John E. Smialek

Tramadol distribution in four postmortem cases

Four postmortem cases are reported in which the analgesic drug tramadol was identified. Tramadol is an alkaline extractable drug and elutes from a HP-5 column without the need for derivatization. Two metabolites of tramadol, N-desmethyl and O-desmethyl tramadol were also identified. Heart blood concentrations of tramadol in the four cases ranged from 0.17 to 4.4 mg/l. Tissue distribution of tramadol in the four cases failed to identify a sequestration site. None of the deaths reported were attributed to tramadol intoxication.

Cocaine fatality: An unexplained blood concentration in a fatal overdose

A case is presented of a 26-year-old female who died as a result of cocaine intoxication. A blood cocaine concentration of 330 mg/l, about 1.5 times greater than the highest concentration previously reported, was found. Blood benzoylecgonine and ecgonine methyl ester concentrations were 50 and 18 mg/l, respectively. The unusually high blood concentrations of cocaine and the metabolites are suggestive of a massive administration, however, the history suggests a series of recreational uses. The manner of death was undetermined.

Pseudo-subarachnoid hemorrhage of the head diagnosed by computerized axial tomography: A postmortem study of ten medical examiner cases

In this report, we describe ten cases of pseudo-subarachnoid hemorrhage on computer axial tomography (CT) scan of the head. A pseudo-subarachnoid hemorrhage is a false positive finding by CT of the head in which the scan is interpreted as being positive for a subarachnoid hemorrhage not substantiated by subsequent neuropathologic findings. This study is a retrospective review of postmortem cases brought into the Office of the Chief Medical Examiner for the State of Maryland over a three-year period (from 1997 to 2000). We compared the clinicians impression of the CT scan with the postmortem neuropathology. The clinical diagnosis of subarachnoid hemorrhage was based on misinterpretation of non-contrast CT scans of the head. In six of the ten cases, the reading was performed by a radiologist and in four cases by nonradiologist physicians (emergency room physician, neurologist, or neurosurgeon). All the patients survived between a few hours to a few days after being admitted to the hospital. For most of the cases (80%), the neuropathology showed hypoxic/ischemic encephalopathy. The most common cause of death (four out of ten cases) was narcotic intoxication. This report is submitted so that clinicians and pathologist become more familiar with this entity.

An unusual morphine fatality

A case is presented of a 90-year-old white female who apparently died of natural causes in a nursing home. Subsequent investigation indicated that the decedent had been administered an unauthorized bolus of morphine just prior to her death. The embalmed body was exhumed, an autopsy performed, and specimens were collected for toxicologic analysis. The liver contained 1.5 mg/kg of free morphine as measured by radioimmunoassay. The presence of morphine was confirmed by gas chromatography/mass spectrometry. A review of the literature as well as in-house data collected from narcotic deaths clearly suggest that the morphine measured in this case was consistent with a lethal concentration. The manner of death was homicide.