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A significant rise in the abuse of a new group of synthetic cathinones was reported recently in Western Europe. We selected four documented cases that recently occurred in Spain to discuss the toxicological significance and the mechanisms that explain the legal facts. All drugs and metabolites were detected using gas chromatography-mass spectrometry (GC-MS) and liquid chromatography-mass spectrometry (LC-MS-MS). Case 1: A 19-year old male was arrested for assaulting his father. He drank a random glass in a discotheque. He described a feeling of elation, irritability and several episodes of amnesia. Methylone and its metabolites, and 11-nor-9-carboxy-delta9-tetrahydrocannabinol (THC-COOH) were detected in urine. Case 2: A 33-year-old gay male committed suicide by hanging. Alpha-pyrrolidinovalerophenone (alpha-PVP) and 4-methylethcathinone were found in blood and urine. Cocaine and its metabolites were detected in urine. Case 3: A 53-year-old male went to the hospital suffering palpitations and thoracic pain and explained that he had inhaled a “white substance” while taking money from a cashier. The case was defined as drug facilitated crime (robbery). Alpha-PVP was detected in blood (0.009 mg/L) and urine, along with nordiazepam and lorazepam and metabolites. Case 4: The police restrained a 39-year-old Colombian male with agitation, persecutory psychosis and irrational behavior. Autopsy samples showed alpha-PVP in blood (1.20 mg/L) and urine along with cocaine, amphetamine, 3,4-methylenedioxy-methamphetamine, lormetazepam and alprazolam. The four cases bring attention to the severe toxicity including behavioral abnormalities induced by easily accessible synthetic cathinones, all of which should be taken into consideration by authorities in order to adjust legislation with celerity to real life circumstances.

Opium is a substance extracted from Papaver somniferum L. Opium latex contains morphine, codeine, and thebaine and non-analgesic alkaloids such as papaverine and noscapine. In Spain opium growing is allowed only for scientific or pharmaceutical purposes and harvest is supervised by the Spanish Health Ministry. This work describes a sudden fatality involving opium consumption in a legal poppy field. The toxicological and autopsy findings, previous disease, paraphernalia, and scenario are discussed in order to clarify cause and manner of death. A 32-year-old white caucasian male was found unresponsive in a legal poppy field in the South of Spain. The emergency medical services responded to the scene where he was pronounced dead. The friends explained that the deceased had presented with about 30min of convulsions; in spite of trying to keep his airway tract open they noted that "he stayed airless". According to them the victim suffered from epilepsy. Tools found beside his body consisted of plain wood sticks with a blade razor, a fabric handle, and paper. A comprehensive toxicological screening for abuse and psychoactive drugs was performed in the deceased samples. This included ethanol and volatile analysis by HS-GC-FID in peripheral blood and urine, enzyme immunoassay in urine by CEDIA, and a basic drug screening in all samples (including paraphernalia) by GC-MS using modes full scan for screening/confirmation and selected ion monitoring for quantitation. The peripheral blood, urine, vitreous, and gastric content contained the following concentrations of opiates expressed in mg/L (gastric content additionally also expressed in mg total): 0.10, 7.12, 0.23, and 14.80 (2.81mg total) of thebaine, 0.13, 4.50, 0.13, and 6.60 (1.25mg total) of morphine (free), 0.48, 0.88, 0.17, and 1.50 (0.28mg total) of codeine. These tree opiates were also detected in the tools (paraphernalia) used by the deceased for opium consumption. Other toxicological findings were metabolites of cocaine and cannabis. Apparently the victim stole poppy capsules and ingested an unknown quantity of the latex with the goal to obtain euphoric effects. The cause of death was considered poly-drug toxicity with a preponderant role of thebaine and morphine. In addition, the epileptic condition of the deceased could have played a role. As far as we know, there are no previous reports of fatalities occurring in legal poppy fields.

