
Mucosal gastric erosions
Malaena if survival sufficiently long
Petechiae through other organs due to anticoagulant effect

esp parietal pleura and epicardium

Paracetamol

Therapeutic

Toxic

10 20 mg/l

>150 mg/l

Lethal

>160 mg/l

Other samples of interest

IMMUNOLOGY ANAPHYLAXIS
BIOCHEMISTRY DIABETES

Immunology - Anaphylaxis
Secure ante-mortem samples
Needs to be peripheral as mast cell rich organs can

release tryptase after death.

Serum (plain tube spun down)
Mast cell tryptase ( = more specific)
Specific IgE

Make sure you give details of any suspected cause

Available for venoms, foods, medicines, contrast agents, latex.

Mast cell tryptase

T during life is ~ 2 hours so may be unhelpful if they have been resuscitated and

have survived and die later ( usu from cerebral anoxia)

Antemortem!!!
Tryptase is a sensitive marker for mast cell activation
High levels will be found post severe anaphylaxis
Levels are not raised in local allergic reaction eg rhinitis
Can be raised in pure asthma deaths but not of the same order of magnitude
Slight increases can be seen in

non-anaphylactic mast cell degranulation EG opioids for chest pain

Trauma disruption of mast cell rich tissues

Unless grossly elevated interpret with caution

In presence of suggestive history and absence of pm findings it may provide

confirmatory evidence.

Normal Levels:

IgE
MCT

MCT can be produced pm

0 122 kU/L
2-14 mg/L

Biochemistry - Diabetes
Vitreous is best for biochem as most blood is already haemolysed
Glucose drops significantly after death

Bacterial metabolism
Drops even in vitreous
So low glucose hypoglycaemia
It is not possible to diagnose hypoglycaemia accurately at pm.
A high vitreous glucose virtually rules out hypoglycaemia as one can assume it was
the same or higher in the antemortem period unless peri-mortem dextrose admin

HbA1c heparinised sample

Insulin

If endogenous the body has to cleave C peptide from pro-insulin to make active insulin.
If exogenous the insulin is already cleaved and so they will have no C peptide.

Case Examples

Case 1
60 yr old male, in house fire, extensive burns, no suspicious injuries, no
soot in airways or stomach.

Ranges

Norm

Tox

Leth

CO = 40%

<10%

15-35%

>50%

Cyanide = 0.5 mg/L

<0.1mg/L

Paracetamol
6mg/l

10-20mg/l

>150mg/l

>160mg/l

Codeine
56ng/ml

30-340ng/ml

>1600ng/ml

Morphine (free)
<5ng/ml

10-100ng/ml

50-4000ng/ml

Case 2
30 year old female found on floor with green fluid trailing

from corner of mouth

Ethanol

Blood
181 mg/100mls
Urine
244 mg/100ml
Ethylglucuronide present in urine
Acetone
negative
Methanol negative
Isopropanol negative

What effect might you expect?

What caveat would you include?

Is this likely to by PM alcohol production?

Ranges:

Methadone
75-1100ng/ml
413 ng/ml
EDDP = 276 ng/ml

Amphetamine
471 ng/ml

Diazepam
21 ng/ml
Nordiaz = 73ng/ml

Cause of Death??

Normal

Toxic

Lethal

200-2000ng/ml

400-2000ng/ml

>500ng/ml

20-4000ng/ml
20-1800ng/ml

>1000ng/ml

>5000ng/ml

>30 000ng/ml

Case 3
Chronic alcoholic found dead at home, head injury

consistent with fall to the ground.

Ethanol

16 mg/100mls
72 mg/100mls
25 mg/100mls
145 mg/100mls

Supports ante-mortem consumption

Acetone

Blood
Urine
Vitreous
Stom Cont

Blood
Urine
Vitreous

3mg/100mls
9mg/100mls
4mg/100mls

Methanol & Isopropanol

2mg/100mls of each in Blood, urine and vitreous

Ketone
But
Can be produced pm

What else do you want to know?

Urine Glucose negative
Vitreous glucose unrecordable
Urine Ketones present

Blood Betahydroxybutyrate 2.3 mmol/L (<0.5 mmol/L)

more specific than acetone

HbA1c 12.1% (4.0 6.1%) Diabetes reconsider urine

alcohol

Urine ethyl glucuronide - present

Case 4
Decomposed @ home on sofa with drug paraphenalia around
LIVER
Homogenate
Ethanol
Methanol

0.88 mg/g
Not detected
Not detected

Isopropanol

Not detected

Acetone

 General drug screen by gas chromatography mass spectrometry (GC-MS)

Liver homogenate:
Morphine, cocaine metabolites, flupenthixol and metabolites, paracetamol,
chlorpromazine metabolites and cotinine detected detected
Liver Tissue Homogenate Quantitative Analysis by Gas chromatography

Mass spectrometry (GC-MS)

Cocaine
= <0.02 ug/g
Benzoylecgonine = 0.28 ug/g
Methylecgonine = 0.26 ug/g
Cocaethylene
= 0.42 ug/g
Morphine (free) = 1.05 ug/g
Morphine (total) = 1.50 ug/g

Was it worth doing if the concentrations mean

nothing?

COMMENTS
The external examination showed an advanced state of decomposition with no evidence of

injury to suggest involvement of another individual.

Within the limits imposed by the degradation of the tissues, the internal examination

showed no apparent pathology which could have caused or contributed to death.

Interpretation of toxicological results is complicated in cases where the individual has

been dead for some time. Drug levels are altered after death by diffusion of the
substances throughout the body (post-mortem redistribution) and certain substances are
produced or degraded in the post-mortem period. As such, it would be unreliable to draw
conclusions from the drug concentrations themselves. However cocaine and morphine
are not produced endogenously by the body and so their presence indicates that cocaine
and morphine (possibly heroin) were taken by the deceased. Alcohol can be produced by
the body after death but the presence of cocaethylene would suggest that alcohol and
cocaine were used concurrently.

 The exact levels of the fore-mentioned drugs within the body at the time of death cannot be

determined with any accuracy. However, we feel that their presence, along with the drug
paraphernalia noted in the vicinity of the body and the absence of identifiable natural disease is
significant. Based on the above information, we are of the opinion that, on the balance of
probabilities, death was in keeping with polydrug toxicity.
The information given within this report represents our understanding of the views, opinions

and circumstances of this case based on the information that we have received to date, either in
writing (all forms) or by oral communication. We recognise that in part this may reproduce or
rely upon witness statements, oral communications or hearsay evidence of second parties and
that the information given to us by others may or may not be factually correct at the time of our
consideration.
We reserve the right to reconsider any aspect of this report should further factual information

arise that contradicts the information provided at the time of the post-mortem examination,
upon which we have based our interpretations.
Cause of Death
Ia. In keeping with polydrug toxicity

Confounding Factors
Considerations

Ask Yourself

Arterial vs venous variation

Where was it from?

Continuing gastric residue

absorption
Redistribution
Post-mortem production or
degradation
Tolerance
Limited reference range data

Vitreous / blood / urine

Site

Was it appropriately preserved

Is there decomposition?
Is it a drug prone to

redistribtution / pm production
Do you know about their drug
taking / drinking habits

In Practice
Seek a drug history from coroners officer
Always give the toxicologists as much info as you

have
If you are looking for a specific substance tell them
as it might not be on their routine screen
Appropriate specimens / appropriate site
If tox is important talk to coroners officer about
accessing ante-mortem bloods.

Resources
http://www.dundee.ac.uk/forensicmedicine/
C. Baselt, Disposition of Toxic Drugs & Chemicals in

Man.