Living in a Cloud of Volatiles

Living in a Cloud of Volatiles
D. Anderson
Los Angeles County Dept. of Coroner
CAT - Pasadena, CA – June 2004
Substance Abuse in America
• Common DOA
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Cocaine
Methamphetamine & like
Opiates
PCP
Marijuana
Prescription medications
Many Others
Volatiles Abuse
• Types of Alcohol
– Ethanol - Good ole’ drinking alcohol
• Probably the most common
– Methanol - Wood alcohol
– Isopropanol - Rubbing alcohol
• Metabolizes to acetone
• Other types of drinking fluids
– Acetone: Nail Polish Remover
– Ethylene Glycol (Anti-freeze)
• High BP - Not volatile
• Insoluble Ca oxalate deposits in kidney& brain
– Propylene Glycol (Simple Green)
Inhalants
• A substance or product that produces a
chemical gas or vapor by concentrating
and intentionally breathed to create an
psychoactive effect.
• Volatility is a measure of the tendency to
vaporize or leave the liquid state
Types
• Aliphatic & Aromatic Hydrocarbons
– Widely distributed in nature, primarily in
natural gas and petroleum.
• Toluene, benzene, xylene and hexane
• Halogenated Hydrocarbons
– Trichloroethylene and the Freons
• Anesthetic gases
– Ether, nitrous oxide, chloroform and
halothane
Common Products
• Volatile solvents and gas products
– Model airplane glue, paint thinner, gasoline, and nail
polish remover
• Aerosols
– Nonstick cooking spray, computer keyboard cleaner and
hair spray
• Anesthetics
– Nitrous oxide or "laughing gas" and ether
• Nitrites
– Amyl, butyl, and isobutyl nitrites
• Often marketed as "poppers" or room odorizers
Location of these Products?
• General Supplies
– Cements and glues, correction fluid; magic
markers, solvent-based dry erase markers
• Cleaning Supplies
– Any product in an aerosol can
– Aerosol air fresheners and deodorizers; computer air duster
• Wood Shop
– Paints, varnishes, stains, paint thinner, contact cement
• Art Supplies
– rubber cement; printing inks; spray paints and clear
finishes
Location of these Products?
• Auto
– Degreasers, spray lubricants, "Fix-a-Flat" type products,
solvents, Freon®, brake fluid; gasoline; lacquers,
lacquer, thinners
• Health and Beauty
– Nail polish and nail polish remover; hair spray;
deodorants
• Cooking Supplies
– Cooking spray; whipping cream in aerosol cans;
whipping cream cartridges (whippets)
Huffing vs. Bagging
• Huffing
– Inhalants are abused either by "sniffing" though the
nose or inhaling fumes through the open mouth
("huffing") much like a smoker inhales cigarette
smoke. Usually the open tube of glue, nail polish, or
marker is placed close to the nose and the fumes are
inhaled.
• Bagging
– People who abuse inhalants may also spray the
substance into a plastic or paper bag and huff that
way ("bagging") or even place the bag over their
entire head.
Who’s Huffing Now?
• According to Substance Abuse and Mental
Health Services Administration’s
(SAMHSA) 2002 National Survey on Drug
Use and Health (NSHUH)
– More than 22.8 million Americans reported
ever having used an inhalant, and about
180,000 were estimated to need treatment
because they were dependent on or abused
inhalants (2.6 million were between the ages of
12 and 17)
Who’s Huffing Now?
• Gender
– Girls begin inhalant use far earlier than boys with a mean
age of first use at 15.0 years, as compared to 16.3 years for
boys.
• Age
– Typically: 10 to 15 year olds
– Atypically: 7 and 8 year olds has been reported.
– Average Age
• Initial use is about 12
• Chronic abuse is usually seen in older adolescents
• Adults
– Dance scene to heighten their experience
– Aphrodisiac effects
What’s all the HUFF about?
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To have fun
For excitement
For intoxication
To be part of the group
To shock adults
To deal with problems
To copy the behavior of adults using alcohol
As an alternative to alcohol
They are easily available
They are cheap to purchase
They’re legal!!
Categories of Huffers
• Experimenter
– They try it once or twice then stop by themselves
– Majority of teenagers fall into this category
• Social/Situational User
– Usually done with a group of friends
– The amount of use varies, depending on what else
is going on in their lives.
– These users often develop other interests and
grow out of this practice.
Categories of Huffers
• Dependent/Long-Term User
– Not common
– Usually have other major problems in their
lives
– May use inhalants alone, or with other people
who use inhalants regularly
– May feel bad about using, but feel unable to
give it up
– One of their few pleasures
General Effects of Inhalants
• Highly lipid soluble (Large Vd)
– Cross both alveolar membranes and the blood-brain barrier.