Opium is a substance extracted from Papaver somniferum L that is chronically abused specially in the traditional production regions. Reports on opium poisoning has largely disappeared from the occidental literature on drug problems but recent scientific articles show cases of death related to opium in industrialized countries. This fact led us to consider the interest of knowing the state of the art of acute opium intoxication in modern times. This work shows a compilation of these uncommon cases occurred in different settings and circumstances. Data were obtained by a computer assisted search of the literature using the key words "opium poisoning", "poppy", "poppy seeds", and "papaver somniferum" in PubMed, accompanied by a hand search of the reference lists of all articles for any relevant studies not included in the database. In addition, Google Scholar, government reports, and cases adequately documented on websites were reviewed. Type 1 cases, Accidental opium intoxications when it is used as a recreational drug: Reported cases came mainly from industrialized countries. They were mostly male with a range age of 17-64 years. Many had antecedents of alcoholism or drug abuse and opium tea was used as a substitute of heroin. Rachacha has caused poisonings in France and has been detected in a stash in Spain. Toxicological analysis was documented in forensic cases. The danger of this renewed interest in opium is exemplified in that many of the poisoning cases resulted in fatalities. Type 2 cases, Accidental opium intoxications in children or adults when it used as folk remedy: Pediatric intoxication after the use of opium as folk remedy are mainly published in traditional opium-producing areas with a long history of use or ethnic communities in England or USA. Addiction to opium was common among relatives. Type 3 cases, Opium intoxications with poppy seeds consumed as food: Due to excessive consumption of opium seeds as food, sporadic cases of mild toxicity had been reported and morphine contents were documented. Type 4 cases: Accidental opium intoxications when using the abdominal or pelvic cavity for concealing the drug: Accidental opium body packer intoxications are seen in patients who traveled from illegal opium areas of production. Type 5 cases: Suicides by opium: Opium was a prevalent agent among cases of suicides in Iran but data are scarce.

The investigation of uncertain fatalities requires accurate determination of the cause of death, with assessment of all factors that may have contributed to it. Gasoline is a complex and highly variable mixture of aliphatic and aromatic hydrocarbons that can lead to cardiac arrhythmias due to sensitization of the myocardium to catecholamines or acts as a simple asphyxiant if the vapors displace sufficient oxygen from the breathing atmosphere. This work describes a sudden occupational fatality involving gasoline. The importance of this petroleum distillate detection and its quantitative toxicological significance is discussed using a validated analytical method. A 51 year-old Caucasian healthy man without significant medical history was supervising the repairs of the telephone lines in a manhole near to a gas station. He died suddenly after inhaling gasoline vapors from an accidental leak. Extensive blistering and peeling of skin were observed on the skin of the face, neck, anterior chest, upper and lower extremities, and back. The internal examination showed a strong odor of gasoline, specially detected in the respiratory tract. The toxicological screening and quantitation of gasoline was performed by means of gas chromatography with flame ionization detector and confirmation was performed using gas chromatography-mass spectrometry. Disposition of gasoline in different tissues was as follows: heart blood, 35.7 mg/L; urine, not detected; vitreous humor, 1.9 mg/L; liver, 194.7 mg/kg; lung, 147.6 mg/kg; and gastric content, 116,6 mg/L (2.7 mg total). Based upon the toxicological data along with the autopsy findings, the cause of death was determined to be gasoline poisoning and the manner of death was accidental. We would like to alert on the importance of testing for gasoline, and in general for volatile hydrocarbons, in work-related sudden deaths involving inhalation of hydrocarbon vapors and/or exhaust fumes.

We would like to alert toxicologists to the importance of testing for gasoline, and for volatile hydrocarbons in general, in deaths involving inhalation of exhaust fumes occurring in closed spaces with running motors or machinery. We present here a case of suicidal inhalation of motorbike exhaust, a mixture of carbon monoxide (CO) and gasoline vapor, by a 38-year-old female. She was found in her closed home garage with a hose extending from the exhaust pipe of a motorbike through a cellophane plastic device into a closed tent in which the victim lay. She left two suicide notes nearby. The carboxyhemoglobin (COHb) was measured using visible spectrophotometry. The toxicological screening and quantitation of gasoline was performed by means of gas chromatography with flame-ionization detector and confirmation was performed using gas chromatography-mass spectrometry. The %COHb determined in blood was 73%. Gasoline concentrations in heart blood and vitreous humor were 22.3 and 1.0 mg/L, respectively. Although fatalities with CO at this rate are common, we would like to highlight the role of gasoline and add new quantitative data of this toxic substance to the scarce literature. Based upon the toxicological data, along with the information provided by the medical examiner, the cause of death was determined to be CO and gasoline poisoning and the manner of death suicide.

