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FORENSIC TOXICOLOGY

FORENSIC TOXICOLOGY. Associate . Prof. ABDİ ÖZASLAN Istanbul Unıversity , Cerrahpasa Medicine Faculty , Forensic Medicine Department. In dictionaries, poison is defined as: “mineral, herbal, animal sourced or synthesized substance that has destructive or fatal effects on human body.”

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FORENSIC TOXICOLOGY

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  1. FORENSIC TOXICOLOGY Associate. Prof. ABDİ ÖZASLAN IstanbulUnıversity, CerrahpasaMedicineFaculty, ForensicMedicineDepartment.

  2. In dictionaries, poison is defined as: “mineral, herbal, animal sourced or synthesized substance that has destructive or fatal effects on human body.” • Forensic toxicology is the use of toxicology in legal investigation. 2 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  3. “The dose makes the poison” Paracelsus (1493-1541) 3 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  4. Effects of Poisoning Depends on, • The structure of the poison, • Application way (exposure type), • Exposureduration, • Exposurerepetition, • Personalsensitivity 4 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  5. Dose Definitions • Effective Dose (ED) • Toxic Dose (TD) • Lethal Dose (LD) 5 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  6. EVALUATION OF DOSE-RESPONSE RELATIONSHIP -1 • It is the relationship between the responseof a biological system and applied toxic amount. • LD50 is the amount of a toxic substance in mg/kg that will, in a single dose, kill 50% of animals in a test group. 6 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  7. EVALUATION OF DOSE-RESPONSE RELATIONSHIP -2 • Threshold dose is lowest amount or exposure level of a chemical substance at which a specified and measurable effect manifests. It cannot be defined empirically. 7 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  8. Most Observed Poisoning Types According to National Poisoning Center Data -1 • Drugs; Analgesic, Antidep, Antihist, Antihypert. etc. • Agricultural drugs and insecticides;Organophosphates, Carbamates, Pyretin group etc. • Household chemicals; Household bleach, Drain opener, Lime remover, Detergent,Naphthalene etc. 8 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  9. Most Observed Poisoning Types According to National Poisoning Center Data -2 • Toxic gases; Carbonmonoxyde, Suffocating gases, • Plants and aliments; Mushroom, Mad honey, Apricot kernel, indoor plants etc. • Poisonous animal bites and stings ; Scorpion, Snake, Spider etc. 9 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  10. Poisoning Classification According to; • Sources, • Duration and frequency of exposure, • Origin • Affected locations, • Toxicological analyze methods, 10 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  11. Poisonings According to Source • Herbal sourced; Belladonna, various alkaloids and heart glycosides, • Animal sourced; Snake, scorpion, spider and insulin, • Mineral sourced; Lead, mercury, arsenic, • Synthesized;DDT, parathion, amphetamine, 11 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  12. According to Duration and Frequency of Exposure • Acute poisoning, • Sub-acute poisoning, • Chronic poisoning, 12 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  13. According to Origin • Accident; Real accidents, Treatment related or work-related poisonings, • Suicide; Generally using prescribed drugs • Homicide; Arsenic, mercury, corrosive acids, strychnine, narcotics, barbiturates, cyanides, organophosphates insecticides, other pesticides and acanitines, phosphor, Zinc blende and radioactive substances 13 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  14. Forensic Medical Examiner’s Responsibilities in Poisoning Cases • Since poisoning is a forensic case, informing judicial authority and healthcare administrators is a legal obligation. • Negligence of this obligation is a delinquency for physician according to TCK 280 and CMK 159. • Autopsy should be performed according to CMK 89. 14 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  15. Firearm Injuries 327 Incisive,incisive-penetrative, penetrative injuries 161 Blunt Trauma 133 Falling down from Height 286 Traffic accidents 528 Deaths due to Explosions 10 Deaths due to Burns 36 Hangings 340 Strangulation, throttling and mechinical asphyxia 29 Drowning 183 Carbonmonoxide poisoning 72 Narcose,drugs poisoning 54 Alcohol (ethylene and methylene) poisonings 21 Medicine poisonings 18 Other poisonings 18 Dead births 21 Child Deaths 497 Pathological Deaths 767 Sending to Commissions 554 Others 365 TOTAL: 3923 Forensic Autopsies-Istanbul 2010 15 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  16. In Forensic Toxicology • Poisoning claim exists. • It is determined during routine investigation . * Physician who performs autopsy should take samples appropriate to claim and/or evidences. 16 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  17. Autopsy in Poisoning Cases • In most of the cases autopsy findings are insufficient since these substances are rarely corrosive or damaging. • Diagnosis is based on toxicological analysis of body fluids and tissues other than history and crime scene investigation. 