– Volatiles accumulate in the brain and other fatty tissues in
the body
• Onset almost immediately after inhalation
– Instant “RUSH”: Rapid entry into the bloodstream through
the lungs.
– Exposure via the pulmonary route avoids first-pass hepatic
metabolism
– Lasts up to about 30 minutes (unless repeated doses)
• Elimination
– Lungs
– Hepatic: Can produce toxic metabolites
– CCl4 CHCl3, CO2, & hepato toxic trichloromethyl free radical
– Benzene Phenol
General Effects of Inhalants
• Initial euphoria and lowering of
inhibitions
– Similar to those when you are drunk
• Disorientation, blurred vision, dizziness, slurred
speech, drowsiness, and some people may even
experience hallucinations.
• Users can also experience nausea, blackouts and
sickness. The after-effects include a mild
hangover that leaves the user feeling tired
and lacking in concentration for about a day.
Suspecting a Huffer ?
• Huffer’s Spots or Huffers “rash”
– Drying and redness around the mouth and nose
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Suffer severe headaches
Nosebleeds
Bloodshot eyes or Glazed eyes
Unpleasant or “Chemical” Breath
Paint stains on clothes, collection of products
Flu-like Symptoms
– Sneezing, Coughing, Runny nose
• Long-term effects
– Brain damage
– Kidney or Liver failure
What Else Can Happen?
• Accidental suffocation
– Plastic bags over their heads to get the full effect from
the solvents
• Risk of choking on their own vomit if they blackout
• Reckless Behavior
– Solvent Abusers do reckless or dangerous things after
using inhalants
• DEATH!! - Sudden sniffing death syndrome
– Irregular heart rate induced by inhalant
– Cardiac effects: Hypertension, tachycardia, and
bradycardia
Laboratory Issues
Specimen Choice?
• Ante-mortem
– Blood
– Urine: Not going to happen!
• Post-mortem
– Blood
– Lung air or Tracheal gas
Volatiles - Factors
• Stability
– ETOH
• Evaporation (large headspace in container)
• Microbial consumption, chemical oxidation to Acetaldehyde
– ETOH
• Glucose
ETOH (microorganisms)
– Vitreous and urine somewhat resistant to Decomp
• Acetone production
– Diabetics
• Inhalants
– Binding vs. Displacement
Analysis
• Factors
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Time
Temperature
Preservation
Storage
• Volatile Analysis
– Headspace GC/FID-most common
• Volatile Type
Helium Deaths
• At least 3 in the last year
– 85-year old female-plastic bag over head with
Helium tank on (Suicide).
– 56-year old male-plastic bag over head with
Helium tank on (Suicide).
– 79-year old male-plastic bag over head with
Helium tank on (Suicide).
• How in the world do you analyze for
Helium?
It’s Time for some
Real Case Studies
Case Study #1:
So Much for a Good Time!
• December 30, 2003
• 43-year old Black Male
• Found unresponsive and lying in bed by
his girlfriend
– She attempted CPR, transported to
Hospital-DOA
– History of chest pains, ulcer, no abuse of
drugs or alcohol.
– No foul play, no trauma
So Much for a Good Time!
• Autopsy
– Unremarkable
– 214 pounds, 68 inches (5’8”)
– Healthy 43-year old male
• Toxicology
– Comprehensive Drug Screen
• Volatiles, DOA & Prescription Medications
So Much for a Good Time!
• Toxicology Results
Heart Blood
Amitriptyline 0.53 ug/ml
Nortriptyline 0.53 ug/ml
Fluoxetine
0.81 ug/ml
Norfluoxetine 0.81 ug/ml
• Volatiles
MEOH/Formaldehyde
1.06
Ethanol
1.62
Acetone
2.357
Isopropanol
2.864
T-Butanol (IS)
3.76
Chloroethane
• Ethylchloride
– Colorless, flammable gas
– Ether-like or pungent odor
– Uses
• Inhalation anesthetic
• Refrigerant
• Local anesthetic for freezing tissues
– Body piercing
– Sports injuries
• Pharmacological effects
– CNS Depression
– Cardiac arrhythmias
So Much for a Good Time!
• Questions?
– Hospital Intervention Artifact
• Topical Anesthetic?
– Huffing?
• No scene visit
• Investigations cannot locate Girlfriend
So Much for a Good Time!
• March 17, 2004 (2 ½ Months later)
– Interview the girlfriend
• Decedent and her went to Mexican Restaurant for
Dinner
• Before having sex, Decedent “sprayed Maximum
Impact onto a towel and inhaled for more stamina”
• Decedent had erection that night, but never ejaculated
• Two of them went to bed and he never awoke.
So Much for a Good Time!
• Cause of Death
– Chloroethane Intoxication
• Mode of Death
– Accident
Case Study #2:
For Adults Only!