Tetridamine is a non-steroidal anti-inflammatory drug of the class indazols used topically as co-adjuvant for vaginitis. No previous data have been published about tetridamine overdoses.Retrospective analysis of single ingestions of tetridamine vaginal douches reported to the Spanish Poison Control Centre from January 1991 to December 2003.Seventy-seven cases met the inclusion criteria; 89.6% of the patients were over age 14 years. Exposures primarily involved female patients (94.4%). In 87% of cases, the tetridamine was ingested when it was mistaken for an oral preparation or for an oral antiseptic. The rest were unintentional exposures in children (10.4%) or suicide attempts (2.6%). Clinical effects, present in 17 patients, were mainly gastrointestinal (11 patients) followed by neurological (3 patients) or both (3 patients). The most common symptom was vomiting, followed by nausea, abdominal pain, and headache. One woman who ingested 4 g in a suicidal attempt became comatose.This is the first report of tetridamine overdoses. An effort should be made by physicians and pharmacists to explain clearly the correct directions for the use of vaginal irrigation preparations.

Benzydamine is a non-steroidal antiinflammatory drug used as vaginal lavage for non-specific vaginitis. Data on overdoses are scarce despite its wide availability.Retrospective analyses of single ingestions of benzydamine vaginal irrigation products from January 1991 to December 2003 reported to the Spanish Poison Control Centre.724 cases met the inclusion criteria; 86.2% of the patients were over age 14 years. Gender was not a factor in young children but 80.9% of patients older than 14 years were female. In 85.9% of cases, benzydamine was ingested when it was mistaken for an oral preparation or for an oral antiseptic. The rest were unintentional exposures in children (13.8%) or suicidal attempts (0.3%). Clinical signs or symptoms, when present, were mainly gastrointestinal (48% of symptomatic patients) followed by neurological (31%) or both (21%). The most common symptom was nausea (32.8% of symptomatic patients) followed by vomiting (27.9%), dizziness (20.1%), hallucinations (15.3%), abdominal pain (13.4%), and esophageal irritation and agitation (10.5%, each). Six of 68 children (mean age 6.2, range 3-11 years) had hallucinations. A severe case was that of a 4-year-old child who had convulsions caused by the unintentional ingestion of benzydamine.This is the largest report of benzydamine ingestions. The outstanding feature was the high percentage of neurological manifestations in children and adults, mainly hallucinations, following the ingestion of an over-the-counter product.

Olanzapine is a second-generation atypical antipsychotic agent approved for the treatment of psychotic disorders and mania. While olanzapine overdoses are common, cases with whole blood concentrations are less so. We describe here a well-documented case of a pure olanzapine overdose in which whole blood concentrations were determined, and compared with other concentrations in the literature.A 58-year-old woman with a 10-year history of paranoid schizophrenia and poor therapeutic compliance was found unconscious with two empty 28-tablet vials of Zyprexa (olanzapine) 10 mg tablets. Her initial vital signs were blood pressure 110/70 mmHg, pulse rate 82 beats/minute (sinus rhythm), respirations 20 breaths/minute, and the Glasgow Coma Scale score was 7. In the Intensive Care Unit, her pulse rate was 160 beats/minute, in sinus rhythm, and QTc 0.423 seconds (normal0.4 seconds). Relevant analytical findings were metabolic acidosis, leukocytosis, creatine phosphokinase 1992 mg/dL, and glucose 207 mg/dL. Ten hours after being found, her blood sugar was 350 mg/dL and became normal at 25 hours. The patient needed intubation and insulin.Olanzapine was detected and quantitated by gas chromatography with nitrogen-phosphorus detector and confirmed by gas chromatography-mass spectrometry using a validated analytical method. At approximately 4, 8, and 12 hours post-ingestion, whole blood concentrations of olanzapine were 0.41, 0.34, and 0.38 mg/L, respectively.This study reports an acute olanzapine monointoxication with severe toxicity and high whole blood olanzapine concentrations. Clinical and analytical data of similar samples obtained in non-fatal life-threatening cases can be very useful when interpreting postmortem cases.