17 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  18. Before Autopsy • Terminal clinical information should be noted as substance intake time and findings’ start time and types. First physical examination, performed treatment and laboratory findings if applied to a hospital should be taken into account as well. 18 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  19. Findings in External Examination • Usually no signs of findings in toxicology cases, but intravenous drug usage let the needle leave a mark on skin, atrophic scar or ulceration, bite marks due to snake,scorpion, insect bites/stings and insect stings can be seen. 19 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  20. Findings in Internal Examination 1 • Mouth and nose space; Dust or colourful material artifacts (tablet or capsule artifacts, pestiside or herbiside artifacts and intranasal drug usage) • Nasal septumPerforation; Cocain • Brainsmell and colour change;Carbolic acid, alcohols, cyanide, methyl salisilate 20 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  21. Findings in Internal Examination -2 • Gastrointestinal system;Many drugs (deaths in short time), plastic packages (package body syndrome), odor (alcohols, acid carbolic, cyanide), irritation and necrosis (acids, alkalis, heavy metals), • Liver;Parenchymatous degeneration(phosphor, carbon tetrachloride,glycols), necrosis (phosphor, carbon tetrachloride, mushroom poisoning), 21 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  22. Findings in Internal Examination -3 • Kidneys;Hemorrhage (heavy metals, cantharidine), parenchymatoustubulus degeneration and/or cortex necrosis (phosphor, carbon tetrachloride, poisonous mushrooms), papilla necrosis (phenacetin), • Heart;Subendocardial hemorrhages (arsenic), • Blood;Color change (CO, cyanide), • Vomit;Color change (acid borique and copper sulphate). 22 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  23. Toxicologic Analysis Examples • In routine; blood, urine, stomach contents, liver and kidney samples are taken for systematical toxicological analysis. • Peripheral blood (especially femoral vein blood)must be preferred firstly for toxicological analysis. • It is useful to take other samples like brain, hair and bone in addition to liver, kidney and muscle samples when the body is putrefied. 23 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  24. Glass container is the most proper material in preservation and transportation of postmortem biological fluids. • Generally 50 ml culture tubes are the best choices for blood and urine samples. • Smaller tubes (i.e. 15, 20 and 30 ml) are more suitable for smaller amounts of blood, vitreous humor and bile samples. 24 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  25. Blood samples should be preserved by adding sodium fluoride. Some laboratories might want to add potassium oxalate, EDTA or 5 mg/mL concentrated sodium citrateanticoagulants as well. • Samples like urine, bile, vitreous tissuesgenerally needn’t preservative material. However, sodium or potassium fluoride must be added to samples for alcohol analysis. 25 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  26. Plastic containers are suitable for gastric content and solid organ samples. • All samples should be preserved in refrigerator temperature (+4°C) if short term like two weeks , in freezer temperature (-20°C) if long termpreservation is the case. • Room temperature is proper for hair and nail samples. 26 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  27. Rutin Toksikolojik Örnek Toplama Kılavuzu (Hearn L. PostortemToxicology) 27 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  28. Substances Searched in Samples 28 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  29. ALCOHOL POISONINGS 29 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  30. ALCOHOL INTOXICATIONS • Alcohol is the most encountered toxic substance in forensic cases as its abuse is frequent. • The most common types are ethyl and methyl alcohol. 30 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  31. ETHYL ALCOHOL Obtained by two ways; • Fermentation:Generally sugar in fresh/dried fruit and grains are fermented by yeast fungi. • Concentration of the alcohol obtained by fermentation is 15-17 %. In the case of exceeding this percentage, fermentation ends due to death of yeast fungi. • Beer, vine, vermouth and liqueur are alcohol examples obtained by fermentation. 31 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  32. Distillation: Separation of the ethyl alcohol from water by vaporization benefiting from its lower degree of vaporization in order to gather it. • Its alcohol ratio is 35-45%. Raki, vodka, gin, whiskey, cognac are such alcohols obtained by distillation. 32 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  33. Factors Affecting Absorption of Alcohol • The amount and speed of drinking, • Alcohol ratio of the beverage ( beverages with 10-30% ratio have the highest absorption quickness) • Other foods accompanying to the beverage ( absorption is quicker when stomach is empty, fat food slows down the absorption of alcohol) • Personal factors (tolerance, sex, weight, physical structure, GIS mucosal surface area, GISblood flow and motility, diabetes, gastrectomy etc. And psychogenic factors are effective) . 33 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  34. Ethyl Alcohol Metabolism -1 • Ethyl alcohol blocks Glutamate NMDA receptors and it is the indirect agonist of GABA receptors. Besides, it augments membrane fluidity. • Alcohol  Acetaldehyde  Acid acetic  Water + CO2 • Alcohol dehydrogenase • Aldehydedehydrogenase (Disulfiram affection point) • Following oral intake, alcohol passes quickly from esophagus to stomach. • 20% of absorption is realized in stomach and 80% in small intestine mucosal surface. 34 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  35. Ethyl Alcohol Metabolism -2 • Chronic alcoholics metabolizes the alcohol faster than others. • While 90% of taken alcohol is metabolized in liver, 10% is excreted from lung, kidney, saliva and sweat without metabolisation. • In an hour, 15-20 mg/100ml. ethyl alcohol is metabolized. This information is helpful in determination of the present alcohol amount at the moment of event. 35 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  36. Effects of Ethyl Alcohol • It is stimulant at low doses, depressant at high doses. • Person in alcohol intoxication may arrive with different complaints such as dizziness, nausea, vomiting, slurred speech, sweating, discomfort, gait disturbance, impairment of consciousness/unconsciousness. 36 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  37. Kan Alkol Konsantrasyonuna Bağlı MSS Etkileri 37