• Scene Investigation (1999)
– Apparent autoerotic Death
• 48-year old Caucasian male
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History of AIDS
Last known to be alive 3-4 days prior
Found during welfare check-nude on bed
Foul play not suspected
• Multiple medications and sexual
paraphernalia recovered
– Video Head Cleaner cans were recovered
For Adults Only!
• Autopsy
– Partially Decomposed
– 183 pounds, 71 inches (5’11”)
– Plastic Bag over head with rope ligature around
neck
• Condensation present inside bag
• Cloth Gag in mouth
– Cerebral and pulmonary edema
– No hyoid trauma or fracture
– Hypertrophic cardiomyopathy
• Moderate Coronary atherosclerosis
For Adults Only!
• Toxicology
– Comprehensive Drug Screen
• Volatiles, DOA & Prescription Medications
For Adults Only!
• Toxicology Results
Alprazolam
Buproprion
Buproprion Metabolites
Heart Blood
69 ng/ml
+<0.10 ug/ml
Present
For Adults Only!
• Cause of Death
– Asphyxia
– Atherosclerotic Heart Disease
– Chloroethane Effect
• Mode of Death
– Accident
For Adults Only!
• Why Solvent Abuse?
– Enhanced his sexual orgasm while
engaged in self gratification
• Inserting metal and plastic catheters
into his penis
• Leather bondage
• Piercing of the body
Case Study #3:
Light Me Up!
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January 23, 2004
13-year old Hispanic Female
Transported to Hospital - DOA
Seen inhaling butane with friends
– Cans of butane were thrown over the fence
and later recovered by police
Light Me Up!
• Father’s Information
– Caught daughter abusing “Fresh Spray” or
room freshener/deodorizer 9 months prior
– He spoke to the principle and told daughter
not to associate with one of her female
friends
• Thought she was poor influence
– Thought she was not inhaling anymore
– No other alcohol, tobacco, or drug use
Light Me Up!
• Autopsy
– ‘Y’ incision present-organ procurement
– Unremarkable
• Healthy 13-year old female
• Toxicology specimens submitted
– Procurement blood
– Tracheal Air
Light Me Up!
“Neon Lighter Butane”
“Neon Lighter Butane”
“Ronson Fuel” – (Butane)
Isobutane
Butane 2.13 min
Light Me Up!
• Toxicology
Femoral Blood Tracheal Air
Propane
Present
Present
Butane
Present
Present
Light Me Up!
• Cause of Death
– Butane and Propane Toxicity
• Mode of Death
– Accident
Case Study #4:
Death by Mistake!
• December 30, 2003
• 12-year old black male’s death reported
• History of asthma
– Required occasional use of inhaler
– Active in sports: Football and Basketball
• Problems in Month of December
– Sent home from school with fever
– Eye Pain and Headaches-3 days prior to death
Death by Mistake!
• Investigative history
– Eyes were red from him rubbing them
– 2nd day of headache-administered Motrin
• On December 30, 2003
– Mother made appointment at Kaiser
• 5-year old brother witnesses decedent
grab his chest and fall onto a small plastic
inflatable chair.
Death by Mistake!
• Autopsy
– Unremarkable
– 125 pounds, 57 inches (4’9”)
– Appeared to be healthy 12-year old boy
• Toxicology
– Comprehensive Drug Screen
• Volatiles, DOA & Prescription Medications
MEOH/Formaldehyde
1.06
Ethanol
1.62
Acetone
2.357
Isopropanol
2.864
T-Butanol (IS)
3.76
Death by Mistake!
• Volatile Confusion??
– Came from Hospital
• Hospital Intervention Artifact?
– Postmortem Production?
• 12-year old kid with no known COD
• Further tests/Investigations?
Death by Mistake!
• More Investigations Needed
– Huffing?
– Need to talk to family/parents
Death by Mistake!
• January 27, 2003
– New Information
• Father repairs Ice Machines
• Freon Tanks in the garage
• Parents intend to talk to the decedents friends
A True Tragic Death!
• January 28, 2003
– Mother calls our office
• The inflatable chair that the decedent collapsed
on
– Inflated on Christmas with a mixture of “Carbon
Dioxide and R22”
• The chair had a slow leak and was deflating.
– The Decedent was trying to blow up the chair with his
mouth and was unintentionally inhaling the Freon gas.
– Parents bring the two chairs and cylinder
tank to the office for testing.
A True Tragic Death!
• Toxicology
– DFCM present in cylinder and chairs
• Cause of Death
– Effects of Difluorochloromethane Inhalation
• Mode of Death
– Accident
Two-fer
• Case History
– Celebration of an 18-Birthday
• 3 Cousins inhaling Freon
• 1 passes out, wakes and finds the tank and
2 others at the bottom of the swimming
pool