Deaths of patients during elective surgery have drawn attention to the danger of anesthesia. Tumescent local anesthesia is subcutaneous infiltration of large volumes of dilute lidocaine with epinephrine to produce vasoconstriction while delivering anesthesia over large areas without lidocaine toxicity. This report documents the case of a 38-year-old woman who attended an outpatient clinic to undergo liposuction of the abdomen and bilateral hips and thighs. According to one witness, around 30 min after anesthesia administration, the victim suffered an episode of tonic-clonic convulsion. When the emergency medical services arrived the patient was in asystole. She died in spite of attempted cardiopulmonary resuscitation. The patient had no significant past medical history including no history of allergies or any known complications with anesthesia. A complete autopsy was performed and possible causes of death such as myocardial infarction, aspiration of food or foreign body, and pulmonary embolism were discarded. Anaphylactic shock was considered a possible but unlikely explanation for the fatality. Toxicological analyses revealed the presence of lidocaine and mepivacaine in heart blood, at concentrations of 4.9 and 16.2mg/L, respectively. All drugs involved in the case were detected using gas chromatography with nitrogen-phosphorus detector and confirmed using gas chromatography-mass spectrometry full scan mode after solid-phase extraction using Chem-Elut columns. An additional high-performance liquid chromatography coupled to diode-array detection screening also obtained the same results. Based on the autopsy findings, case history, and toxicology results, the forensic pathologists ruled that the cause of death was an overdose of local anesthetic agents. The Court of Law ruled the death as an involuntary homicide due to gross negligence.

This paper presents a simple, rapid, reliable, and validated method suited for forensic examination of gasoline in biological samples. The proposed methodology has been applied to the investigation of four fatal cases due to gasoline poisoning that occurred in Spain in 2003 and 2004. Case histories and pathological and toxicological findings are described in order to illustrate the danger of gasoline exposure under several circumstances. Gasoline's tissular distribution, its quantitative toxicological significance, and the possible mechanisms leading to death are also discussed. The toxicological screening and quantitation of gasoline was performed by means of gas chromatography (GC) with flame-ionization detection, and confirmation was performed using GC-mass spectrometry in total ion chromatogram mode. m,p-Xylene peak was selected to estimate gasoline in all biological samples. Gasoline analytical methodology was validated at five concentration levels from 1 to 100 mg/L. The method provided extraction recoveries between 77.6% and 98.3%. The limit of detection was 0.3 mg/L, and the limit of quantitation was 1.0 mg/L. The linearity of the blood calibration curves was excellent with r2 values of > 0.997. Intraday and interday precisions had a coefficient of variation < or = 5.4% in all cases. Cases 1 and 2 consist of the accidental inhalation of gasoline vapor inside a small enclosed space. Case 3 is a death by recreational gasoline inhalation in a male adolescent. Heart blood concentrations were 28.4, 18.0, and 38.3 mg/L, respectively; liver concentrations were 41.4, 52.9, and 124.2 mg/kg, respectively; and lung concentrations were 5.6, 8.4, and 39.3 mg/kg, respectively. Case 4 was an accidental death due to gasoline ingestion of a woman with senile dementia. Peripheral blood concentration was 122.4 mg/L, the highest in our experience. Because pathological findings were consistent with other reports of gasoline intoxication and constituents of gasoline were found in the body, cause of death was attributed to acute gasoline intoxication. As a rule, this kind of poisoning offers little difficulty in diagnosis because there is a history of exposure, and the odor usually clings to the clothes, skin, or gastric contents. However, anatomic autopsy findings will be nonspecific and therefore toxicological analysis is necessary. There is a paucity of recent references regarding analytical and toxicological data, and this article provides evidence about toxic concentrations and is a useful adjunct to the postmortem toxicological interpretation of fatalities if the decedent has been involved in gasoline use.