  38. Promille:The amount of alcohol( gr/lt) in one liter blood. • In order to convert mg to promil, it is divided by 100. 38 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  39. Alcohol level over than 200 mg/100 ml is considered to be “life-threatening” when clinical findings also support. • However, there exist some cases survived in spite of 1500 mg/100 ml level. 39 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  40. DEATH • Person under effect of alcohol is open to traumas. Death can occur as a result of traumas such as traffic accidents, falls, electric shocks, burning or of pathologies such as aspiration of food, stomach bleeding. • Autopsy findings; Findings are non-specific in acute ethyl alcohol intoxication. 40 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  41. Autopsy Findings in Chronic Ethyl Alcohol Intoxication -1 • Trauma, malnutrition, portal hypertension, varices, gastrointestinal bleeding, alcoholic hepatitis, chronic pancreatitis, acute hemorrhagic pancreatitis, chronic gastritis, peptic ulcus, achlorhydra are the probable findings to be obtained. 41 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  42. Autopsy Findings in Chronic Ethyl Alcohol Intoxication -2 • At the beginning; hepatomegaly due to hepatosteatosis, pale yellow appearance, at advanced stage; gray-yellow color small liver with hard consistency, macro nodular cirrhosis are observed. • Atrophy in cerebrum and cerebellum, dilatation of the side ventricles and of interhemispheric fissures occur. 42 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  43. METHYL ALCOHOL • Obtained from distilation of wood. • Its origin is frequently an accident and rarely a suicide. • It is not toxic before oxidation. • 58% is absorbed. Its absorption in gastrointestinal system is very quick. 43 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  44. Methyl alcohol Formaldehyde Acid formic CO2+H2O • Alcohol dehydrogenase • Aldehydedehidrogenase • Its toxic affect depends on the accumulation of acid formic. 44 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  45. After methyl alcohol intake there exists a typical 12-24 hour period before findings appear. • Sample taking, preserving and analysis methods are the same with ethyl alcohol. 45 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  46. Alcohol level over than 30 mg/100 ml or if problems related to optic functions appears, the situation is considered to be “life-threatening” when clinical findings also support. • 80-100 mg/100 ml blood level is the limit lethal level. 46 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  47. In physical examination, smell of alcohol in breath, CNS symptoms, Kussmaul breathing, respiratory depression, blurred vision, scintillation, photophobia, visual field defects, or different visual disturbances from 'snow storm' image to a complete loss of light perception, nausea, vomiting, abdominal pain are probable to be observed. 47 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  48. In acute poisoning cases blindness does not occur although in chronic poisoning blindness occur. 48 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  49. Methyl Alcohol Autopsy Findings • No specifically pathologic finding. • Long time exposure to methyl alcohol may result in optic nerve atrophy, areas of hemorrhagic necrosis of the pancreas, CNS degenerative changes, fatty infiltration of the liver and kidneys, fatty degeneration of heart muscle. 49 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

  50. NARCOTIC SUBSTANCE POISONING 50 19.08.2012 Doç. Dr. A.ÖZASLAN: CTF. ADLİ TIP ANABİLİM DALI.

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