Competent Interpretation of PM BAC & Use of Alternative Matrices

ACMT ASMHuntington Beach, CA

March 17, 2016

Michael G. Holland, MD, FAACT, FACMT, FACOEM, FACEPAssociate Professor, SUNY Upstate Medical University

Consulting Medical Toxicologist, Upstate New York Poison Center, Syracuse, NYOccupational Medicine Director, Glens Falls Hospital Center for Occupational Health; Glens Falls, NY

Senior Medical Toxicologist, Center for Toxicology and Environmental Health; North Little Rock, AR

Ethanol Case #1 SF, 38 yo WF, had 3 drinks & meal over 2 hrs On drive home failed to negotiate a curve Struck a light post, SF ejected (no SB), flew

30 feet into building wall Suffered massive thoracoabdominal/head

injuries Coroner called to scene, DOA, examined body Collected PM specimens, released to FH

Ethanol Case #1 PM alcohol 0.268g% by State Police Crime

Lab Family brings Dram shop lawsuit vs. bar

owner– Allege improperly served her too much alcohol– Proximate cause of her death

Bartender testifies served 3 standard rum & cokes (one shot, i.e. 1.25 oz rum per drink)

Pt weight (145 lb), and 3 standard drinks over 2 hrs does not seem to correlate

Ethanol Case #2 AJ, 47 yo male, motorcycle accident

~ 6/17/05 in south Texas, missing for 3+ days

Body and cycle found by squirrel hunters down roadside embankment 6/20/05

Autopsy performed 6/21/05

Ethanol Case #2 Body extremely bloated, Severe decompositional

Δ’s: – blisters, green-tan skin discoloration, extensive skin

slippage & sloughing– All cavities contain gas and decomposition fluid &

severe decomposition odor– All organs show extensive decomposition, but no

other abnormalities Fx neck C1-2 Cause of death: C-spine fx & spinal cord

transection Manner of death: accident

Case #2 Toxicology Specimens sent to forensic lab Lab report: Heart blood specimen

– Ethanol 0.09g/dL– Methanol ND– N-propanol +– Acetone +– Drugs of abuse ND

No urine or vitreous sampling done

Case #3: Alcohol

DS, 38 yo male went fishing alone in a small boat spring 2006 in Minnesota.

Empty boat washed up on a nearby shore a day later.

Body was found (no life vest) by dredging the lake, and was promptly refrigerated.

Autopsy revealed a COD: drowning; MOD: accident

Case #3: Alcohol

Peripheral BAC of 0.20 g%, other volatiles were negative;

Vitreous ethanol 0.24g%; Urine ethanol 0.24 g%. Insurance death benefits denied due to

alcohol intoxication; family appeals the decision, claiming he does not drink alcohol, and post-mortem alcohol production was the cause.

PMR and/or quality of results also depends on:

Manner of death- trauma Stomach contents Conditions of storage of body- refrigeration Amount of decomposition/putrefaction Storage of blood: temp., preserv (NaF)., time Type of blood tube (Li) Site of blood sample- C vs. P; ligated? Method of blood sampling (i.e. blind stick) Interpretation depends on type of blood

tested: serum (plasma) v whole blood

Post-Mortem Ethanol Production

Ethanol produced from fermentation of blood glucose & lactate

Begins only after at least 2 days of decomposition through ≈ day 10

Bacteria, yeast, Candida all can ferment Generally levels produced are < 50mg/dL

(0.05gm%)– Although levels of 200mg% (0.20gm%) have

been reported

Post-Mortem Ethanol Production When fermentation does occur, other volatiles are also

produced:– Methanol, n-propanol, acetaldehyde, acetone

Simultaneous urine, VH testing can distinguish– VH [EtOH] lags behind BAC, avg. 0.9-1.3 x BAC– Caveat: urine in DM can have higher PM EtOH production

Cocaethylene NOT produced via this mechanism Ethyl glucuronide (ETG)

– Used to monitor abstinence, present for 4-5 days post-ingestion– NOT produced by fermentation– Quandry: is +ETG due to acute intoxication, or just recent use

Method of sampling Blind chest stick to obtain blood

– Most often by local coroners (often morticians, not MD’s)

– Cardiac blood or great vessels– Contaminated with gastric contents, esp.

with thoracoabdominal trauma– Can markedly elevate ethanol, drug levels

if recently ingested

Alternative Matrices:Vitreous Humor Sampling VH Essentially 98% water with salt solution Very little protein Very isolated, not subject to PMR Useful when blood is not acceptable or

available– Severely burned bodies– Exsanguinating trauma – Extensive decomposition: VH can remain sterile

Vitreous Humor

Lags behind BAC Usually BAC is < VAC since most deaths occur

in post-absorptive, metabolizing phase of BAC-time curve

Occasionally BAC > VAC, indicating death occurred during rising arm of BAC-t curve

Very useful for corroborating BAC values Especially useful when blood is not available,

or to confirm or dismiss PM fermentation

Urine Alcohol

Usually 25% higher than BAC (wide variability)

More prone to PM fermentation than WB, especially DM- EtS & EtG can discriminate

Useful for corroborating BAC & VHAC values Especially useful when blood is not available,

or to confirm or dismiss PM fermentation

Cavity Blood Alcohol Testing

WB collected from hemothorax, hemoperitoneum

Very prone to dilution, contamination from gastric/intestinal spillage

Worst possible specimen for PM tox Useful only for qualitative Should always prompt VH, urine testing

Other Specimens for BAC Testing

Subdural/Epidural hematoma blood Isolated from general circulation, no metabolism Acts as a snapshot of BAC at time of head trauma Can be tested days later

Skeletal muscle alcoholNext most preferred/accurate specimen when WB,

VH, Urine not available Fair estimate of BAC at time of death

Conclusion of Ethanol Case #1 3 drinks in 145 lbwould give BAC of 116mg% if

100% absorption, no metabolism– Cb= Dose/(Vd)(wt in kg)= (3x14)/(0.55 x 66)– Approx 86mg% if over 2 hrs

Avg female needs 4 drinks to achieve BAC 0.08g% Family alleges bartender lying to protect himself, that

drinks with double the alcohol would predict this BAC– 172-232mg% if 3 “doubles” were served, with complete

absorption, no metabolism Any other explanation? Important Issues?

Conclusion of Ethanol Case #1 Coroners record: blood obtained via transthoracic No autopsy; “severely traumatized body”: DOA Very possible gastric rupture/spillage

– 3 drinks, MVA a few minutes after leaving bar– Transthoracic specimens notorious for gastric alcohol

contamination1

This could explain BAC higher than what was predicted

Settled out of court, no details on award

1. Winek. Forensic Sci Int. 1995 Jan 21;71(1):1-8.

Ethanol Case #2 Conclusion Due to severe decomposition, PM ethanol

fermentation very possible– Appropriate temperature, lag time, conditions– Positive co-volatiles found:

N-propanol, acetone Indicates + PM fermentation Heart blood more susceptible- earlier bacterial contamin.

– This means fermentation did take place Conclusion: Ethanol may be all due to PM

fermentation Without VH alcohol, unable to conclude DWI

Case #3: Recap:

Peripheral BAC of 0.20 g%, other volatiles were negative

Vitreous ethanol 0.24g%

Urine ethanol 0.24 g%

Alcohol Case#3

Body properly handled, stored Specimens appropriately obtained &

analyzed Alcohol in peripheral blood corroborated

by levels in VH, urine Conclusion:

– Acute alcohol intoxication despite family contention that he does not drink

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