Roger E. Mittleman

Cocaine and sudden "natural" death

The cardiovascular effects of cocaine may culminate in clinical episodes of angina pectoris, myocardial infarction, arrhythmias, and intracranial hemorrhage. To clarify whether or not cocaine causes fatalities by these mechanisms, we studied 24 cases of sudden, apparently natural deaths as a result of coronary arteriosclerosis (15 cases), hypertensive cardiovascular disease (4 cases), and intracranial hemorrhage (5 cases) associated with cocaine use. In 11 cases, cocaine was found in the blood (average concentration: 0.57 mg/L, range: 0.05 to 1.45 mg/L), whereas in the remainder, cocaine or its major metabolite was found in the urine or other tissues. In the majority of decedents, autopsy disclosed the existence of severe natural disease which could have been exacerbated by the administration of stimulant drugs, including cocaine. These data, and a review of the current medical literature, indicate that cocaine may precipitate the sudden death of an individual with undiagnosed cardiovascular disease. A contributory role of cocaine should be considered in any apparently natural death occurring in a population where cocaine abuse is prevalent.

Tissue distribution of cocaine in a pregnant woman

Reports of cocaine-related obstetrical problems, including abruptio placentae and spontaneous abortion, have become increasingly evident in the medical literature; however, little is known about tissue distribution of cocaine in the pregnant woman. We report the toxicologic results of distribution studies performed on a pregnant woman and her fetus. Maternal/fetal cocaine concentration ratios were high when comparing blood (9:1), brain (6:5), and kidney (10:6). Possible explanations of the mechanism for lower fetal cocaine concentrations may include uterine vasoconstriction, incomplete maternal/fetal equalibration, or rapid placental/fetal clearance.

Aortoesophageal fistula and sudden death. A report of two cases and review of the literature.

Two cases of aortoesophageal fistula are presented. The etiology, symptoms, and diagnosis of aortoesophageal fistula are reviewed. Signs and symptoms of gastrointestinal hemorrhage followed by sudden collapse hours to days later should prompt consideration of an aortoesophageal fistula. Accidental ingestion of foreign bodies, particularly by children, is a frequent etiology

Forensic science aspects of fatal sexual assaults on women

The case files of 41 female victims of proven fatal sexual assault were reviewed. They averaged 42 years of age, but a bimodal age distribution was evident. Younger victims (averaging 31 years of age) were most often found in canals, fields, or vacant lots, whereas older women (averaging 51 years of age) were found most often in their residences. Death usually resulted from mechanical asphyxiation, and the use of firearms was infrequent. Various instruments used to harm, restrain, or kill the victim were most often obtained at the scene of death and reflected the emotionality and impulsivity of the incident. Alcohol was found in the blood of 40% of the victims and averaged 0.14%. Ligature bindings, torn clothing, varying degrees of disrobing, and bite marks were not infrequent. The average yearly incidence of fatal sexual assaults on females is calculated to be 0.14/100 000 population in Dade County, FL and has not changed appreciably since 1959. Thus, death resulting from sexual assault was found to be distinctly unusual. Black victims were represented more frequently than their racial distribution in this community. The scene and autopsy findings of the average female sexual assault victim form a characteristic profile that should direct further investigation on a particular case.

Xylazine Toxicity—Literature Review and Report of Two Cases

Xylazine is a veterinary sedative, analgesic or general anesthetic. Its pharmaceutical action results in sympathetic discharge via stimulation of alpha-2-adrenoceptors. In humans, toxicity consists of central nervous system depression, bradycardia and hypotension. The dosages known to produce toxicity in humans vary from 40 mg up to 2400 mg. Because of decomposition, xylazine blood concentrations in two homicide victims were unknown; however, the concentrations in the brain, liver, and kidneys were much higher in the 23-year-old female versus the 33-year-old male victim. A bottle of xylazine found on the crime scene had a concentration of 100 mg/mL. This 50 mL bottle had 32 mL remaining. Therefore at some point in time 18 mL had been utilized. The amount of available milligrams of xylazine (1800 mg) were enough to cause toxicity in both the woman and the man. Of interest was the fact that the partially skeletonized heads were found remote from the torsos, however, the concentration of xylazine in the body tissues provided a toxicological match of which head belonged to which body. Xylazine toxicity in humans and its relationship to these homicides will be the focus of this report.

Endotracheal tube ignition by electrocautery during tracheostomy: case report with autopsy findings.

This case of upper airway tract fire resulting from the use of electrocautery during elective tracheostomy has significance for surgeons, anesthetists, and forensic pathologists alike. The major autopsy findings are described and illustrated. Suggestions that may help to prevent or minimize the risk of fire in this context are reviewed.

Hypopharyngeal lipoma as a cause for sudden asphyxial death.

Lipomas of the hypopharynx are uncommon tumors that are rarely life threatening. When positioned in the hypopharynx, asphyxia may be the result of the tumor size or sudden displacement into the oropharynx. We present a case of a large hypopharyngeal lipoma, review the literature, and discuss mechanisms by which these lesions may cause sudden asphyxial death.

Stud guns revisited: report of a suicide and literature review.

Stud guns (powder-actuated fastening tools) are a commonly used construction tool. Accidental injuries and fatalities are no longer frequent, presumably because of current safety features and practices. A case of an intentional fatal wound (suicide) is described. A literature review of stud gun injuries is also presented.

Practical approach to investigative ethics and religious objections to the autopsy.

The application of investigative ethics to religious objections to the autopsy is essential for harmony in achieving the mission of medical legal death investigations. In Florida, an ethical advisory committee composed of religious, ethics, legal, and medical leaders established a unified statement for the practice of discretionary judgment and liaison with clergy. Our approach to religious objections to the autopsy as well as illustrative cases will be discussed.

Suicide by ingestion of methyl ethyl ketone peroxide

Methyl ethyl ketone peroxide (MEKP) is a free radical-generating compound used as a fiberglass resin hardener. A 41-year-old Haitian man developed severe metabolic acidosis, hemolysis, esophageal and gastric necrosis, and perforation of the stomach after drinking an undetermined amount of MEKP in a successful suicide attempt. The biochemical effects of free radicals explain the necrosis and hemolysis observed.